Publications by authors named "Hojjat Salmasian"

48 Publications

A SARS-CoV-2 Cluster in an Acute Care Hospital.

Ann Intern Med 2021 Feb 9. Epub 2021 Feb 9.

Brigham and Women's Hospital, Boston, Massachusetts (R.T., K.F., D.G., C.B., H.S., N.W., E.G., A.R., M.P., K.B., J.S., C.A.M.).

Background: Little is known about clusters of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in acute care hospitals.

Objective: To describe the detection, mitigation, and analysis of a large cluster of SARS-CoV-2 infections in an acute care hospital with mature infection control policies.

Design: Descriptive study.

Setting: Brigham and Women's Hospital, Boston, Massachusetts.

Participants: Patients and staff with cluster-related SARS-CoV-2 infections.

Intervention: Close contacts of infected patients and staff were identified and tested every 3 days, patients on affected units were preemptively isolated and repeatedly tested, affected units were cleaned, room ventilation was measured, and specimens were sent for whole-genome sequencing. A case-control study was done to compare clinical interactions, personal protective equipment use, and breakroom and workroom practices in SARS-CoV-2-positive versus negative staff.

Measurements: Description of the cluster, mitigation activities, and risk factor analysis.

Results: Fourteen patients and 38 staff members were included in the cluster per whole-genome sequencing and epidemiologic associations. The index case was a symptomatic patient in whom isolation was discontinued after 2 negative results on nasopharyngeal polymerase chain reaction testing. The patient subsequently infected multiple roommates and staff, who then infected others. Seven of 52 (13%) secondary infections were detected only on second or subsequent tests. Eight of 9 (89%) patients who shared rooms with potentially contagious patients became infected. Potential contributing factors included high viral loads, nebulization, and positive pressure in the index patient's room. Risk factors for transmission to staff included presence during nebulization, caring for patients with dyspnea or cough, lack of eye protection, at least 15 minutes of exposure to case patients, and interactions with SARS-CoV-2-positive staff in clinical areas. Whole-genome sequencing confirmed that 2 staff members were infected despite wearing surgical masks and eye protection.

Limitation: Findings may not be generalizable.

Conclusion: SARS-CoV-2 clusters can occur in hospitals despite robust infection control policies. Insights from this cluster may inform additional measures to protect patients and staff.

Primary Funding Source: None.
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http://dx.doi.org/10.7326/M20-7567DOI Listing
February 2021

Rethinking standardised infection rates and risk adjustment in the COVID-19 era.

BMJ Qual Saf 2021 Jan 8. Epub 2021 Jan 8.

Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1136/bmjqs-2020-012074DOI Listing
January 2021

Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors.

JAMA Netw Open 2020 11 2;3(11):e2019652. Epub 2020 Nov 2.

Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

Importance: Wrong-patient order entry (WPOE) errors have a high potential for harm; these errors are particularly frequent wherever workflows are complex and multitasking and interruptions are common, such as in the emergency department (ED). Previous research shows that interruptive solutions, such as electronic patient verification forms or alerts, can reduce these types of errors but may be time-consuming and cause alert fatigue.

Objective: To evaluate whether the use of noninterruptive display of patient photographs in the banner of the electronic health record (EHR) is associated with a decreased rate of WPOE errors.

Design, Setting, And Participants: In this cohort study, data collected as part of care for patients visiting the ED of a large tertiary academic urban hospital in Boston, Massachusetts, between July 1, 2017, and June 31, 2019, were analyzed.

Exposures: In a quality improvement initiative, the ED staff encouraged patients to have their photographs taken by informing them of the intended safety impact.

Main Outcomes And Measures: The rate of WPOE errors (measured using the retract-and-reorder method) for orders placed when the patient's photograph was displayed in the banner of the EHR vs the rate for patients without a photograph displayed. The primary analysis focused on orders placed in the ED; a secondary analysis included orders placed in any care setting.

Results: A total of 2 558 746 orders were placed for 71 851 unique patients (mean [SD] age, 49.2 [19.1] years; 42 677 (59.4%) female; 55 109 (76.7%) non-Hispanic). The risk of WPOE errors was significantly lower when the patient's photograph was displayed in the EHR (odds ratio, 0.72; 95% CI, 0.57-0.89). After this risk was adjusted for potential confounders using multivariable logistic regression, the effect size remained essentially the same (odds ratio, 0.57; 95% CI, 0.52-0.61). Risk of error was significantly lower in patients with higher acuity levels and among patients whose race was documented as White.

Conclusions And Relevance: This cohort study suggests that displaying patient photographs in the EHR provides decision support functionality for enhancing patient identification and reducing WPOE errors while being noninterruptive with minimal risk of alert fatigue. Successful implementation of such a program in an ED setting involves a modest financial investment and requires appropriate engagement of patients and staff.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.19652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7658731PMC
November 2020

Expert Consensus on Currently Accepted Measures of Harm.

J Patient Saf 2020 Aug 5. Epub 2020 Aug 5.

From the *Division of Nephrology, Massachusetts General Hospital †Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital ‡Harvard Medical School §Division of Pulmonary and Critical Care, Massachusetts General Hospital ∥Department of Quality and Safety ¶Division of General Internal Medicine, Brigham and Women's Hospital, Boston **Division of General Internal Medicine, Mt Auburn Hospital, Cambridge ††Risk Management Foundation of the Harvard Medical Institutions (CRICO) ‡‡Clinical and Quality Analysis, Mass General Brigham §§Department of Surgery, Massachusetts General Hospital ∥∥Harvard T. H. Chan School of Public Health ¶¶Division of Internal Medicine, Massachusetts General Hospital ***Department of Health Care Policy, Harvard Medical School, Boston, MA.

Background: Twenty-five years after the seminal work of the Harvard Medical Practice Study, the numbers and specific types of health care measures of harm have evolved and expanded. Using the World Café method to derive expert consensus, we sought to generate a contemporary list of triggers and adverse event measures that could be used for chart review to determine the current incidence of inpatient and outpatient adverse events.

Methods: We held a modified World Café event in March 2018, during which content experts were divided into 10 tables by clinical domain. After a focused discussion of a prepopulated list of literature-based triggers and measures relevant to that domain, they were asked to rate each measure on clinical importance and suitability for chart review and electronic extraction (very low, low, medium, high, very high).

Results: Seventy-one experts from 9 diverse institutions attended (primary acceptance rate, 72%). Of 525 total triggers and measures, 67% of 391 measures and 46% of 134 triggers were deemed to have high or very high clinical importance. For those triggers and measures with high or very high clinical importance, 218 overall were deemed to be highly amenable to chart review and 198 overall were deemed to be suitable for electronic surveillance.

Conclusions: The World Café method effectively prioritized measures/triggers of high clinical importance including those that can be used in chart review, which is considered the gold standard. A future goal is to validate these measures using electronic surveillance mechanisms to decrease the need for chart review.
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http://dx.doi.org/10.1097/PTS.0000000000000754DOI Listing
August 2020

Early Performance Trends After the Public Posting of Ambulatory Patient Satisfaction Reviews.

J Patient Exp 2019 Dec 7;6(4):329-332. Epub 2019 Mar 7.

Division of General Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.

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http://dx.doi.org/10.1177/2374373519833649DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908990PMC
December 2019

Does Addition of Intravenous Metronidazole to Oral Vancomycin Improve Outcomes in Clostridioides difficile Infection?

Clin Infect Dis 2020 Dec;71(9):2414-2420

Department of Medicine, Columbia University Medical Center, New York, New York, USA.

Background: Guidelines recommend adding intravenous (IV) metronidazole to oral vancomycin for fulminant Clostridioides difficile infection (CDI). In this study, we compared dual therapy with IV metronidazole and vancomycin vs vancomycin monotherapy. We assessed prevalence of use and effectiveness of dual therapy in nonfulminant and fulminant CDI.

Methods: This was a 2-center retrospective study conducted from 2010 to 2018. Adult inpatients were included if they had a positive C. difficile polymerase chain reaction (PCR) performed on an unformed stool and received vancomycin within 2 days of testing. Patients were classified as having received dual therapy if IV metronidazole was given within the same time window, and otherwise classified as vancomycin monotherapy. The primary outcome was death or colectomy within 90 days after the index test. Logistic regression modeling was used to adjust for CDI severity and other established predictors of CDI outcomes. CDI recurrence was examined as a secondary outcome, adjusting for death as a competing risk.

Results: The study included 2114 patients (dual therapy, 993; monotherapy, 1121); 23% met the primary outcome. There was no association between dual therapy and the primary outcome (adjusted odds ratio [aOR], 1.07; 95% confidence interval [CI], .79-1.45), which remained true when the analysis was restricted to patients with fulminant CDI (aOR, 1.17; 95% CI, .65-2.10). There was also no association between dual therapy and CDI recurrence.

Conclusions: Dual therapy with IV metronidazole and vancomycin was common for nonfulminant and fulminant CDI but was not associated with improved outcomes compared with vancomycin alone.
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http://dx.doi.org/10.1093/cid/ciz1115DOI Listing
December 2020

Medication stewardship using computerized clinical decision support: A case study on intravenous immunoglobulins.

Pharmacol Res Perspect 2019 10 29;7(5):e00508. Epub 2019 Aug 29.

NewYork-Presbyterian Hospital New York NY USA.

Background: Healthcare delivery organizations face increasing pressure to manage the use of medications in terms of safety, waste reduction, and cost containment.

Objective: To describe a computerized provider order entry (CPOE) system intervention to optimize use of a commonly ordered, high-cost therapeutic: intravenous immune globulin (IVIG).

Design: Description of IVIG order configuration, medication use patterns, and subsequent order set configuration development in a CPOE system.

Measurements: IVIG orders were extracted from the CPOE system before and after the implementation of a specialty orderset to determine the indications for use, dosing, and duration of therapy. Orders were compared to a theoretical dosing schedule created from published evidence and data from a prior medication use evaluation.

Results: During 36 months before the implementation of the IVIG order set, 1965 IVIG orders were reviewed. The prescribed IVIG dose varied considerably from the expected dose (mean = -1.8, range = -4.9-1.5). In the 27 months after order set implementation, 848 IVIG orders were reviewed. The prescribed IVIG dose was closer to the expected dose (mean = -1.2, range = -3.9-2.6,  < .0001).

Conclusions: Order configuration processes are cumbersome and time-consuming, but can be streamlined to enhance a medication's usage in the healthcare system. A better understanding of institution-specific ordering patterns may facilitate more efficient and effective order configuration and optimize drug use.
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http://dx.doi.org/10.1002/prp2.508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6715593PMC
October 2019

Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems.

JAMA Pediatr 2019 Aug 26. Epub 2019 Aug 26.

Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Importance: Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants.

Objectives: To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors).

Design, Setting, And Participants: A retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission. Data were collected from 4 NICUs at New York-Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included.

Main Outcomes And Measures: Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes.

Results: A total of 10 819 infants were included: 85.5% were singleton-birth infants and 14.5% were multiple-birth infants (male, 55.8%; female, 44.2%). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100 000 orders, respectively; adjusted odds ratio, 1.75; 95% CI, 1.39-2.20; P < .001). The rate of extrafamilial RAR events among multiple-birth infants (36.1 per 100 000 orders) was similar to that of singleton-birth infants (41.7 per 100 000 orders). The excess risk among multiple-birth infants (29.9 per 100 000 orders) appears to be owing to intrafamilial RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births.

Conclusions And Relevance: This study suggests that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. This excess risk appears to be owing to misidentification between siblings. These results suggest that a distinct naming convention as required by The Joint Commission may provide insufficient protection against identification errors among multiple-birth infants. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families.
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http://dx.doi.org/10.1001/jamapediatrics.2019.2733DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714004PMC
August 2019

Challenges with quality of race and ethnicity data in observational databases.

J Am Med Inform Assoc 2019 08;26(8-9):730-736

Value Institute, NewYork-Presbyterian Hospital, New York, New York, USA.

Objective: We sought to assess the quality of race and ethnicity information in observational health databases, including electronic health records (EHRs), and to propose patient self-recording as an improvement strategy.

Materials And Methods: We assessed completeness of race and ethnicity information in large observational health databases in the United States (Healthcare Cost and Utilization Project and Optum Labs), and at a single healthcare system in New York City serving a racially and ethnically diverse population. We compared race and ethnicity data collected via administrative processes with data recorded directly by respondents via paper surveys (National Health and Nutrition Examination Survey and Hospital Consumer Assessment of Healthcare Providers and Systems). Respondent-recorded data were considered the gold standard for the collection of race and ethnicity information.

Results: Among the 160 million patients from the Healthcare Cost and Utilization Project and Optum Labs datasets, race or ethnicity was unknown for 25%. Among the 2.4 million patients in the single New York City healthcare system's EHR, race or ethnicity was unknown for 57%. However, when patients directly recorded their race and ethnicity, 86% provided clinically meaningful information, and 66% of patients reported information that was discrepant with the EHR.

Discussion: Race and ethnicity data are critical to support precision medicine initiatives and to determine healthcare disparities; however, the quality of this information in observational databases is concerning. Patient self-recording through the use of patient-facing tools can substantially increase the quality of the information while engaging patients in their health.

Conclusions: Patient self-recording may improve the completeness of race and ethnicity information.
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http://dx.doi.org/10.1093/jamia/ocz113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6696496PMC
August 2019

An electronic notification system for improving patient flow in the emergency department.

AMIA Jt Summits Transl Sci Proc 2019 6;2019:242-247. Epub 2019 May 6.

Brigham and Women's Hospital and Harvard Medical School, Boston, MA.

Healthcare providers make time-sensitive care decisions based on EHR data. As systems of record, the EHR is often not configured to optimally surface timely information. For patients awaiting admission, infection control concerns that potentially require private rooms can prolong stays in the Emergency Department. We aim to determine if an event-based notification platform connected with a commercial EHR can help prioritize timely information and improve patient flow in the emergency department. We undertook a pre-post analysis for patients being admitted from the emergency room who were tested for influenza. We used a primary outcome of mean time from negative test result to inpatient transfer. The median time decreased by 27%, from 4.1 hours to 3.0 hours. The distribution of transfer times pre and post-intervention were significantly different with a p-value of <0.001. Our findings support the use of event-based notification systems to improve patient flow in the emergency department.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6568086PMC
May 2019

An Internet of Things Buttons to Measure and Respond to Restroom Cleanliness in a Hospital Setting: Descriptive Study.

J Med Internet Res 2019 06 19;21(6):e13588. Epub 2019 Jun 19.

Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States.

Background: Restroom cleanliness is an important factor in hospital quality. Due to its dynamic process, it can be difficult to detect the presence of dirty restrooms that need to be cleaned. Using an Internet of Things (IoT) button can permit users to designate restrooms that need cleaning and in turn, allow prompt response from housekeeping to maintain real-time restroom cleanliness.

Objective: This study aimed to describe the deployment of an IoT button-based notification system to measure hospital restroom cleanliness reporting system usage and qualitative feedback from housekeeping staff on IoT button use.

Methods: We deployed IoT buttons in 16 hospital restrooms. Over an 8-month period, housekeeping staff received real-time notifications and responded to button presses for restroom cleaning. All button presses were recorded. We reported average button usage by hospital area, time of day, and day of week. We also conducted interviews with housekeeping supervisors and staff to understand their acceptance of and experience with the system.

Results: Over 8 months, 1920 requests to clean restrooms in the main hospital lobby and satellite buildings were received. The hospital lobby IoT buttons received over half (N=1055, 55%) of requests for cleaning. Most requests occurred in afternoon hours from 3 PM to midnight. Requests for cleaning remained stable throughout the work week with fewer requests occurring over weekends. IoT button use was sustained throughout the study period. Interviews with housekeeping supervisors and staff demonstrated acceptance of the IoT buttons; actual use was centered around asynchronous communication between supervisors and staff in response to requests to clean restrooms.

Conclusions: An IoT button system is a feasible method to generate on-demand request for restroom cleaning that is easy to deploy and that users will consistently engage with. Data from this system have the potential to enable responsive scheduling for restroom service and anticipate periods of high restroom utilization in a hospital.
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http://dx.doi.org/10.2196/13588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6607773PMC
June 2019

Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial.

JAMA 2019 05;321(18):1780-1787

Division of Hospital Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York.

Importance: Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation.

Objective: To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently.

Design, Setting, And Participants: This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings.

Interventions: Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687).

Main Outcomes And Measures: The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient).

Results: Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings (P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions.

Conclusions And Relevance: A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors.

Trial Registration: clinicaltrials.gov Identifier: NCT02876588.
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http://dx.doi.org/10.1001/jama.2019.3698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6518341PMC
May 2019

Identifying the risk factors for catheter-associated urinary tract infections: a large cross-sectional study of six hospitals.

BMJ Open 2019 02 21;9(2):e022137. Epub 2019 Feb 21.

Value Institute, NewYork-Presbyterian Hospital, New York, USA.

Motivation: Catheter-associated urinary tract infections (CAUTI) are a common and serious healthcare-associated infection. Despite many efforts to reduce the occurrence of CAUTI, there remains a gap in the literature about CAUTI risk factors, especially pertaining to the effect of catheter dwell-time on CAUTI development and patient comorbidities.

Objective: To examine how the risk for CAUTI changes over time. Additionally, to assess whether time from catheter insertion to CAUTI event varied according to risk factors such as age, sex, patient type (surgical vs medical) and comorbidities.

Design: Retrospective cohort study of all patients who were catheterised from 2012 to 2016, including those who did and did not develop CAUTIs. Both paediatric and adult patients were included. Indwelling urinary catheterisation is the exposure variable. The variable is interval, as all participants were exposed but for different lengths of time.

Setting: Urban academic health system of over 2500 beds. The system encompasses two large academic medical centres, two community hospitals and a paediatric hospital.

Results: The study population was 47 926 patients who had 61 047 catheterisations, of which 861 (1.41%) resulted in a CAUTI. CAUTI rates were found to increase non-linearly for each additional day of catheterisation; CAUTI-free survival was 97.3% (CI: 97.1 to 97.6) at 10 days, 88.2% (CI: 86.9 to 89.5) at 30 days and 71.8% (CI: 66.3 to 77.8) at 60 days. This translated to an instantaneous HR of. 49%-1.65% in the 10-60 day time range. Paraplegia, cerebrovascular disease and female sex were found to statistically increase the chances of a CAUTI.

Conclusions: Using a very large data set, we demonstrated the incremental risk of CAUTI associated with each additional day of catheterisation, as well as the risk factors that increase the hazard for CAUTI. Special attention should be given to patients carrying these risk factors, for example, females or those with mobility issues.
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http://dx.doi.org/10.1136/bmjopen-2018-022137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398917PMC
February 2019

Reducing indwelling urinary catheter use through staged introduction of electronic clinical decision support in a multicenter hospital system.

Infect Control Hosp Epidemiol 2018 08 13;39(8):902-908. Epub 2018 Jun 13.

6The Value Institute,New York-Presbyterian Hospital,New York,New York.

Objective: To integrate electronic clinical decision support tools into clinical practice and to evaluate the impact on indwelling urinary catheter (IUC) use and catheter-associated urinary tract infections (CAUTIs).Design, Setting, and ParticipantsThis 4-phase observational study included all inpatients at a multicampus, academic medical center between 2011 and 2015.InterventionsPhase 1 comprised best practices training and standardization of electronic documentation. Phase 2 comprised real-time electronic tracking of IUC duration. In phase 3, a triggered alert reminded clinicians of IUC duration. In phase 4, a new IUC order (1) introduced automated order expiration and (2) required consideration of alternatives and selection of an appropriate indication.

Results: Overall, 2,121 CAUTIs, 179,070 new catheters, 643,055 catheter days, and 2,186 reinsertions occurred in 3·85 million hospitalized patient days during the study period. The CAUTI rate per 10,000 patient days decreased incrementally in each phase from 9·06 in phase 1 to 1·65 in phase 4 (relative risk [RR], 0·182; 95% confidence interval [CI], 0·153-0·216; P<·001). New catheters per 1,000 patient days declined from 53·4 in phase 1 to 39·5 in phase 4 (RR, 0·740; 95% CI, 0·730; P<·001), and catheter days per 1,000 patient days decreased from 194·5 in phase 1 to 140·7 in phase 4 (RR, 0·723; 95% CI, 0·719-0·728; P<·001). The reinsertion rate declined from 3·66% in phase 1 to 3·25% in phase 4 (RR, 0·894; 95% CI, 0·834-0·959; P=·0017).

Conclusions: The phased introduction of decision support tools was associated with progressive declines in new catheters, total catheter days, and CAUTIs. Clinical decision support tools offer a viable and scalable intervention to target hospital-wide IUC use and hold promise for other quality improvement initiatives.
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http://dx.doi.org/10.1017/ice.2018.114DOI Listing
August 2018

Challenges with Collecting Smoking Status in Electronic Health Records.

AMIA Annu Symp Proc 2017 16;2017:1392-1400. Epub 2018 Apr 16.

NewYork-Presbyterian Hospital, New York, NY.

Smoking is the leading cause of preventable death in the United States. Obtaining patients' smoking status is the first step in delivering smoking cessation counseling. In this study, we assessed the quality of smoking status captured in an electronic health record from a large academic medical center. We analyzed data from structured notes, finding that smoking status was documented in 98% of 64,451 hospital encounters in 2016. 32% hospital encounters had discrepant documentation, and 54.5% of patients had implausible changes (e.g., changes from "current smoker" to "never smoker"). Overall, only 2.9% of patients were documented as active smokers, but 36.4% were documented as "unknown" or had discrepancies in their smoking status. These results suggest that patients that smoke are not appropriately identified. Centralized documentation with clinically actionable smoking status categories and implementation of patient-facing tools that allow patients to directly record their information could improve data quality of smoking status.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977725PMC
April 2019

Disease Heritability Inferred from Familial Relationships Reported in Medical Records.

Cell 2018 06 17;173(7):1692-1704.e11. Epub 2018 May 17.

Department of Biomedical Informatics, Columbia University, New York, NY, USA; Institute for Genomic Medicine, Columbia University, New York, NY, USA; Observational Health Data Sciences and Informatics (OHDSI), New York, NY, USA; Department of Medicine, Columbia University, New York, NY, USA; Department of Systems Biology, Columbia University, New York, NY, USA; Data Science Institute, Columbia University, New York, NY, USA. Electronic address:

Heritability is essential for understanding the biological causes of disease but requires laborious patient recruitment and phenotype ascertainment. Electronic health records (EHRs) passively capture a wide range of clinically relevant data and provide a resource for studying the heritability of traits that are not typically accessible. EHRs contain next-of-kin information collected via patient emergency contact forms, but until now, these data have gone unused in research. We mined emergency contact data at three academic medical centers and identified 7.4 million familial relationships while maintaining patient privacy. Identified relationships were consistent with genetically derived relatedness. We used EHR data to compute heritability estimates for 500 disease phenotypes. Overall, estimates were consistent with the literature and between sites. Inconsistencies were indicative of limitations and opportunities unique to EHR research. These analyses provide a validation of the use of EHRs for genetics and disease research.
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http://dx.doi.org/10.1016/j.cell.2018.04.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6015747PMC
June 2018

Surgical Antibiotic Prophylaxis and Risk for Postoperative Antibiotic-Resistant Infections.

J Am Coll Surg 2017 Nov 10;225(5):631-638.e3. Epub 2017 Oct 10.

Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY. Electronic address:

Background: Antibiotic-resistant infections have high rates of morbidity and mortality, and exposure to antibiotics is the crucial risk factor for development of antibiotic resistance. If surgical antibiotic prophylaxis (SAP) increases risk for antibiotic-resistant infections, prophylaxis may cause net harm, even if it decreases overall infection rates.

Study Design: This retrospective cohort study included adults who underwent elective surgical procedures and developed infections within 30 postoperative days. Procedures from multiple disciplines were included if SAP was considered discretionary by current guidelines. Postoperative antibiotic-resistant infections were defined as positive culture results from any site within 30 postoperative days, showing intermediate or nonsusceptibility across 1 or more antibiotic classes. Surgical antibiotic prophylaxis included use of antibiotics within any class and at any dose from 1 hour before first incision until the end of the operation.

Results: Among 689 adults with postoperative infections, 338 (49%) had postoperative resistant infections. Use of SAP was not associated with postoperative antibiotic-resistant infections (odds ratio [OR] 0.99; 95% CI 0.67 to 1.46). This result remained robust when the SAP definition was extended to antibiotics given within 4 hours before first incision (OR 0.94; 95% CI 0.63 to 1.40) and when the follow-up window was narrowed to 14 days (OR 0.82; 95% CI 0.50 to 1.34). Previous antibiotic-resistant infections were associated with risk for postoperative antibiotic-resistant infections (OR 1.81; 95% CI 1.16 to 2.83).

Conclusions: Use of SAP was not associated with risk for postoperative antibiotic-resistant infections in a large cohort of patients with postoperative infections. This provides important reassurance regarding use of surgical antibiotic prophylaxis.
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http://dx.doi.org/10.1016/j.jamcollsurg.2017.08.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5673556PMC
November 2017

Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.

J Am Med Inform Assoc 2018 06;25(6):739-743

Department of Medicine.

To reduce the risk of wrong-patient errors, safety experts recommend allowing only one patient chart to be open at a time. Due to the lack of empirical evidence, the number of allowable open charts is often based on anecdotal evidence or institutional preference, and hence varies across institutions. Using an interrupted time series analysis of intercepted wrong-patient medication orders in an emergency department during 2010-2016 (83.6 intercepted wrong-patient events per 100 000 orders), we found no significant decrease in the number of intercepted wrong-patient medication orders during the transition from a maximum of 4 open charts to a maximum of 2 (b = -0.19, P = .33) and no significant increase during the transition from a maximum of 2 open charts to a maximum of 4 (b = 0.08, P = .67). These results have implications regarding decisions about allowable open charts in the emergency department in relation to the impact on workflow and efficiency.
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http://dx.doi.org/10.1093/jamia/ocx099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646860PMC
June 2018

Asynchronous automated electronic laboratory result notifications: a systematic review.

J Am Med Inform Assoc 2017 Nov;24(6):1173-1183

Department of Biomedical Informatics, Columbia University, New York, NY, USA.

Objective: To systematically review the literature pertaining to asynchronous automated electronic notifications of laboratory results to clinicians.

Methods: PubMed, Web of Science, and the Cochrane Collaboration were queried for studies pertaining to automated electronic notifications of laboratory results. A title review was performed on the primary results, with a further abstract review and full review to produce the final set of included articles.

Results: The full review included 34 articles, representing 19 institutions. Of these, 19 reported implementation and design of systems, 11 reported quasi-experimental studies, 3 reported a randomized controlled trial, and 1 was a meta-analysis. Twenty-seven articles included alerts of critical results, while 5 focused on urgent notifications and 2 on elective notifications. There was considerable variability in clinical setting, system implementation, and results presented.

Conclusion: Several asynchronous automated electronic notification systems for laboratory results have been evaluated, most from >10 years ago. Further research on the effect of notifications on clinicians as well as the use of modern electronic health records and new methods of notification is warranted to determine their effects on workflow and clinical outcomes.
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http://dx.doi.org/10.1093/jamia/ocx047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787253PMC
November 2017

A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites.

J Am Med Inform Assoc 2017 Sep;24(5):992-995

Department of Medicine, Division of Hospital Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

To reduce the risk of wrong-patient errors, safety experts recommend limiting the number of patient records providers can open at once in electronic health records (EHRs). However, it is unknown whether health care organizations follow this recommendation or what rationales drive their decisions. To address this gap, we conducted an electronic survey via 2 national listservs. Among 167 inpatient and outpatient study facilities using EHR systems designed to open multiple records at once, 44.3% were configured to allow ≥3 records open at once (unrestricted), 38.3% allowed only 1 record open (restricted), and 17.4% allowed 2 records open (hedged). Decision-making centered on efforts to balance safety and efficiency, but there was disagreement among organizations about how to achieve that balance. Results demonstrate no consensus on the number of records to be allowed open at once in EHRs. Rigorous studies are needed to determine the optimal number of records that balances safety and efficiency.
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http://dx.doi.org/10.1093/jamia/ocx034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7651980PMC
September 2017

Prophylaxis for Stress Ulcers With Proton Pump Inhibitors Is Not Associated With Increased Risk of Bloodstream Infections in the Intensive Care Unit.

Clin Gastroenterol Hepatol 2017 Jul 18;15(7):1030-1036.e1. Epub 2017 Jan 18.

Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York. Electronic address:

Background & Aims: Proton pump inhibitors (PPIs) have been associated with increased risk of infection, likely because of changes in intestinal epithelial permeability and the gastrointestinal microbiome. PPIs are frequently given to patients in the intensive care unit (ICU) to prevent stress ulcers. These patients are at risk for bloodstream infections (BSIs), so we investigated the relationship between PPI use and BSIs among patients in the ICU.

Methods: We performed a retrospective cohort study of adults (≥18 years) admitted to 1 of 14 ICUs within a hospital network of 3 large hospitals from 2008 through 2014. The primary exposure was PPI use for stress ulcer prophylaxis in the ICU. The primary outcome was BSI, confirmed by culture analysis, arising 48 hours or more after admission to the ICU. Subjects were followed for 30 days after ICU admission or until death, discharge, or BSI. Multivariable Cox proportional hazards modeling was used to test the association between PPIs and BSI after controlling for patient comorbidities and other clinical factors.

Results: We analyzed data from 24,774 patients in the ICU, including 756 patients (3.1%) who developed BSIs while in the ICU. The cumulative incidence of BSI was 3.7% in patients with PPI exposure compared with 2.2% in patients without PPI exposure (log-rank test, P < .01). After adjusting for potential confounders, PPI exposure was not associated with increased risk of BSI while in the ICU (adjusted hazard ratio, 1.08; 95% confidence interval, 0.91-1.29). Comorbidities, antibiotic use, and mechanical ventilation were all independently associated with increased risk for BSIs.

Conclusions: In a retrospective study of patients in the ICU, administration of PPIs to prevent bleeding was not associated with increased risk of BSI. These findings indicate that concern for BSI should not affect decisions regarding use of PPIs in the ICU.
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http://dx.doi.org/10.1016/j.cgh.2016.12.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5474142PMC
July 2017

Proton Pump Inhibitors Do Not Increase Risk for Clostridium difficile Infection in the Intensive Care Unit.

Am J Gastroenterol 2016 11 30;111(11):1641-1648. Epub 2016 Aug 30.

Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York, USA.

Objectives: Patients in the intensive care unit (ICU) frequently receive proton pump inhibitors (PPIs) and have high rates of Clostridium difficile infection (CDI). PPIs have been associated with CDI in hospitalized patients, but ICU patients differ fundamentally from non-ICU patients and few studies have focused on PPI use exclusively in the critical care setting. We performed a retrospective cohort study to determine the associations between PPIs and health-care facility-onset CDI in the ICU.

Methods: We analyzed data from all adult ICU patients at three affiliated hospitals (14 ICUs) between 2010 and 2013. Patients were excluded if they had recent CDI or an ICU stay of <3 days. We parsed electronic medical records for ICU exposures, focusing on PPIs and other potentially modifiable exposures that occurred during ICU stays. Health-care facility-onset CDI in the ICU was defined as a newly positive PCR for the C. difficile toxin B gene from an unformed stool, with subsequent receipt of anti-CDI therapy. We analyzed PPIs and other exposures as time-varying covariates and used Cox proportional hazards models to adjust for demographics, comorbidities, and other clinical factors.

Results: Of 18,134 patients who met the criteria for inclusion, 271 (1.5%) developed health-care facility-onset CDI in the ICU. Receipt of antibiotics was the strongest risk factor for CDI (adjusted HR (aHR) 2.79; 95% confidence interval (CI), 1.50-5.19). There was no significant increase in risk for CDI associated with PPIs in those who did not receive antibiotics (aHR 1.56; 95% CI, 0.72-3.35), and PPIs were actually associated with a decreased risk for CDI in those who received antibiotics (aHR 0.64; 95% CI, 0.48-0.83). There was also no evidence of increased risk for CDI in those who received higher doses of PPIs.

Conclusions: Exposure to antibiotics was the most important risk factor for health-care facility-onset CDI in the ICU. PPIs did not increase risk for CDI in the ICU regardless of use of antibiotics.
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http://dx.doi.org/10.1038/ajg.2016.343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5096970PMC
November 2016

Receipt of Antibiotics in Hospitalized Patients and Risk for Clostridium difficile Infection in Subsequent Patients Who Occupy the Same Bed.

JAMA Intern Med 2016 Dec;176(12):1801-1808

Department of Epidemiology, Mailman School of Public Health, School of Nursing, Columbia University, New York, New York.

Objective: To assess whether receipt of antibiotics by prior hospital bed occupants is associated with increased risk for CDI in subsequent patients who occupy the same bed.

Design, Setting, And Participants: This is a retrospective cohort study of adult patients hospitalized in any 1 of 4 facilities between 2010 and 2015. Patients were excluded if they had recent CDI, developed CDI within 48 hours of admission, had inadequate follow-up time, or if their prior bed occupant was in the bed for less than 24 hours.

Main Outcomes And Measures: The primary exposure was receipt of non-CDI antibiotics by the prior bed occupant and the primary outcome was incident CDI in the subsequent patient to occupy the same bed. Incident CDI was defined as a positive result from a stool polymerase chain reaction for the C difficile toxin B gene followed by treatment for CDI. Demographics, comorbidities, laboratory data, and medication exposures are reported.

Results: Among 100 615 pairs of patients who sequentially occupied a given hospital bed, there were 576 pairs (0.57%) in which subsequent patients developed CDI. Receipt of antibiotics in prior patients was significantly associated with incident CDI in subsequent patients (log-rank P < .01). This relationship remained unchanged after adjusting for factors known to influence risk for CDI including receipt of antibiotics by the subsequent patient (adjusted hazard ratio [aHR], 1.22; 95% CI, 1.02-1.45) and also after excluding 1497 patient pairs among whom the prior patients developed CDI (aHR, 1.20; 95% CI, 1.01-1.43). Aside from antibiotics, no other factors related to the prior bed occupants were associated with increased risk for CDI in subsequent patients.

Conclusions And Relevance: Receipt of antibiotics by prior bed occupants was associated with increased risk for CDI in subsequent patients. Antibiotics can directly affect risk for CDI in patients who do not themselves receive antibiotics.
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http://dx.doi.org/10.1001/jamainternmed.2016.6193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5138095PMC
December 2016

Medication-indication knowledge bases: a systematic review and critical appraisal.

J Am Med Inform Assoc 2015 Nov 2;22(6):1261-70. Epub 2015 Sep 2.

Department of Biomedical Informatics, Columbia University, New York, New York, USA.

Objective: Medication-indication information is a key part of the information needed for providing decision support for and promoting appropriate use of medications. However, this information is not readily available to end users, and a lot of the resources only contain this information in unstructured form (free text). A number of public knowledge bases (KBs) containing structured medication-indication information have been developed over the years, but a direct comparison of these resources has not yet been conducted.

Material And Methods: We conducted a systematic review of the literature to identify all medication-indication KBs and critically appraised these resources in terms of their scope as well as their support for complex indication information.

Results: We identified 7 KBs containing medication-indication data. They notably differed from each other in terms of their scope, coverage for on- or off-label indications, source of information, and choice of terminologies for representing the knowledge. The majority of KBs had issues with granularity of the indications as well as with representing duration of therapy, primary choice of treatment, and comedications or comorbidities.

Discussion And Conclusion: This is the first study directly comparing public KBs of medication indications. We identified several gaps in the existing resources, which can motivate future research.
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http://dx.doi.org/10.1093/jamia/ocv129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5009909PMC
November 2015

Orders for intravenous proton pump inhibitors after implementation of an electronic alert.

JAMA Intern Med 2015 Mar;175(3):452-4

Department of Emergency Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York.

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http://dx.doi.org/10.1001/jamainternmed.2014.6680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5022559PMC
March 2015

Intercepting wrong-patient orders in a computerized provider order entry system.

Ann Emerg Med 2015 Jun 18;65(6):679-686.e1. Epub 2014 Dec 18.

Department of Biomedical Informatics, Columbia University, New York, NY; Medical Informatics Services, NewYork-Presbyterian Hospital, New York, NY.

Study Objective: We evaluate the short- and long-term effect of a computerized provider order entry-based patient verification intervention to reduce wrong-patient orders in 5 emergency departments.

Methods: A patient verification dialog appeared at the beginning of each ordering session, requiring providers to confirm the patient's identity after a mandatory 2.5-second delay. Using the retract-and-reorder technique, we estimated the rate of wrong-patient orders before and after the implementation of the intervention to intercept these errors. We conducted a short- and long-term quasi-experimental study with both historical and parallel controls. We also measured the amount of time providers spent addressing the verification system, and reasons for discontinuing ordering sessions as a result of the intervention.

Results: Wrong-patient orders were reduced by 30% immediately after implementation of the intervention. This reduction persisted when inpatients were used as a parallel control. After 2 years, the rate of wrong-patient orders remained 24.8% less than before intervention. The mean viewing time of the patient verification dialog was 4.2 seconds (SD=4.0 seconds) and was longer when providers indicated they placed the order for the wrong patient (4.9 versus 4.1 seconds). Although the display of each dialog took only seconds, the large number of display episodes triggered meant that the physician time to prevent each retract-and-reorder event was 1.5 hours.

Conclusion: A computerized provider order entry-based patient verification system led to a moderate reduction in wrong-patient orders that was sustained over time. Interception of wrong-patient orders at data entry is an important step in reducing these errors.
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http://dx.doi.org/10.1016/j.annemergmed.2014.11.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4447590PMC
June 2015

Response to Daniell.

Am J Gastroenterol 2014 Jun;109(6):922-3

Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York, USA.

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http://dx.doi.org/10.1038/ajg.2014.91DOI Listing
June 2014