Publications by authors named "D S Diekema"

442 Publications

Competencies and Milestones for Bioethics Trainees: Beyond ASBH's Healthcare Ethics Certification and Core Competencies.

J Clin Ethics 2021 ;32(2):127-148

Seattle Children's Research Institute, 1900 Ninth Ave., M/S JMB-6, Seattle, Washington 98101 USA.

Clinical ethics training programs are responsible for preparing their trainees to be competent ethics consultants worthy of the trust of patients, families, surrogates, and healthcare professionals. While the American Society for Bioethics and Humanities (ASBH) offers a certification examination for healthcare ethics consultants, no tools exist for the formal evaluation of ethics trainees to assess their progress toward competency. Medical specialties accredited by the Accreditation Council for Graduate Medical Education (ACGME) use milestones to report trainees' progress along a continuum of professional development as a means of "operationalizing and implementing" medical competencies. Utilizing the Core Competencies for Healthcare Ethics Consultation and the ACGME and American Board of Pediatrics' (ABP) Pediatric Milestones Project, we developed milestones for 17 subcompetencies in clinical ethics consultation and academic bioethics. As the field of clinical ethics becomes more standardized, such tools will be needed to promote the development of robust training programs and to certify that their graduates are competent practitioners.
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June 2021

Experience With Pretravel Testing for SARS-CoV-2 at an Academic Medical Center.

Acad Pathol 2021 Jan-Dec;8:23742895211010247. Epub 2021 Apr 28.

Department of Pathology, University of Iowa Hospitals and Clinics, IA, USA.

International travel has been a significant factor in the coronavirus disease 2019 pandemic. Many countries and airlines have implemented travel restrictions to limit the spread of the causative agent, severe acute respiratory syndrome coronavirus-2. A common requirement has been a negative reverse-transcriptase polymerase chain reaction performed by a clinical laboratory within 48 to 72 hours of departure. A more recent travel mandate for severe acute respiratory syndrome coronavirus-2 immunoglobulin M serology testing was instituted by the Chinese government on October 29, 2020. Pretravel testing for severe acute respiratory syndrome coronavirus-2 raises complications in terms of cost, turnaround time, and follow-up of positive results. In this report, we describe the experience of a multidisciplinary collaboration to develop a workflow for pretravel severe acute respiratory syndrome coronavirus-2 reverse-transcriptase polymerase chain reaction and immunoglobulin M serology testing at an academic medical center. The workflow primarily involved self-payment by patients and preferred retrieval of results by the patient through the electronic health record patient portal (Epic MyChart). A total of 556 unique patients underwent pretravel reverse-transcriptase polymerase chain reaction testing, with 13 (2.4%) having one or more positive results, a rate similar to that for reverse-transcriptase polymerase chain reaction testing performed for other protocol-driven asymptomatic screening (eg, inpatient admissions, preprocedural) at our medical center. For 5 of 13 reverse-transcriptase polymerase chain reaction positive samples, the traveler had clinical history, prior reverse-transcriptase polymerase chain reaction positive, and high cycle thresholds values on pretravel testing consistent with remote infection and minimal transmission risk. Severe acute respiratory syndrome coronavirus-2 immunoglobulin M was performed on only 24 patients but resulted in 2 likely false positives. Overall, our experience at an academic medical center shows the challenge with pretravel severe acute respiratory syndrome coronavirus-2 testing.
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http://dx.doi.org/10.1177/23742895211010247DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8110896PMC
April 2021

Practical Considerations for Implementation of SARS-CoV-2 Serological Testing in the Clinical Laboratory: Experience at an Academic Medical Center.

Acad Pathol 2021 Jan-Dec;8:23742895211002802. Epub 2021 Apr 7.

Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.

Molecular techniques, especially reverse transcriptase polymerase chain reaction (RT-PCR), have been the gold standard for the diagnosis of acute severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Serological tests for SARS-CoV-2 have been widely used for serosurveys, epidemiology, and identification of potential convalescent plasma donors. However, the clinical role of serologic testing is still limited and evolving. In this report, we describe the experience of selecting, validating, and implementing SARS-CoV-2 serologic testing for clinical purposes at an academic medical center in a rural state. Successful implementation involved close collaboration between pathology, infectious diseases, and outpatient clinics. The most common clinician concerns were appropriateness/utility of testing, patient charges/insurance coverage, and assay specificity. In analyzing test utilization, serologic testing in the first month after go-live was almost entirely outpatient and appeared to be strongly driven by patient interest (including health care workers and others in high-risk occupations for exposure to SARS-CoV-2), with little evidence that the results impacted clinical decision-making. Test volumes for serology declined steadily through October 31, 2020, with inpatient ordering assuming a steadily higher percentage of the total. In a 5-month period, SARS-CoV-2 serology test volumes amounted to only 1.3% of that of reverse transcriptase polymerase chain reaction. Unlike reverse transcriptase polymerase chain reaction, supply chain challenges and reagent availability were not major issues for serology testing. We also discuss the most recent challenge of requirements for SARS-CoV-2 testing in international travel protocols. Overall, our experience at an academic medical center shows that SARS-CoV-2 serology testing assumed a limited clinical role.
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http://dx.doi.org/10.1177/23742895211002802DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8040556PMC
April 2021

A 2020 Executive Order That Threatens Progress in Shared Decision-Making.

Pediatrics 2021 May 2;147(5). Epub 2021 Apr 2.

Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Seattle Children's Research Institute, Seattle, Washington; and.

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http://dx.doi.org/10.1542/peds.2020-038794DOI Listing
May 2021

Palliative care consultation in patients with bacteremia.

Palliat Med 2021 04 24;35(4):785-792. Epub 2021 Mar 24.

Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.

Background: Palliative care consultation has shown benefits across a wide spectrum of diseases, but the utility in patients with bacteremia remains unclear despite its high mortality.

Aim: To examine the frequency of palliative care consultation and factors associated with palliative care consult in bacteremia patients in the United States.

Design: A population-based retrospective analysis using the Nationwide Inpatient Sample database in 2014, compiled by the Healthcare Costs and Utilization Project of the Agency for Healthcare Research and Quality.

Setting/subjects: All inpatients with a discharge diagnosis of bacteremia (ICD-9-CM codes; 038.11 and 038.12).

Measurements: Palliative care consultation was identified using ICD-9-CM code V66.7. Patients' baseline characteristics and outcomes were compared between those with and without palliative care consult.

Results: A total of 111,320 bacteremia admissions were identified in 2014. Palliative care consult was observed in 8140 admissions (7.3%). Palliative care consultation was associated with advanced age, white race, comorbidities, higher income, teaching/urban hospitals, Midwest region, Methicillin-resistant bacteremia and the lack of echocardiogram. Palliative care consult was also associated with shorter but more expensive hospitalizations. Crude mortality was 53% (4314/8140) among admissions with palliative care consult and 8% (8357/10,3180) among those without palliative care consult ( < 0.001).

Conclusions: Palliative care consultation was infrequent during the management of bacteremia, and a substantial number of patients died during their hospitalizations without palliative care consult. Given the reported benefit in other medical conditions, palliative care consultation may have a role in bacteremia. Selecting patients who may benefit the most should be explored.
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http://dx.doi.org/10.1177/0269216321999574DOI Listing
April 2021