Measuring Faculty Reflection on Adverse Patient Events: Development and Initial Validation of a Case-Based Learning System

BACKGROUND  

Critical reflection by faculty physicians on adverse patient events is important for changing physician’s behaviors. However, there is little research regarding physician reflection on quality improvement (QI).     

Simple Statistical Measures for Diagnostic Accuracy Assessment

The aim of diagnostic medicine research is to estimate and compare the accuracy of diagnostic tests to provide reliable information about a patient's disease status and thereby influencing patient care. When developing screening tools, researchers evaluate the discriminating power of the screening test by using simple measures such as the sensitivity and specificity of the test, as well as the positive and negative predictive values. In this brief report, we discuss these simple statistical measures that are used to quantify the diagnostic ability of a test.     

Breast lesions: evaluation with US strain imaging--clinical experience of multiple observers

PURPOSE: To prospectively determine the accuracy of using an ultrasonographic (US) strain imaging technique known as lesion size comparison to differentiate benign from malignant breast lesions. MATERIALS AND METHODS: Institutional Review Board approval and patient informed consent were obtained for this HIPPA-compliant study. US strain imaging was performed prospectively for 89 breast lesions in 88 patients. Lesions were imaged by using freehand compression and a real-time strain imaging algorithm. Five observers obtained manual measurements of lesion height, width, and area from B-mode and strain images. By using these size measurements, individual observer and group performances were assessed by using the area under the receiver operating characteristic curve (A(z)). The performance of a single size parameter versus that of a combination of size parameters was evaluated by using univariate and multivariate logistic regression. RESULTS: Group A(z) values showed that width ratio and area ratio yielded the best results for differentiating benign and malignant breast lesions, and they were not statistically different from one another (P = .499). For the group, the performance of area and width, which was superior to that of height and aspect ratio, was statistically significant for all cases (P < .011) except for those that compared area with aspect ratio (P = .118). By using a group threshold of 1.04 for width ratio and 1.13 for area ratio, the sensitivity and specificity of the technique were 96% and 21%, respectively, for width and 96% and 24%, respectively, for area. The best observer achieved a sensitivity of 96% and a specificity of 61% by using the area ratio. For all but one observer, combined size parameters did not improve observer performance (P > .258). Significant interobserver performance variability was observed (P < .001). CONCLUSION: Results suggest that US strain imaging has the potential to aid diagnosis of breast lesions. However, manually tracing lesion boundaries for size ratio differentiation in a busy clinical setting did not match the diagnostic performance levels previously reported. Focusing on measurements of lesion width, along with additional observer training or automated processes, may yield a suitable method for routine clinical application.     

Validity of the FOUR Score Coma Scale in the Medical Intensive Care Unit

OBJECTIVE: To evaluate the validity of the FOUR (Full Outline of UnResponsiveness) score (ranging from 0 to 16), a new coma scale consisting of 4 components (eye response, motor response, brainstem reflexes, and respiration pattern), when used by the staff members of a medical intensive care unit (ICU).PATIENTS AND METHODS: This interobserver agreement study prospectively evaluated the use of the FOUR score to describe the condition of 100 critically ill patients from May 1, 2007, to April 30, 2008. We compared the FOUR score to the Glasgow Coma Scale (GCS) score. For each patient, the FOUR score and the GCS score were determined by a randomly selected staff pair (nurse/fellow, nurse/consultant, fellow/fellow, or fellow/consultant). Pair wise weighted κ values were calculated for both scores for each observer pair.RESULTS: The interrater agreement with the FOUR score was excellent (weighted κ: eye response, 0.96; motor response, 0.97; brainstem reflex, 0.98; respiration pattern, 1.00) and similar to that obtained with the GCS (weighted κ: eye response, 0.96; motor response, 0.97; verbal response, 0.98). In terms of the predictive power for poor neurologic outcome (Modified Rankin Scale score, 3-6), the area under the receiver operating characteristic curve was 0.75 for the FOUR score and 0.76 for the GCS score. The mortality rate for patients with the lowest FOUR score of 0 (89%) was higher than that for patients with the lowest GCS score of 3 (71%).CONCLUSION: The interrater agreement of FOUR score results was excellent among medical intensivists. In contrast to the GCS, all components of the FOUR score can be rated even when patients have undergone intubation. The FOUR score is a good predictor of the prognosis of critically ill patients and has important advantages over the GCS in the ICU setting.FOUR = Full Outline of UnResponsiveness; GCS = Glasgow Coma Scale; ICU = intensive care unitAssessing impaired consciousness in the medical and surgical intensive care unit (ICU) is very difficult. The complexity of such an assessment relates in part to the difficulty of finding usable terminology, as illustrated in an earlier study in which 3 observers variously described a single patient as “somnolent,” “difficult to arouse,” and “deeply comatose.”¹ In recognition of this problem, Teasdale and Jennett¹ devised the Glasgow Coma Scale (GCS) in 1974 in an attempt to bring uniformity to the clinical examination and to clinical communication about the level of consciousness.The GCS has become a fixture in the initial assessment of abnormal consciousness but is not designed to capture distinct details of the neurologic examination. The GCS has been routinely used in medical and surgical ICUs and is commonly used in the Acute Physiology and Chronic Health Evaluation (APACHE) scoring system. However, its reliability in predicting patient outcomes is unsatisfactory, particularly with regard to the verbal component.² Other investigators have found additional shortcomings of the GCS and have suggested that adding measures of brainstem reflexes to the GCS could provide better prognostic information.³ Rowley and Fielding⁴ found that the reliability of the GCS increases with the experience of its users and that user inexperience is associated with a high rate of errors.We have developed a new coma scale, the Full Outline of UnResponsiveness (FOUR) score. Although the FOUR score is based on the bare minimum of tests necessary for assessing a patient with altered consciousness, it includes much important information that is not assessed by the GCS, including measurement of brainstem reflexes; determination of eye opening, blinking, and tracking; a broad spectrum of motor responses; and the presence of abnormal breath rhythms and a respiratory drive. Because the FOUR score, unlike the GCS, does not include an assessment of verbal response, it is more useful for assessing critically ill patients who have undergone intubation.The FOUR score was originally tested with staff members of a neuroscience ICU⁵ and has been subsequently validated by tests with experienced and inexperienced neuroscience ICU nurses.⁶ To determine whether the FOUR score is equally suited for use by intensivists, fellows, residents, and nurses without a neuroscience background, we prospectively tested the validity of the FOUR score coma scale when used by staff members of a medical ICU.     

Magnetic resonance imaging of surgically confirmed anterior cruciate ligament graft disruption

Objective To evaluate previously described primary and secondary MRI signs of disruption to anterior cruciate ligament (ACL) grafts in surgically proven cases. Materials and methods We retrospectively analyzed MR images of 48 patients (mean age 29 years) with clinically suspected ACL graft disruption. All patients had surgical confirmation of the MRI findings. The reviewers analyzed the cases blinded to the surgical results and assessed each of the primary and secondary MRI signs of graft disruption individually. Subsequently, a final impression of the graft integrity based on a comprehensive assessment of all of the primary and secondary findings was made. Results Utilizing a comprehensive assessment of previously described primary and secondary MR findings of ACL graft disruption, the blinded reviewers were able to identify correctly full-thickness graft tears with test accuracy of 85%, sensitivity of 72%, and specificity of 100%. Individual assessment of the primary finding of graft fiber discontinuity had sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 72%, 100%, 100%, 77% and 85%, respectively, for full-thickness tears. Other individual primary and secondary findings were less reliable; however, the primary findings of marked segmental thinning of the graft and markedly abnormal graft orientation, and the secondary findings of bone contusions in the lateral compartment and large joint effusion, had high specificity and positive predictive value. Of the four missed cases, two had associated arthrofibrosis. Conclusion The comprehensive assessment of previously described primary and secondary MRI findings of ACL graft disruption has high test specificity and moderately high test accuracy. The presence of graft fiber discontinuity is the most reliable primary or secondary finding when assessed individually. Marked segmental thinning of the graft and abnormal fiber orientation, and the presence of bone contusions in the lateral compartment and large joint effusion, are less reliable overall but are highly suggestive of full-thickness graft tear when present.     

Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project

Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project.

Objectives

To (1) reduce deep sedation and delirium to permit mobilization, (2) increase the frequency of rehabilitation consultations and treatments to improve patients' functional mobility, and (3) evaluate effects on length of stay.

Design

Seven-month prospective before/after quality improvement project.

Setting

Sixteen-bed medical intensive care unit (MICU) in academic hospital.

Participants

57 patients mechanically ventilated 4 days or longer.

Intervention

A multidisciplinary team focused on reducing heavy sedation and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines.

Main Outcome Measures

Sedation and delirium status, rehabilitation treatments, functional mobility.

Results

Compared with before the quality improvement project, benzodiazepine use decreased markedly (proportion of MICU days that patients received benzodiazepines [50% vs 25%, P=.002]), with lower median daily sedative doses (47 vs 15mg midazolam equivalents [P=.09] and 71 vs 24 mg morphine equivalents [P=.01]). Patients had improved sedation and delirium status (MICU days alert [30% vs 67%, P<.001] and not delirious [21% vs 53%, P=.003]). There were a greater median number of rehabilitation treatments per patient (1 vs 7, P<.001) with a higher level of functional mobility (treatments involving sitting or greater mobility, 56% vs 78%, P=.03). Hospital administrative data demonstrated that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4-3.8) and 3.1 (0.3-5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year.

Conclusions

Using a quality improvement process, intensive care unit delirium, physical rehabilitation, and functional mobility were markedly improved and associated with decreased length of stay.