Tag Archives: Healthcare

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Dialysis, kidney transplant recipients at higher risk for cancer death

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Dialysis and transplant patients face nearly three times the risk of dying from cancer as compared with the general population, according to new research.

Previous research has shown that patients on dialysis or have received a kidney transplant are at higher risk of developing cancer, but there have been few studies to assess cancer mortality rates among these patients.

To investigate, Eric H. Au, M.B.B.S., of the University of Sydney and colleagues compared the cancer-related mortality rates in kidney transplant recipients and dialysis patients with those of the general population. They published their results online in American Society of Nephrology on Feb. 14.

The researchers compared cancer mortality rates among transplant and dialysis patients using data collected from the Australia and New Zealand Dialysis and Transplant Registry from 1980 through 2014. They followed 52,936 dialysis patients for 170,055 patient-years, and tracked 16,820 transplant patients for 128,352 patient-years. The research team identified 2,739 cancer-related deaths among dialysis patients and 923 cancer deaths among transplant patients.

The Findings: Cancer Mortality Rates Higher in Dialysis and Transplant Patients

Over the span of 10 years, mortality rates were 6.1 percent in dialysis patients and 4.5 percent in transplant patients. Both dialysis and transplant recipients experienced over 2.5 times higher risks of cancer deaths than do individuals of the same age and gender in the general population, with the overall cancer standardized mortality ratios (SMRs) showing a 2.6 times higher risk for those on dialysis and 2.7 times higher risk for recipients of kidney transplants.

Multiple myeloma scored the highest SMR at 30.7 for dialysis patients, followed by testicular cancer at 17.0 and kidney cancer at 12.5. The highest SMRs for transplant recipients were non-Hodgkin lymphoma at 10.7, followed by kidney cancers at 7.8, and melanoma at 5.8.

Compared with the general population, women and younger patients experienced particularly high risks. Transplant and dialysis patients aged 20 to 34 had a tenfold higher risk of cancer-related death as compared with the general public.

The main driver for cancer deaths differed between the dialysis and transplant patients: the main driver for cancer deaths in dialysis patients was from cancers present before the start of dialysis, whereas the main driver for cancer mortality among transplant patients were cancers that developed after transplantation.

Of those who died from cancer-related causes, 9.6 percent of transplant recipients and 61.0 percent of dialysis patients had pre-existing cancer. SMR was 1.2 and 2.6 for dialysis and transplant patients, respectively, for de novo cancer. The increase in cancer-related deaths among kidney transplant recipients may be associated with the long-term immunosuppressive drugs patients must take after receiving an organ transplant.

Transplant patients died within a median of 8.6 years, while dialysis patients died within a median of two years. The research group observed that the higher cancer mortality rate in dialysis patients with pre-existing cancer that can lead to the development of end-stage renal disease (ESRD) and the relatively short time to cancer death would “suggest that despite commencement of dialysis, these patients’ overall prognosis may still be predominantly affected by their underlying malignancy.”

“Results from this study will assist clinicians and researchers in understanding the patterns of cancer-related mortality in dialysis and transplant patients,” said Dr. Au in a press release. “Further research may help us understand which patients are particularly at risk of cancer and the reasons why they have higher chances of dying from cancer.”

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Healthcare groups: Payers are lagging with prior authorization reform

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Prior authorization requirements over the past half-decade have increased and an overwhelming number of physicians say that the practice of seeking them interferes with continuity of care. In fact, more than 85 percent of the physicians asked said the practice impacts them, according to a new survey from the American Medical Association.

The survey connected with 1,000 physicians, which found that more than “two-thirds said it’s difficult for them to determine whether a prescription or service needs prior authorization.” Contrarily, fewer than 10 percent of the physicians interviewed said they contract with a health plan that allows programs that can exempt providers from the requirement.

Separately, a 2017 MGMA survey showed similar results, with 86 percent of providers reporting an increase in prior authorization requirements that year, and a separate survey from the AMA found 90 percent of providers agreed that prior authorizations delay care.

However, despite these figures and the growing concern by physicians, payers have yet to widely implement reforms. The survey found that the majority of physicians in the survey (88 and 86 percent, respectively) report that the number of prior authorizations required for prescription drugs and medical services increased over the last five years.

This second survey found health payers have stalled their progress with implementing the other prior authorization reforms, too. Additionally, 8 percent of physicians reported contracting with health plans that offer selective application of prior authorization requirements or prior authorization requirement exemptions based on the provider’s performance and adherence to evidence-based medicine.

Sixty-nine percent of physicians still find it difficult to determine whether a prescription or service requires prior authorization; 85 percent of physicians say prior authorizations still interfere with continuity of care; the majority of physicians agree phone and fax are still the primary method for completing prior authorizations. Only 21 percent report their EHR systems offer electronic prior authorizations for prescription drugs.

Based on this feedback, prior authorizations are a stumbling block at the point of care, physicians say.

Per the AMA report mentioned at the top, most prior authorizations are obtained by phone or fax. Only about 20 percent of physicians said their EHRs allowed for electronic approvals, which can be more efficient.

AMA and groups like the American Academy of Family Physicians continue to argue that payers need to improve the prior authorization process. In a statement released with the survey findings, AMA said insurance companies have a “year of foot-dragging and opposition” to prior authorization reforms.

However, payers view prior authorizations as a vital cost control that limits unnecessary care. Prior authorizations also have their supporters in Washington. A Government Accountability Office report released in 2017 found that prior authorization in Medicare saved as much as $1.9 billion through March 2017. The Trump administration’s proposed budget also includes expanded prior authorization measures for Medicare.

America’s Health Insurance Plans and the Blue Cross Blue Shield Association joined the AMA, American Hospital Association, American Pharmacists Association and Medical Group Management Association, releasing a “Consensus Statement on Improving the Prior Authorization Process” last year.

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New study: Effective change depends on 4 key attributes of nurse managers

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Anyone who’s ever worked in healthcare knows there’s a seemingly endless battle between administration and staff. Change can be extremely difficult to implement in any facility when the pressure to cut costs and improve metrics is high.

But, a new study, published in Nursing Open, offers hope. According to the study, nurse managers who exhibit four key attributes have an easier time implementing changes in their wards.

The four attributes are empathy; proactivity; respect for personal beliefs as well as external standards; and “having both micro and macro perspectives.”

Four Key Attributes of Nurse Managers Who Can Produce Change

1. Empathy

Nurse managers that successfully implemented changes recognized staff nurses’ feelings, experiences, and pride. They understood that empathy for their staff was essential to the change process.

2. Proactivity

It was essential for nurse managers to have long-term visions for their wards. Those who could separate current problems from future problems, predict future difficulties, and determine which situations would deteriorate without intervention were better at making changes. Their desire to prevent issues from worsening supported their motivation to prioritize long-term transformation.

3. Respect for personal beliefs and external standards

Better results were achieved when nurse managers’ personal beliefs about leadership, change, and nursing aligned with their facilities’.

4. Micro and macro perspectives

Successful nurse managers assessed their wards using micro and macro perspectives. They collected information about turnover rates, staff characteristics, number of incidents, and relationships between staff members.

However, they also interpreted their findings within the context of what was happening in their wards. They weren’t afraid to interview staff and were capable of accurately “reading between the lines.”

Study Demographics

The findings of this study are the result of interviews with 23 nurse managers and 17 nurses. Most were in their 40s, though a few were in their 30s, 50s, and 60s. Participants were predominately female.

Some had less than a year of management experience while others had decades of managerial experience under the belts. Most employers offered training for certified nurse managers.

The nurse managers interviewed worked in medical/surgical, long-term care/rehabilitation, ICU, or palliative care at a university hospital, sub-acute rehabilitation center, or an acute care facility. Facilities ranged in size from 100 to 800 beds.

Key Takeaways for Healthcare Administrators

If change is a sore spot for your organization, you may want to consider cultivating the four attributes identified in this study.

Management training, nurse manager mentorship programs, and robust orientations are excellent ways to support nurse administrators. However, because some attributes may be difficult to teach, it’s prudent to assess whether prospective candidates exhibit the characteristics of successful nurse managers.

Interview Questions to Assess Nurse Manager Attributes

To determine whether a candidate has the traits highlighted in this study, consider asking the following questions during an interview:



“What disagreements have you had with staff when you’ve had to make changes? How did you handle the situation? What was the result?”

Desirable Answers:

Look for candidates that demonstrate social awareness. You want to know that the candidate will try to understand their staffs’ feelings, experiences, and pride. Nurse managers that understand the differences between the role of nurse and nurse manager may be better equipped to institute change.



“What did you do in the past when you recognized a problem? What was the result?”

Desirable Answers:

Candidates should be able to detect problems and forecast potential results. They should also value long-term change and demonstrate a sense of urgency or a preference for being proactive.



“After collecting data on key metrics in your ward, how would you approach addressing weak areas?”

Desirable Answers:

Successful nurse managers will often seek to investigate their findings thoroughly and in the context of what’s happening in their wards. They’ll also conduct informational interviews with staff and thoroughly investigate underlying causes before making any changes.

Belief Alignment


“What are some of your beliefs about nursing and leadership?”

“What do you know about our mission?”

Desirable Answers:

Answers should demonstrate that the candidate is self-aware. Interviewees should have a firm set of personal beliefs regarding nursing and leadership. Their personal beliefs should align with your mission. Misalignments will quickly lead to problems when implementing change.


Healthcare organizations face tremendous pressure to meet high standards while staying on budget. A nurse manager who can get the buy-in of his or her staff and improve their ward is invaluable. Now, administrators and human resource professionals know what attributes to look for and cultivate.

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Baby boomers are changing the senior living paradigm

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Having spent a lifetime demanding and indulging their independence, members of the baby boom generation are showing no signs of letting up as they prepare for their next life-stage. Now in their early 70s, leading-edge boomers are looking ahead to how they want to spend their later years.

One thing most of them don’t want is to wind up like their parents or grandparents in an isolated senior care facility. They are pressing builders and developers to give them more options to remain connected to their communities.

In the latest edition of its biennial white paper on the state of senior living, Perkins Eastman finds that of the many factors affecting senior living now and for the near future, boomers’ desire for more autonomy and self-control will have the greatest impact. It is already prompting the industry, says the report, to broaden the number of options to meet the needs of a greater variety of individuals.

Although it takes different forms and has evolved over the years, the predominant paradigm for senior living for decades has been the stand-alone, age-restricted, one-stop-shop senior living community. It is a model focused on care, congregation and convenience, but tilted more toward the needs of those who are more infirm or dependent.

Today’s healthier and more affluent boomers are looking for living arrangements that will allow them to maintain the autonomous lifestyle to which they are accustomed. They want to be close to and stay in contact with the larger community, and to live on their own.

For many, that means doing whatever is necessary to stay in their current home for as long as they can. For others, it may involve downsizing and moving to a location where they can more easily access activities and services on foot or by public transportation.

According to industry leaders on Senior Housing News’ Architecture and Design Trends for 2019 panel, development trends such as intergenerational living, senior housing as a mixed-use component, and the demand for senior housing in dense urban cores are gaining in popularity.

Instead of creating separate senior villages, the new paradigm is to weave senior living into existing communities. This places seniors in closer proximity to places of interest, such as theaters, museums and other cultural events, as well as to more varied retail options. It also encourages them to engage in more socialization and physical activity.

Anticipating that aging boomers will need more assistance in the future, some developments under construction are combing independent living residences with some assisted living and memory care facilities so that residents can age-in-place in the same community. This helps to alleviate the worry of what will happen if at some point residents find they can no longer function on their own.

In recent years, as the client for senior communities has become younger and healthier, the design trend in senior living has been to move away from a healthcare emphasis to more of a hospitality, resort-like ambience. With the trend toward more independent living, observed one of the Senior Housing News panelists, the aesthetic in the future likely will shift again, toward a more residential model. Independent baby boomers will want to feel that they are living in their own home, whatever form that takes.

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Study on marijuana, male reproductive health spawns misleading conclusion

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Ever hopeful to report positive aspects related to marijuana use, writers often leave out key points. As an example, a report from a Boston-based publication had the following headline, “Harvard researchers link smoking marijuana with higher sperm concentration.” It further concluded, “Experts say men who smoked marijuana have significantly higher concentrations of sperm than those who have never lit up.”

The report describes the work with research participants, “…scientists collected 1,143 semen samples from 662 mostly college educated white men.” What the media report left out was the description that appeared in the published research, “…This longitudinal study included 662 subfertile men.”

The men observed in this study were already suffering from reproductive problems related to the men’s reduced chance of conceiving.

The definition of subfertile is as follows: “Infertility is defined as the failure to conceive after regular unprotected intercourse for two years in the absence of known reproductive pathology … Causes include impaired semen quality, azoospermia, or inadequate coitus. Couples where the man is subfertile have a reduced chance of conceiving.”

The researchers involved in this study do recommend further study on the topic. “These unexpected findings highlight how little we know about the reproductive health effects of marijuana, and in fact of the health effects of marijuana in general,” said Jorge Chavarro, associate professor of nutrition and epidemiology at the Harvard T.H. Chan School of Public Health. “Our results need to be interpreted with caution and they highlight the need to further study the health effects of marijuana use.”

The study found that over one-half of the group stated having used two joints at some point in their lives and only 11 percent defined themselves as current users of marijuana. It would not be appropriate to conclude that marijuana use is in anyway responsible for levels of testosterone, high or low, based on the information obtained.

This may be a disappointment to those who are searching for a positive impact of marijuana on male testosterone and reproductive potential. Other research has found negative consequences of marijuana use in this regard.

One study was very small with only 24 participants but found that cannabis use was associated with significantly lower sperm concentration. These findings can result in pre-conception paternal reproductive problems. Ironically, reproductive problems were main reasons for why the men were being seen in the other study, which found an increased level of sperm in men reporting to have used marijuana at some point.

And it is not just male use of marijuana that is influencing hormones and reproduction. The male’s maternal use of marijuana has been shown to have long-lasting consequences in animal models. While there do seem to be conflicting reports related to male reproduction and sperm count with marijuana use, the research seems to be stronger in identifying negative consequences.

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How to protect yourself from blood clots during business travel

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How much do you know about deep vein thrombosis (DVT) and pulmonary embolism (PE)? Both of these conditions can result if you develop a blood clot — a risk for business travelers who sit for long periods on a plane, train, or in a car.

The CDC reports that as many as 900,000 Americans will suffer a blood clot this year. Also according to the CDC, DVT can form in your legs during travel because you are sitting still in a confined space for long periods of time — specifically, four hours or more.

Life-threatening problems can occur when a part of the blood clot breaks off and travels to the lungs, becoming a PE, which can cause a fatal blockage.

What other essential information do you need to know about protecting yourself from clots while you travel?

Wear compression stockings.

You probably already know that both DVTs and PEs can be caused by immobility of your legs, pregnancy, or cancer. But did you know that your height can also figure in to your risk for clots?

The American Heart Association says that those around 6 feet are at the highest risk, while those under 5-foot-1 have a lower DVT/PE predisposition. This is probably because taller people have longer leg veins and therefore more surface space where clots can form. Additionally, the gravitational pressure of a longer leg is more likely to slow or stop blood flow there.

Ask your doctor if wearing compression stockings when you fly — available at medical supply stores and drug stores — is a good preventative option for you.

Be smart about medication.

Recent research found that common anti-allergy drugs (like hay fever meds) might be able to boost the cells in your body that protect you from a DVT in your leg. Although more research needs to be done before doctors will prescribe these meds as a travel precaution, you should always ask your doctor if any medication you’re on increases your chance of blood clots during travel. Also, make sure you take any blood thinners you have been prescribed prior to boarding for your journey.

Get up and walk around frequently.

Do this at least every 2-3 hours if you’re on a plane, train or bus, and stop to walk around if traveling by car. Make a habit of getting up from your chair at work during the day, too.

Try this exercise recommended by the CDC while sitting:

  • Raise and lower your heels while keeping your toes on the floor.
  • Raise and lower your toes while keeping your heels on the floor.
  • Tighten and release your leg muscles.

Drink plenty of water.

Dehydration can contribute to the formation of clots, according to the Mayo Clinic.

Watch for these symptoms, the Mayo Clinic also advises:

  • Coughing up blood
  • A fast heartbeat
  • Lightheadedness
  • Difficult or painful breathing
  • Chest pain or tightness
  • Pain extending to your shoulder, arm, back or jaw
  • Sudden weakness or numbness of your face, arm or leg
  • Sudden difficulty speaking or understanding speech (aphasia)
  • Sudden changes in your vision

Get immediate medical attention if these symptoms occur. Call your doctor right away if you develop these signs or symptoms in an area on an arm or leg:

  • Swelling
  • Redness
  • Pain

Play it safe — if something doesn’t feel right, get it checked out, even if you’re on the road. A little common sense and proactive behavior can save your life.

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Study: Clinicians using workarounds when operating EHRs

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The majority of U.S. hospitals have implemented electronic health records (EHRs). While the benefits of EHRs have been widely touted, little is known about their effects on inpatient care, including how well they meet workflow needs and support care.

Despite the proliferation of the technology, there appears to be a high degree of variance in the ways care teams use EHRs during morning rounds. There are a high number of workarounds clinicians employ at critical points of care. Additionally, the EHRs are not used for information sharing and frequently impede intra-care team communication.

These points are the results from a new study, “Assessing EHR use during hospital morning rounds: A multi-faceted study,” published by PLOS.org. Ultimately, the research shows that electronic health record system design and hospital room settings “do not adequately support care team workflow.”

“Gaps between EHR design and the functionality needed in the complex inpatient environment result in lack of standardized workflows, extensive use of workarounds and team communication issues,” researchers said. “These issues pose a threat to patient safety and quality of care. Possible solutions need to include improvements in EHR design, care team training and changes to the hospital room setting.”

Originally, EHRs were intended to improve some aspects of care, including patient safety, clinical decision-making and information exchange; and were supposed to be a cost-effective tool for improving quality of care. For many organizations, challenges remain, including prolonged documentation time, interference with communication, usability difficulties, lack of cognitive support, failure to support the clinical workflow and low user satisfaction.

“There is little evidence that EHRs are improving the quality of inpatient care,” researchers said. “Even though efficiency seems to have improved, usability appears to be mixed at best and EHRs’ ability to provide proper support for care team workflow has not yet been established. Anecdotal reports suggest that EHRs may be contributing to clinician burnout.”

The study was conducted at a major teaching hospital in New England with more than 700 participants. The hospital implemented Epic’s EHR across all units.

Most clinicians said they always use the EHR before entering the patient’s room, but only sometimes in the room. Before rounds, most clinicians said they always use the EHR before entering the patient’s room, but only sometimes when in the patient’s room.

When asked about EHR use after leaving the patient’s room, clinician types varied in their responses. More than 40 percent of the attending clinicians and 50 percent of the residents reported using the EHR after leaving the patient’s room sometimes, whereas 50 percent of the interns and nearly 54 percent of the PAs reported always using the EHR after leaving the room, researchers found.

Workarounds are nonstandard procedures typically used because of deficiencies in system or workflow design. Workarounds that were documented during observations and interviews included extended use of handwriting, emails and verbal discussions. Printouts of patient summary reports were used to add information from the EHR in handwriting, such as vital signs and recent lab results.

“We also observed various workarounds during the handoff process, both before and after morning rounds. Email and verbal discussions were used to convey important information and overnight events regarding patients,” researchers said. “For example, updates on events that took place during rounds monitoring and debriefing after rounds were carried out either verbally or through email.”

Most clinicians said that they visually share EHR information sometimes, and when asked if EHR use interrupts care team communication, responses varied among clinician types. “Most attending clinicians and interns responded that EHR use never interrupts care team communication, while most residents and PAs responded that it does sometimes,” the study found.

Most clinicians also said that they find EHRs useful for synchronizing the care team regarding patients and for teaching purposes sometimes but attending clinicians’ responses on the EHR’s role in efficiency during rounds were inconsistent, with nearly half of them reporting that it is useful only sometimes, and the other half reporting that it is useful most of the time. Residents said they find the EHR useful for efficient rounding only sometimes, whereas most interns and PAs find it useful most of the time.

“Our findings indicate that the EHR is not regularly used in patients’ rooms as part of the workflow. When it is used in the room, verbal and visual sharing of EHR information among care team members are rare. Screen location, screen size and the available technology do not facilitate a shared view of the EHR. Recognizing the importance of effective communication and teamwork for delivery of high-quality and safe patient care, several medical team training programs have set out to enhance communication between team members.”

Some workarounds, such as handwritten notes, were used as a cognitive aid for clinicians. Others were used because of a lack of system support.

Studies have shown that the format and layout of paper records are critical to the clinicians’ ability to search, read and assess relevant information. The ability to markup important findings is important to the cognitive processing of clinical information and could be lost when working directly in the EHR.

Researchers suggested three solutions to the workflow issues:

1. EHR design changes and interface improvement:

It would be beneficial to consider different ways of visualizing data to prevent information overload and make the system easy to use in real time in the patient’s room.

There is need to better integrate mobile devices that are easy to carry around between different floors/units in the hospital. It is equally important to consider integrating complementary HIT tools that support clinicians’ needs and workflow, such as handwriting recognition capabilities on mobile devices.

2. Hospital room adjustments and redesign:

The current study site hospital room setting does not provide the infrastructure for sharing information between care team members or with the patient. Possible approaches include whiteboards that will allow projecting EHR data in the room, and positioning the bedside computer so that it does not require the clinician to turn her/his back toward other clinicians in the room and the patient.

3. Care team training programs that consider EHR use during rounds:

Such programs need to address how the EHR can be better integrated into the workflow in ways that do not impede team communication, especially during rounds and promote EHR use for improving communication and information sharing between care team clinicians.

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The baffling nature of auditory processing disorders

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Unlike many deficits that fall under the umbrella of audiology, auditory processing disorders are not diagnosed during infancy, toddlerhood or even the early school years.

In fact, most audiologists wait until age 7 to make a definitive diagnosis. This is due to the child’s neural pathways not being sufficiently mature to make a full evaluation prior to this age, explains Tracy Hagan Winn, audiologist at the Northwestern University Center for Audiology, Speech, Language, and Learning in Evanston, Illinois.

Conducting evaluations for central auditory processing disorders, which can only be diagnosed by an audiologist, is one of Winn’s areas of expertise.

The children she tests are usually between 7 and 18 years of age. Most are referred for a full evaluation through the school system — often after a school speech pathologist or psychologist sees signs of an auditory processing disorder on a child’s screening.

While most children with hearing loss will be identified through a universal hearing screening at birth or when they don’t talk around age 2, an auditory processing disorder won’t show up until much later, she explains.

Frequently the disorder doesn’t emerge or become noticed until middle school when the student’s academic workload gets more challenging. Suddenly, it becomes hard to pay attention and take notes.

“We even have kids that we think have had APD their whole lives but we don’t catch them until college. They’ve gotten by all their lives, but suddenly they’re in a lecture with 300 people and they can’t keep up,” says Winn.

What are auditory processing disorders?

Central auditory processing, per the American Speech-Language-Hearing Association (ASHA) literature, begins when the neural representation of acoustic signals are processed after they leave the cochlea and travel through the auditory nerve to the primary auditory cortices of the left and right hemispheres.

So, people with CAPD or APD generally have their hearing capabilities intact.

There are three main types of auditory processing disorders, which Winn summarizes. The first affects the ability to decode information and discriminate between words, so often information is not interpreted correctly. This can become even more difficult when there is a lot of background sound or in a noisy classroom.

The second involves extracting keywords so the meaning of a message is missed because the person is not able to pick up on the emphasis. Winn illustrates this with the example, “Look out! The window!” or “look out the window” — the same phrase with drastically different meanings based on the speaker’s emphasis.

The third central APD is an integration deficit where people have difficulty in assigning meaning because the transfer of information from right to left hemisphere doesn’t occur.

Identifying this elusive disorder

Unfortunately, there are no distinct red flags to distinguish APD because it shares common signs and symptoms with many other disorders.

“To begin with these kids appear to be hearing impaired because they’ll often have difficulty understanding what’s being said so there’s a lot of ‘what’ or ‘huh,’” says Winn. “So first and foremost hearing loss is ruled out, usually through a screening at the school.”

Along with a hearing problem, characteristics of APD, such as difficulties with writing, spelling and math, slow response in oral communication situations, or being easily distracted can also reflect a learning problem, an attention issue, or a memory issue, notes Winn.

Other behavioral characteristics of APD are listed on the ASHA site. They include difficulty understanding spoken language in competing messages, in noisy backgrounds, in reverberant environments, or when presented rapidly. Children may also find learning songs, nursery rhymes and foreign languages particularly challenging.

Misunderstanding messages or not being able to detect stress and intonation variances that aid in interpreting sarcasm or jokes may also be due to an auditory processing disorder. However, an individual with a social communication or pragmatics difficulties may also have this challenge, as discussed in a previous MultiBriefs article.

Collaborative evaluation and treatment process

Given such overlap with other deficits, detecting auditory processing disorders is a complicated process that requires an interdisciplinary approach.

“We don’t do our testing for auditory processing in isolation,” emphasizes Winn.

After normal hearing has been checked at the school, Winn requires candidates to get both speech-language and psychological evaluations. Often they have other issues with learning disabilities, such as ADHD or language processing.

“It’s a ruling out process. We just look at each component and then see how that component might influence another,” says Winn. “Many times the kids we’re seeing are also seeing a speech language pathologist, possibly an educational specialist who is working with auditory memory or working memory.”

The clinic at Northwestern is multidisciplinary, so children who’ve exhausted their options within the school system come in for a comprehensive evaluation lasting over two days, shares Winn. It includes learning, speech and language and auditory processing.

The process begins with a test to rule out any peripheral hearing loss.

“We would then look at all the components of the central auditory system so it’s between four to seven sub tests to put the full picture together. We look for very specific patterns in the test results to indicate what type of disorder, if any, they have,” explains Winn.

Once the type of auditory processing disorder present is determined, she’ll make recommendations for treatment to be carried out by a speech and language therapist — usually within the child’s school.

Treatment, which depends on the type of APD present, often includes a combination of direct skills remediation such as auditory discrimination, compensatory strategies and environmental modifications.

Examples of compensatory strategies Winn shares are keyboarding instead of writing, having a note taker, and using Cliffs Notes to support reading. Environmental modifications could include using an FM set for direct communication between teacher and student, preferential seating in the classroom, or being placed in a quiet classroom.

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Medical scribes boost productivity among ER docs

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Medical scribes can increase an ER physician’s productivity, resulting in shorter lengths of stays for patients, according to a study published in The BMJ in late January.

Conducted at hospitals in the Australian state of Victoria, the study compared ER shifts where trained scribes were utilized with those where clinicians were required to complete clinical documentation and other clerical tasks.

Scribes enter the exam room with the physician and use a computer to document consultations, schedule follow-up appointments, order diagnostic tests, complete patients’ electronic health records, request inpatient beds, print discharge paperwork and locate information for the physician. The goal is to enable physicians to spend as much time as possible managing direct patient care.

In the study, 88 emergency department physicians were randomly assigned one of 12 scribes during routine shifts. Data were collected from 589 scribed shifts, totaling 5,098 patients, and 3,296 nonscribed shifts with 23,898 patients.

Physicians who were assigned scribes were 15.9 percent more productive than those who weren’t. Specifically, these physicians saw 1.13 to 1.31 patients per hour. Physicians also completed 25.6 percent more primary consultations, from 0.83 to 1.04 patients per hour per doctor.

No changes were noted in door-to-doctor time. However, the median length of patient stay decreased by around 20 minutes.

The study found that scribes could be best utilized at triage. The smallest increases in productivity were recorded at the subacute treatment level. No harmful events were noted as a result of scribe utilization.

This isn’t the first study to note greater physician productivity resulting from the use of medical scribes. A study published last September in JAMA looked at the use of scribes in the primary care setting. That study also found a positive correlation among physician workflow and patient satisfaction.

A team from Kaiser Permanente Northern California in Oakland evaluated 18 primary care doctors’ productivity with and without scribes. The internists and family physicians were randomly assigned to work with a scribe for alternating three-month periods over the course of a year. A six-question survey was given at the end of each quarter.

Physicians said they spent less time after-hours documenting electronic health records during the periods they were assigned scribes. They also spent more time interacting with patients during scribed periods and documentation was completed quicker. Patients also reported higher levels of satisfaction. The majority reported the scribe having a positive effect on their visit with only 2.4 percent indicating a negative encounter.

“Our results support the use of medical scribes as one strategy for improving physician workflow and visit quality in primary care,” the authors write.

Indeed, unrelated research indicates that patients willingly accept the presence of scribes during emergency department encounters and less than 1 percent of patient interactions are inappropriate for scribe utilization. The majority of doctors also indicate they prefer to work with scribes, with only 15 percent indicating otherwise. The overall quality of scribes notes and documentation is consistent, sometimes exceeding that of physicians, according to a 2016 study.

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What is Safety II? New opportunities for safety leadership

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Researchers in Europe may have defined and given structure to the challenges associated with safety. Their white paper on Safety I vs. Safety II highlights where scientific methods, standardization, root cause analysis and reliability alone fall short. They assert that safety needs to progress beyond a bimodal model to employ multiple approaches for reducing error/failure and achieving fully resilient systems.

Safety I, as experienced today, is the push to eliminate all accidents, system failures and injury. The researchers define this as the “state where as few things as possible go wrong” with involved components — technology, procedures, humans and the organization in which they operate. This makes sense intractable and well-engineered systems. However, Safety I is really just the starting point for healthcare; which by its very nature is intractable.

Safety II recognizes that medicine and healthcare processes are not an exact science and that there is sometimes an art to caregiving.

Going beyond Safety I involves a focus on what went right; usually the adjustments made in human performance to match the conditions of work. Below is a listing of key concepts from the whitepaper reinforcing the understanding that variability and flexibility and the need to ensure as many things as possible go right.

  1. It is false to assume good outcomes are simply due to systems functioning as they should, because people worked as imagined (an idealized view).
  2. The world and healthcare have become more complex; outcomes can no longer be viewed simply along linear models of cause-effect relations.
  3. Instead, task performance must adjust to constantly changing conditions of the work and environment. When this occurs, the work-as-done may be very different from the work-as-imagined and delineated in to policy, protocol, guidelines, rules, checklists, etc.
  4. “In the normal course of clinical work, doctors, nurses, and all allied staff perform safely because they are able to adjust their work so that it matches the conditions.”
  5. Healthcare leaders should acknowledge that things often go right, because clinicians adjusted their work to conditions, instead of working as imagined. In these cases, outcomes are emergent, not resultant.
  6. Eliminating variability and the pushing the wrong highly reliable systems could increase the occurrence of poor outcomes.
  7. Safety management must become more proactive and promote interventions to prevent the unintended consequences of policy, protocol, guidelines, rules, checklists, etc.
  8. Safety II is based on the principle that performance adjustments are ubiquitous and that performance not only always is variable, but it must be so.
  9. Policy makers, regulators and healthcare leaders should recognize that they are removed in time and space from the actual operation of the systems and services. And, they have limited opportunities to observe or experience how work (caregiving) is actually done.

Thus, managers and leaders have an opportunity to recognize the important role of variability and flexibility in safety. This is accomplished when they:

  • Make the effort to truly consider how work is done,
  • provide the necessary resources and
  • prepare for the unexpected.

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