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Health Policy, Pediatrics, Research, Stanford News

Less burnout, better safety culture in hospitals with hands-on executives, new study shows

Less burnout, better safety culture in hospitals with hands-on executives, new study shows

walkroundsA specific method for fostering interaction between hospital executives and front-line health-care workers can reduce burnout and improve a hospital’s safety culture, new research from Stanford and other institutions has found.

“Caregiver burnout is a huge problem for health care,” said Stanford’s Jochen Profit, MD, in a conversation with me about the new study, which he led. Profit is also a neonatologist at Lucile Packard Children’s Hospital Stanford. “Across the industry, a third to half of our staff are burned out. How do you maintain quality and safety in that environment?”

The method that Profit’s team evaluated holds an answer. Called executive walk-rounds, it consists of regular, safety-focused visits by hospital executives to the units where patients receive care. The study, published last week in BMJ Quality & Safety, evaluated the effects of walk-rounds on the staff of neonatal intensive care units, the nurseries that care for the sickest newborns. Walk-rounds provide doctors, nurses and other caregivers with an opportunity to point out safety problems, and, ideally, also give executives a chance to tell staff about resolutions used for the problems they’ve raised.

The study surveyed worker engagement and safety culture in 44 NICUs during a quality improvement project led by the California Perinatal Quality Care Collaborative. The surveys asked workers if walk-rounds were used at their institution and whether they had participated in the process. They also asked about caregivers’ levels of burnout, the hospital’s overall culture of safety and about feedback returned from hospital leadership to front-line caregivers to follow up on suggestions made during walk-rounds.

“Walk-rounds are a way for organizations to make sure they make the lines of communication open,” Profit said. “It can help show that they care for the people in the trenches.” Walk-rounds might help clear up confusion about the hospital’s chain of command or resolve difficulties with getting equipment or supplies in a timely fashion, to name a few anecdotal examples from the study.

Follow-up was the key to successful walk-rounds, the study showed. About 30 percent of the hospitals surveyed used walk-rounds, and these differed in the extent to which staff said they received feedback on how the safety suggestions they identified were resolved. Staff at hospitals with the highest levels of follow-up said they had lower rates of burnout, better communication about errors, and better teamwork and safety climates.

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Big data, In the News, Pediatrics, Research, Stanford News, Technology

How efforts to mine electronic health records influence clinical care

How efforts to mine electronic health records influence clinical care

medical_recordsDeveloping new ways to mine the vast amount of information contained in electronic medical charts holds the potential to advance diagnosis and treatment for patients. The quantity of health information, which ranges from physician observations to lab results, is huge – and as Stanford researcher Nigam Shah, MBBS, PhD, commented in a Wall Street Journal story published today, “We should be learning from the record of routine medical practice.”

In his work, Shah has developed methods for extracting data from electronic medical record to glean valuable information about possible drug side effects and off-label uses for medications. The article goes on to highlight another Stanford example of how the practice of data mining has influenced clinical care:

Jennifer Frankovich, a pediatric rheumatologist at Lucile Packard Children’s Hospital Stanford in Palo Alto, Calif., follows pediatric patients who have juvenile idiopathic arthritis. Doctors know that these patients are at higher risk of getting an eye inflammation disease called uveitis. If not detected and treated in time, uveitis can cause serious eye damage, including blindness.

The difficulty for doctors is predicting which patients will get the condition. Sometimes the children experience blurry vision but don’t tell anyone. Other times, there are no obvious signs of a problem until serious damage is done.

As a result, eye exams are done on the patients at random times. When several families mentioned during routine checkups that the uveitis seemed to act up when their children had allergies, Dr. Frankovich wondered if there might be a connection. Stanford researchers used data from electronic health records of unnamed patients from Lucile Packard Children’s Hospital from 2000 to 2011, including clinical notes. They concluded that there was an association between allergies and flare-ups of uveitis in patients with juvenile arthritis.

Next week, Shah and others from academia, industry and government will gather for the Big Data in Biomedicine conference at Stanford.

Previously: NIH Director: “Big Data should inspire us”, Chief technology officer of the United States to speak at Big Data in Biomedicine conference, Big Data in Biomedicine technical showcase to feature companies’ innovations related to big data and Euan Ashley discusses harnessing big data to drive innovation for a healthier world
Photo by Oklahoma Army National Guard

Chronic Disease, Health Policy, Nutrition, Obesity, Pediatrics, Videos

Fed Up: A documentary looks for answers about childhood obesity

Fed Up: A documentary looks for answers about childhood obesity

I can’t wait to see Fed Up, a new documentary about childhood obesity.

In the early 2000s, when I was earning a PhD in nutrition at UC Davis, I heard a lot of scientific debate about possible causes of the U.S. obesity epidemic. Was it too much fat in our diets? Too much sugar? Processed food? Junk food ads on TV? An “obesogenic environment” – one in which snacks are ubiquitous, adults drive everywhere and neighborhoods aren’t safe enough for kids to play outside?

Or was it something else?

“The message has been pushed on us: It’s your fault you’re fat,” says Mark Hyman, MD, chair of the Institute for Functional Medicine, in the Fed Up trailer above.

The movie assembles an impressive roster of experts in nutrition research, pediatric health and public advocacy to oppose that message. Michael Pollan, Mark Bittman, Robert Lustig, Marion Nestle, Harvey Karp, former President Bill Clinton and others say we should not be blaming individuals – especially kids – for struggles with their weight. Instead, they are taking a hard look for answers at the food environment.

“This is the first generation of American children expected to lead shorter lives than their parents,” says a voice-over in the Fed Up trailer. That definitely makes untangling the causes of the obesity epidemic worthy of the efforts of our best scientists. Like I said, I can’t wait to see it.

Previously: Childhood obesity a risk for imminent heart problems, research shows, Using hip hop to teach children about healthy habits and Sugar intake, diabetes and kids: Q&A with a pediatric obesity expert
Via Food Politics

Health Disparities, In the News, Patient Care, Pediatrics

Adolescent Health Van wins community award for aiming to “help kids turn their lives around”

Adolescent Health Van wins community award for aiming to "help kids turn their lives around"

ammerman-and-teen-van-2Paying for a basic doctor’s visit is often impossible for low-income teens and young adults. That’s why Seth Ammerman, MD, has been bringing free health care to young people in the communities around Lucile Packard Children’s Hospital Stanford for nearly two decades. Ammerman, an adolescent medicine specialist at the hospital, is the founder and medical director of the hospital’s Adolescent Health Van, a mobile clinic that makes regular visits to high schools, community centers and other stops between San Francisco and San Jose.

Now, Ammerman’s work has been recognized with a Bay Area Jefferson Award for Public Service from our local CBS affiliate, KPIX-5. In the news segment CBS aired about Ammerman’s work, they mention that his efforts began years ago with free immunizations for local teens. But he soon realized that the kids he saw needed much more than just immunizations. “Dr. A,” as his patients affectionately call him, now addresses a wide range of adolescent health concerns in the teen van – including alcohol and drug use, anxiety and depression, high-risk sexual behaviors, poor nutrition, and, yes, lack of immunizations. His team in the van includes a nurse-practitioner, a social worker and a dietitian.

“The kids that we work with, a lot of people have given up on them,” Ammerman says in the CBS news segment. “But we haven’t. We know that we can help these kids turn their lives around.”

Congratulations, Dr. Ammerman! And a hat-tip to Steve Westly of the Westly Foundation, who nominated Dr. Ammerman for the award.

Previously: Packard Children’s Adolescent Health Van celebrates 15 years
Photo courtesy of Lucile Packard Children’s Hospital Stanford

Chronic Disease, Clinical Trials, Pediatrics, Research

New research shows how to keep diabetics safer during sleep

New research shows how to keep diabetics safer during sleep

sleeping girlLife with type 1 diabetes requires an astonishing number of health-related decisions – about 180 per day. But patients’ vigilant monitoring of their daytime blood sugar, food intake, insulin and activity levels is perhaps less exhausting than the worries they face about getting a safe night’s sleep. During sleep, diabetics often fail to sense when their blood glucose veers too low. Low blood sugar levels can cause seizures and even, in rare cases, death.

“At night you lose control,” said Bruce Buckingham, MD, a pediatric endocrinologist who treats children with diabetes at Lucile Packard Children’s Hospital Stanford. “It’s when things can happen.” Among children with diabetes, about 75 percent of hypoglycemic seizures occur at night, he said.

That’s why Buckingham and his colleagues across the United States and Canada have been testing various methods to automate blood sugar control during sleep. Our press release on their new research describes an approach that could make a big difference – automated shut-offs of patients’ insulin pumps to keep their sugar levels above the hypoglycemia danger zone:

The new study, which [appeared] online May 7 in Diabetes Care, coupled a glucose sensor worn under the skin to an insulin pump that was connected wirelessly to a computer at the bedside. The computer ran an algorithm that calculated when a low blood-sugar level might occur and then temporarily suspended insulin delivery until the sugar level was trending upward. This occurred without waking the patient. The shutoffs reduced the cumulative time patients spent with low blood sugars during sleep by 81 percent, with only a minimal increase in nighttime glucose levels.

“A system like this should dramatically decrease diabetics’ risk of having a seizure overnight,” said Bruce Buckingham, MD, professor of pediatric endocrinology at Stanford, who led the trial and is a co-author of the study. “Patients and parents will be able to have a better night’s sleep, knowing that there is a much lower risk of severe hypoglcyemia at night.”

During the study, the researchers monitored close to 2,000 nights of sleep in 45 people with type 1 diabetes. The patients, who were 15 to 45 years of age, slept in their own homes and didn’t know ahead of time which nights their insulin pumps could be shut off by the computer and which nights their pumps operated normally. Several measures of hypoglycemia indicated that patients were safer on treatment versus control nights. Morning blood sugar levels were slightly higher after treatment nights, but still within the healthy range.

To get a sense of what the results mean for patients and their families, I spoke with Jack Leguria, whose 14-year-old daughter, Rosa, has had type 1 diabetes for almost 10 years. Rosa participated in the second phase of Buckingham’s research, which is now testing whether the benefits his team documented for older teenagers and adults will extend to children as young as 3. Seeing the new technology in action was exciting for Rosa and her parents.

“This is going to be life-altering for us,” Leguria said. “In four years, Rosa will be ready for college. For a child with type 1 diabetes who is not able to recognize low blood sugar at night, that’s a very difficult prospect for us.”

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Emergency Medicine, Health Costs, Health Disparities, Pediatrics, Research, Stanford News

ER visits for U.S. newborns show racial disparities

ER visits for U.S. newborns show racial disparities

Haiti Earthquake“Baby’s first trip to the ER” is probably one photo that no one ever wants to put in a baby book. But a surprising number of newborns – 320,000 each year – visit an emergency department within their first month of life. For reasons that are likely a complex mix of socioeconomic and biological factors, black newborns across the U.S. are more than twice as likely to make the trip.

Henry Lee, MD, an assistant professor of pediatrics at Stanford, broke down the stats of how often newborns end up in the emergency department and looked at race, age and insurance status. In collaboration with researchers at the University of California-San Francisco, Lee analyzed data from nationwide emergency room visits collected by the National Center for Health Statistics. The study appears in the May issue of the journal Pediatric Emergency Care.

The researchers found that 14.4 percent of black babies visited the emergency department, compared to 7.7 percent of Hispanic babies and 6.7 percent of white newborns. Some trips to the ER are unavoidable, such as when a baby has an infection or isn’t gaining weight. But it’s likely that some of these visits could have been prevented.

All babies must get a checkup within several days of being born. But if the delivering doctor failed to counsel the new parents about checkups – or if the doctor missed a common problem, such as jaundice – then the new family might end up in the ER instead of at a clinic. In addition to representing a lack of continuity of care for the newborns, these visits drive up health-care costs.

Additional studies may tease apart the factors that cause black newborns to end up in the emergency room more often than other groups, and to find ways to reduce spending on health care while providing better services.

“Improving the quality of care for this higher-risk group could also help to improve disparities and outcomes as well,” Lee said.

Patricia Waldron is a science writing intern in the medical school’s Office of Communication & Public Affairs.

Previously: Decreasing demand on emergency department resources with “ankle hotline” and Speed it up: Two programs help reduce length of stay for emergency-room visitors
Photo by Olav Saltbones / Norwegian Red Cross

Pediatrics, Sleep

How sleep benefits those with a rare neurological disease

How sleep benefits those with a rare neurological disease

In the latest Huffington Post blog entry from the Stanford Center for Sleep Sciences and Medicine, a pediatric neurologist highlights a rare neurological disease that’s characterized by an improvement of symptoms after sleep. Mara Cvejic, MD, shares the dramatic story of a young patient, writing:

As a sleep physician today, Jane’s face still haunts me — but in a good way. The miracles of sleep are too numerous for the scope of this article, but there is plenty of undisputed evidence to show that healthy sleep improves our mood, our heart, our ability to eat healthy, to exercise, and perform at our best during the day at work or school. It is even linked to lower cancer rates. But can it take away what appears to be Parkinson’s disease and make a little girl walk? Oddly, that answer is yes. Jane had Segawa’s disease.

Read on for the full story.

Previously: Stanford center launches Huffington Post blog on the “very mysterious process” of sleep

Autism, Behavioral Science, Pediatrics, Stanford News

Home videos could help diagnose autism, says new Stanford study

Home videos could help diagnose autism, says new Stanford study

Autism is more complex to diagnose than many other childhood conditions. There’s no physical sign or lab test; rather, making the diagnosis requires careful observation for clues such as poor language and social skills or repetitive behaviors. Standard diagnostic tests take several hours of a professional’s time, and families may wait months to see someone who can assess their child.

But new research from Stanford and Harvard Medical School suggests that faster diagnoses might become possible. The research team, whose findings appear today in PLOS ONE, tested whether short home videos could be harnessed to speed the process. Using a scoring system that was pared down from the “gold standard” diagnostic test, they assessed kids’ behavior in 100 short videos pulled from YouTube. About half of the videos showed children with autism; the rest did not. The scoring system classified 97 percent of the videos accurately.

The system is unlikely to replace traditional diagnostic methods, but could help relieve the diagnostic bottleneck, study author Dennis Wall, PhD, explained in our press release:

“For instance, we could use this system for clinical triage, as a way to channel traffic so that children can get the kind of attention they need as early as possible,” Wall said. Children who clearly have autism might be diagnosed primarily with videos and quickly started on therapy, freeing clinicians to spend more time evaluating children whose diagnosis is less clear-cut.

Home videos also provide information that is otherwise unavailable to those making the diagnosis, Wall said:

Another potential advantage of using video for diagnosis is that young children often behave differently in a doctor’s office than at home.

“Clinical settings are often stark, artificial and can elicit behaviors that are abnormal,” Wall said. “The odds are stacked against the diagnostic professional because the child is in an unknown environment with strangers.”

The researchers plan to explore whether the same method could also be used for making other behavior-based diagnoses, such as detecting attention-deficit hyperactivity disorder or adult-onset neurologic conditions such as Alzheimer’s or Parkinson’s disease.

Previously: Using Kinect cameras to automate autism diagnosis, Director of Stanford Autism Center responds to your questions on research and treatment and New imaging analysis reveals distinct features of the autistic brain

Autism, In the News, Pediatrics, Research

Using theater’s sensory experiences to help children with autism

Using theater's sensory experiences to help children with autism

Gesamkunstwerk, my favorite German word and a term commonly associated with the operas of Richard Wagner, can be translated as a “total work of art” playing to many of the senses and synthesizing numerous art forms. The word came to mind as I read about a pilot study using theater as an environment for children with autism-spectrum disorders  to explore “communication, social interaction, and imagination skills – the ‘triad of impairments’ seen in autism,” a New Scientist piece notes, “engaging all the children’s senses at once.”

Twenty-two children ages 7-12 attended one weekly 45-minute session for 10 weeks involving improvisation exercises led by trained performers in enclosed make-believe environments such as a forest or outer space.

From the piece:

As well as looking at whether behaviours used to diagnose autism changed after the drama sessions, the researchers also assessed emotion recognition, imitation, IQ and theory of mind – the ability to infer what others are thinking and feeling. Subjective ratings were also gathered from parents and teachers and follow-up assessments were conducted up to a year later.

At the early assessments, all children showed some improvement. The most significant change was in the number of facial expressions recognised, a key communication skill. Nine children improved on this. Six children improved on their level of social interaction. The majority of these changes were also seen at the follow-up assessments.

The project’s lead psychologist, David Wilkinson, PhD, at the University of Kent, told New Scientist, ”It’s an opportunity for children to create their own narratives in an unconstrained, unfamiliar environment.” He continued, “They find this empowering, and we know from the psychology literature that individuals who are empowered enjoy increased attention skills and an improved sense of well-being.”

Previously: Making museums more inviting for autistic children and their familiesStanford study reveals why human voices are less rewarding for kids with autismDirector of Stanford Autism Center responds to your questions on research and treatment and A mother’s story on what she learned from her autistic son

Autoimmune Disease, Chronic Disease, Patient Care, Pediatrics

A wake-up call from a young e-patient: “I need to be heard”

We’ve partnered with Inspire, a company that builds and manages online support communities for patients and caregivers, to launch a patient-focused series here on Scope. Once a month, patients affected by serious and often chronic diseases share their unique stories. Our latest comes from 15-year-old Morgan Gleason, who lives with the autoimmune disease juvenile dermatomyositis. 

Before June 18, 2010, the day I was diagnosed, I knew the medical system the way that most kids do. I went to the doctor for immunizations, physicals, sore throats and bones that might be broken. Then, I developed a rash on my joints. I started sleeping more than normal, was very weak in my muscles, and experienced frequent stomachaches and headaches.

At the age of 11, after a year of these symptoms, I was diagnosed with a rare autoimmune disease called juvenile dermatomyositis. I suddenly was in a whole new medical system. I had to learn to swallow pills, wait for hours in doctors offices, spend nights in the hospital, worry about what was happening, deal with some not-so-nice doctors and nurses, and endure a lot of pain. I also watched my parents get frustrated with figuring out medical bills and trying to understand all of the claim statements and appeal denials.

Now I take 21 pills a day, get two infusions a month by an IV, and give myself an injection once a week. I have more specialists than my grandparents, and I spend a lot of time as a patient.

This January, I was hospitalized for the second time in four months for meningitis due to a reaction from a treatment I received. After four days of little sleep and an excruciating headache, I made a video about my hospital experience and posted it online. To my surprise, the video got a lot of attention. Forbes, Time, the Huffington Post and other outlets wrote about it. I believe that the video was popular because my experience was a common one and struck a nerve with others.

I am appreciative of the care I have been given. I love the hospital where I get my treatment, and I think it’s a great hospital. The medical students, residents, attending physicians, and specialists are great doctors. The nurses are also really great. This is not an issue with the individual people or hospitals. The issue is much bigger, and it’s the way the system as a whole is designed.

My video had a few main points. I was frustrated that I couldn’t get any rest in the hospital. The system is designed around the schedules of the doctors and the desire to discharge patients by noon instead of around the circumstances and needs of the patient. Second, the doctors come in individually instead of coming together and addressing all the concerns at one time. Third, when patients are awoken from deep sleep, they’re not going to be as engaged as they would be when they are alert and comfortable. Finally, patients, and even children and teenagers, appreciate having the doctor talk with them instead of having the doctors talk over them or away from them in the hallway.

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