Importance:People with opioid use disorder (OUD) are often hospitalized for emergent medical problems, but opioid use is seldom addressed during the inpatient stay. In a recent trial, patients randomized to Substance Use Treatment and Recovery Team (START), a hospital-based addiction consultation service, were more likely to initiate medication for opioid use disorder and be linked to OUD-focused follow-up care compared with patients receiving usual OUD care, which was at the discretion of the primary team. Objective:To evaluate the incremental cost-effectiveness of START from the health sector and limited societal perspectives relative to usual care. Design, Setting, and Participants:This economic evaluation was an incremental cost-effectiveness analysis based on the START trial, which was conducted at 3 major academic medical centers. START participants were adults with a probable OUD diagnosis documented during an inpatient hospitalization from November 2021 to September 2023. This economic evaluation used trial participant-level cost and health outcomes data, supplemented with published data. Exposures:Two strategies were compared: (1) START and (2) usual care. Main Outcomes and Measures:Costs, quality-adjusted life year (QALYs), and incremental cost-effectiveness ratios (ICERs). ICERs were estimated using a Markov model over a 12-month horizon, with deterministic and probabilistic sensitivity analyses. ICERs were expressed as cost per QALY gained, with a willingness-to-pay threshold of USD $150 000/QALY. Results:A total of 325 participants were randomized to the START (164 [50.5%]) or usual care (161 [49.5%]); 213 were male (66%) and the median (IQR) age was 41 (32-50) years. START implementation costs were $640 per patient (personnel, $602; training and onboarding, $38). Compared with usual care, START was associated with an incremental cost of $162 (95% UI, -$93 to $179) and a gain in QALYs of 0.0103 (95% UI, 0.0102 to 0.0106) per person from a health sector perspective, leading to an ICER of $15 750 (95% UI, $8742 to $17 034) per QALY gained. The ICER was $20 921 (95% UI, $13 747 to $22 190) per QALY gained from a limited societal perspective. Sensitivity analyses demonstrated that health care expenditures and intervention effectiveness were the strongest drivers of cost-effectiveness. Conclusions and Relevance:In this trial-based economic evaluation, START was a cost-effective approach for addressing opioid use disorder in the inpatient setting by increasing the initiation of medication for OUD and linkage to OUD-focused care after discharge.

BACKGROUND:Patient reported outcome measures (PROMs) can be used to quantify responses to treatment and for quality measurement purposes. However, the clinical importance of a given change in a PROM score is hard to interpret. The minimal important change (MIC) is the smallest change in score that patients consider important. OBJECTIVE:To estimate MICs for three PROMs at 3- and 9-month follow-ups for a large five-institution sample of patients with carpal tunnel syndrome. DESIGN:Cohort study. SETTING:Two university, two Veterans Affairs, and one community nonprofit health care systems. PATIENTS:Patients receiving initial consultation with a hand surgeon for carpal tunnel syndrome. MEASURES AND METHODS:Patients completed baseline, 3-month, and 9-month PROMs: the Boston Carpal Tunnel Questionnaire Symptom (BCTQ-SS) and Functioning (BCTQ-FN) Scales, and the Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) scale. Anchor-based methods and Youden J-statistics were used to find the optimal MIC cut points that maximized sensitivity and specificity for patients being satisfied with the outcome of treatment. RESULTS:Six hundred thirty-five patients completed the baseline PROMs, and 551 (87%) and 516 (81%) completed the 3- and 9-month PROMs, respectively. The percentage of patients who were at least somewhat satisfied with the results of treatment differed between the carpal tunnel release and nonoperative subgroups (91% vs. 67% at 9 months), as did the MIC estimates. At 9 months, 295 of 326 (91%) of carpal tunnel release patients were satisfied with the results of treatment, with MICs of 0.81, 0.66, and 15.7 for the BCTQ-SS, BCTQ-FN, and QDASH, respectively. We also produced MICs for the 3-month assessment, the nonoperative, and overall samples. CONCLUSIONS:These MIC estimates can be used in clinics or research to gauge response to treatment and used in the design of PROM-based quality measures.

Abstract Background Emergency physicians face considerable workflow challenges in the emergency department (ED) due to unpredictable work environments, frequent interruptions, and mounting documentation requirements, all of which contribute to substantial computer-based work. Excessive time away from direct patient care is increasingly viewed as detrimental to the quality of care, communication, and patient safety. Objective This study aimed to quantify and visualize how emergency physicians allocate their time during ED shifts, particularly the time spent on the computer. Methods This cross-sectional observational time-motion study was conducted in a high-volume, urban ED. We used the validated TimeCaT application to continuously track physician activities, including computer use, direct patient care, communication, and all other tasks carried out during the shift. Electronic health record event log data were queried to estimate physicians’ computer use after their scheduled shift. The main outcome was the proportion of time spent on each activity. The primary measure was the total minutes of computer use (during and after the shift) per scheduled hour of clinical work. Additionally, we generated data visualizations to illustrate ED workflow-sequencing, task switching, and between-shift variability. Results We observed 20 emergency physicians for one 8- to 9-hour clinical shift each, generating over 150.0 hours of real-time observation data quantifying physicians’ ED workflow. Physicians spent a median of 34.1% of their shift minutes using the computer (156.5, IQR 145.2-179.3 min) and 26.9% with patients (115.2, IQR 102.0-154.1 min). Other activities included 15.9% for verbal communication with staff (73.3, IQR 45.6-96.4 min), 9.5% phone use (41.4, IQR 33.4-59.2 min), 5.5% miscellaneous tasks (24.2, IQR 18.4-30.1 min), 3.9% personal time (16.8, IQR 9.9-25.4 min), 0.7% electrocardiogram review (3.8, IQR 1.4–5.0 min), and 0.4% other procedures (median 1.7, IQR 0.6-6.4 min). Electronic health record log analysis showed that physicians spent an additional median 1.3 (IQR 0.5‐2.6) hours using the computer after their scheduled shifts, for a combined 29.8 (IQR 25.6‐38.5) minutes on the computer per scheduled hour of their ED shift. Workflow visualizations showed frequent alternation among activity categories and noticeable variability in within-shift fragmentation across physicians. Conclusions Emergency physicians spent more than one-third of their ED shift working on the computer, which was more time than they spent with patients. They also spent 1 to 2 hours using the computer after their scheduled shift. These findings demonstrate the need for strategies to reduce unnecessary computer use during and after clinical shifts to enhance workflow efficiency and improve patient care.

This randomized clinical trial examines whether pharmacist-led transitions-of-care interventions after hospital discharge reduce subsequent readmissions and other health care utilization among patients aged 55 years or older with polypharmacy. QuestionPharmacist-led peridischarge transitions of care (TOC) interventions reduce adverse drug events after hospital discharge, but do they reduce readmissions and other health care utilization?FindingsThis randomized clinical trial included 6478 patient hospitalizations among adults aged 55 years or older with polypharmacy or taking high-risk medications, randomized to either usual care (admission medication reconciliation) or pharmacist-led medication review, discharge medication reconciliation, and addressing of medication adherence and safety. No significant between-group difference was detected in all-hospital unplanned 30-day postdischarge health care utilization.MeaningAmong older adults with polypharmacy, a pharmacist-led TOC intervention did not reduce 30-day unplanned health care utilization after hospital discharge. ImportancePharmacist-led peridischarge transitions of care (TOC) interventions reduce adverse drug events after hospitalization. However, health care organizations do not usually see a financial incentive to fund these interventions.ObjectiveTo test whether pharmacist-led TOC interventions could drive reductions in health care resource utilization after hospital discharge.Design, Setting, and ParticipantsThis pragmatic randomized clinical trial was conducted in 2 urban teaching hospitals in the US. Participants were hospitalized adults aged 55 years or older taking 10 or more long-term prescribed medications or 3 or more high-risk medications (defined as anticoagulants, antiplatelet agents, or antihyperglycemics including insulin), enrolled between December 23, 2019, and December 30, 2022. Data were analyzed from January 2023 to June 2025.InterventionPharmacist-led peridischarge and postdischarge medication management with patients and their care partners, including medication review, discharge medication reconciliation, and addressing medication adherence and safety. Usual care consisted of obtaining a best possible medication history and conducting an admission medication order reconciliation.Main Outcomes and MeasuresThe primary outcome was the proportion of patients with all-hospital unplanned 30-day postdischarge hospital or emergency department (ED) utilization. A sample size of 9776 patients would detect absolute differences of 2.5% from an expected baseline of 27.5%. Secondary end points included same-hospital unplanned utilization and several prespecified subgroup analyses to evaluate effect modification.ResultsA total of 6478 patient hospitalizations were randomized and 6428 (3215 usual care and 3213 intervention) were analyzed; 3265 (50.8%) were among male patients. Patients had a mean (SD) age of 75.5 (10.2) years and were taking a median of 16 (IQR, 12-22) long-term prescription medications and 2 (IQR, 1-3) high-risk medications. Three-quarters of patients (4824 [75.0%]) were discharged home. The per-protocol analysis included 6238 patient encounters, 4472 (71.7%) of which were among patients using fee-for-service Medicare for whom all-hospital utilization claims were obtainable; in this group, no significant reduction was found in the proportion with unplanned 30-day all-hospital utilization (593 of 2242 usual care [26.4%] vs 570 of 2230 intervention [25.6%]; difference, 0.9 percentage points [pp]; 95% CI, -1.7 to 3.5 pp). Among all patients randomized, there was also no significant reduction in same-hospital unplanned 30-day utilization (606 of 3112 usual care [19.5%] vs 579 of 3126 intervention [18.5%]; difference, 1.0 pp; 95% CI, -1.0 to 3.0 pp). Among the 589 patients with low medication adherence and literacy, there was a 10.4 pp (95% CI, 3.4-17.4 pp) absolute reduction in same-hospital unplanned utilization (69 of 240 usual care [28.8%] vs 64 of 349 intervention [18.3%]; P = .003) (P = .01 for effect modification).Conclusions and RelevanceAmong older adults with polypharmacy, no reduction overall in 30-day unplanned hospital and ED utilization from a pharmacist-led TOC intervention was detected, but a reduction was found among patients with low medication adherence and literacy, suggesting benefit for this subgroup.Trial RegistrationClinicalTrials.gov Identifier: NCT04071951

Objectives:Voluntary incident reporting has improved safety in many high-risk industries, but barriers limit its effectiveness in hospitals. To overcome these, we designed the Safety Action Feedback and Engagement (SAFE) Loop to obtain input from nurses about and prioritize patient safety problems, teach nurses to write more informative reports and report priority incidents, standardize investigations, and provide feedback to nurses about mitigation plans. The present work sought to iteratively test and refine the nascent intervention.Methods:Set at a large US academic hospital, this work had 3 phases: (A) proof-of-concept testing on 2 nursing units, exploring potential feasibility and acceptability; (B) iterative refinements to intervention design and implementation plans; and (C) structured pilot testing on one nursing unit to produce descriptive and qualitative data related to the feasibility and acceptability of the refined intervention, and feasibility of future outcome measures.Results:Proof-of-concept testing demonstrated the feasibility of intervention elements and nurses' enthusiasm. Incorporating iterative refinements, the structured pilot testing reaffirmed the feasibility of implementing the full SAFE Loop intervention and of collecting outcome data. Qualitative interviews after the pilot reaffirmed intervention acceptability.Conclusions:The SAFE Loop shows promise as an approach to enhancing hospital incident reporting systems. The present work illustrates how patient safety leaders can build from an initial intervention design toward a refined design and implementation plan, with demonstrated acceptability to stakeholders and feasible implementation.

Study objective To develop definitions of (1) diagnostic excellence and (2) missed diagnostic opportunity to guide research and quality/safety programs in the emergency department (ED). Methods We used a modified RAND/UCLA panel method, which is a modified Delphi panel that is designed to measure consensus among clinical experts. First, we identified existing definitions of diagnostic error and related terms and extracted conceptual components (eg, accuracy and timeliness). Second, we recruited 11 multidisciplinary panelists, selected for diversity in professional role, clinical setting, geography, and diagnostic error exposure. Third, panelists rated conceptual components on validity, relevance to the ED, and overall importance using a 1 to 9 scale. Conceptual components with final-round median ratings ≥7 on all dimensions were selected for inclusion in narrative definitions. Results Diagnostic excellence in the ED is “the use of optimal, evidence-based practice to attain an accurate and timely explanation about a patient’s condition based on the information available at the time and communicate that explanation to the patient/family. Diagnostic excellence is patient-centered and equitable. Diagnostic excellence includes avoidance of divergent practices. It leads to better choices in management, prevents missed opportunities, and reduces the risk of preventable patient harm.” A missed diagnostic opportunity is “a measurable divergence from optimal, evidence-based practice that may lead to: an inaccurate or delayed explanation of a patient’s condition, despite information available at the time, or a failure in shared communication related to the diagnosis with the patient/family. A missed diagnostic opportunity may lead to suboptimal management, preventable patient harm, or inequitable outcomes.” Conclusion Future work should study implementation of these definitions into ED diagnostic research and quality/safety programs.

Importance:Pharmacist-led peridischarge transitions of care (TOC) interventions reduce adverse drug events after hospitalization. However, health care organizations do not usually see a financial incentive to fund these interventions. Objective:To test whether pharmacist-led TOC interventions could drive reductions in health care resource utilization after hospital discharge. Design, Setting, and Participants:This pragmatic randomized clinical trial was conducted in 2 urban teaching hospitals in the US. Participants were hospitalized adults aged 55 years or older taking 10 or more long-term prescribed medications or 3 or more high-risk medications (defined as anticoagulants, antiplatelet agents, or antihyperglycemics including insulin), enrolled between December 23, 2019, and December 30, 2022. Data were analyzed from January 2023 to June 2025. Intervention:Pharmacist-led peridischarge and postdischarge medication management with patients and their care partners, including medication review, discharge medication reconciliation, and addressing medication adherence and safety. Usual care consisted of obtaining a best possible medication history and conducting an admission medication order reconciliation. Main Outcomes and Measures:The primary outcome was the proportion of patients with all-hospital unplanned 30-day postdischarge hospital or emergency department (ED) utilization. A sample size of 9776 patients would detect absolute differences of 2.5% from an expected baseline of 27.5%. Secondary end points included same-hospital unplanned utilization and several prespecified subgroup analyses to evaluate effect modification. Results:A total of 6478 patient hospitalizations were randomized and 6428 (3215 usual care and 3213 intervention) were analyzed; 3265 (50.8%) were among male patients. Patients had a mean (SD) age of 75.5 (10.2) years and were taking a median of 16 (IQR, 12-22) long-term prescription medications and 2 (IQR, 1-3) high-risk medications. Three-quarters of patients (4824 [75.0%]) were discharged home. The per-protocol analysis included 6238 patient encounters, 4472 (71.7%) of which were among patients using fee-for-service Medicare for whom all-hospital utilization claims were obtainable; in this group, no significant reduction was found in the proportion with unplanned 30-day all-hospital utilization (593 of 2242 usual care [26.4%] vs 570 of 2230 intervention [25.6%]; difference, 0.9 percentage points [pp]; 95% CI, -1.7 to 3.5 pp). Among all patients randomized, there was also no significant reduction in same-hospital unplanned 30-day utilization (606 of 3112 usual care [19.5%] vs 579 of 3126 intervention [18.5%]; difference, 1.0 pp; 95% CI, -1.0 to 3.0 pp). Among the 589 patients with low medication adherence and literacy, there was a 10.4 pp (95% CI, 3.4-17.4 pp) absolute reduction in same-hospital unplanned utilization (69 of 240 usual care [28.8%] vs 64 of 349 intervention [18.3%]; P = .003) (P = .01 for effect modification). Conclusions and Relevance:Among older adults with polypharmacy, no reduction overall in 30-day unplanned hospital and ED utilization from a pharmacist-led TOC intervention was detected, but a reduction was found among patients with low medication adherence and literacy, suggesting benefit for this subgroup. Trial Registration:ClinicalTrials.gov Identifier: NCT04071951.

BACKGROUND:Dementia and cognitive impairment are common among hospitalized older adults yet frequently go unrecognized, contributing to poorer outcomes and disparities in care. Systematic inpatient cognitive screening remains rare in U.S. hospitals. We evaluated the feasibility, reach, and screening outcomes of a hospital-wide, multicomponent inpatient cognitive screening program integrating an electronic health record (EHR) dementia diagnosis algorithm with nurse-administered brief cognitive assessments (4AT and AD8) among adults aged ≥ 65 years. METHODS:We conducted an observational study across eight inpatient medical and surgical units in a large academic medical center, implementing systematic screening for previously diagnosed dementia and newly detected cognitive impairment from June 2023 to November 2024. Screening activity and screening positivity were assessed overall and across sociodemographic and clinical subgroups. Logistic regression models examined factors associated with screening completion and positive findings. RESULTS:Among 11,180 hospitalizations between June 2023 and August 2024, 83.3% were screened; 18.0% had previous dementia diagnoses, 4.3% screened positive for potential dementia, and 9.0% for cognitive impairment. Older adults (age 85+) and Black patients (37.5% vs. 26.7%) were more likely to screen positive for potential dementia than younger or White patients. Screening completion rates were high and largely consistent across demographic groups, with minimal evidence of new disparities introduced by the screening process. CONCLUSION:Inpatient cognitive screening is feasible and increases detection of potential dementia. This approach promoted more consistent detection in dementia diagnosis and can potentially improve hospital care and outcomes for older adults with dementia or cognitive impairment.

Importance High-quality evidence guiding opioid prescribing decisions for acute pain across common diagnoses is lacking. Objective To describe pain trajectories and patterns of opioid and nonopioid treatment use among individuals who were offered opioids for the treatment of acute pain. Design, Setting, and Participants This was a prospective cohort study of patients recruited from 5 US health systems between September 2020 and March 2023 in emergency departments (EDs), primary care clinics, dental practices, or after cesarean delivery or knee replacement. Eligible patients were opioid-naive adults aged 18 years or older at all study sites, as well as adolescents aged 15 to17 years undergoing impacted molar extraction at 1 site, who were offered an opioid prescription for acute pain. Analysis was conducted April 2023 through February 2026. Exposure Offer of a prescription for an opioid analgesic. Main Outcomes and Measures Time to pain resolution (3 consecutive reports of no pain), patterns of opioid and nonopioid treatment use, and opioid-related adverse effects, ascertained from digital questionnaires. Results Among 1708 enrolled patients (median age, 38 years [IQR, 28-52 years]; 615 [36.0%] reporting race or ethnicity underrepresented in studies of acute pain management) followed up for 180 days, 915 (53.6%) were recruited in EDs, 307 (18.0%) in primary or urgent care, 263 (15.4%) in dental settings, and 223 (13.1%) in inpatient settings. Pain sources included dental (302 patients [17.7%]), trauma or injury (302 [17.7%]), obstetric (176 [10.3%]), musculoskeletal (131 [7.7%]), and low back (100 [5.9%]). Among 1502 patients reporting pain level at least once, median time to pain resolution irrespective of the treatment approach was 20 days (IQR, 8-88 days), with longer durations for surgical pain (74 days [IQR, 30 days to not reached]) and low back pain (69 days [IQR, 18 days to not reached]). The median time to opioid discontinuation among 1189 patients (69.6%) who reported any opioid use was 7 days (IQR, 2-31 days); an estimated 10.0% (95% CI, 7.7%-12.7%) of patients used opioids for at least 90 days, with higher rates in people reporting frequent pain before enrollment. Of 1482 patients (86.8%) completing at least 1 survey during the first 2 weeks of follow-up, 1153 (77.8%) reported using any opioids and 1287 (86.8%) reported using acetaminophen or ibuprofen. Among 619 (52.1%) patients with any opioid use who reported the dose of opioids taken in the first 15 days, daily doses were low (median, 10 [IQR, 5-15] morphine milligram equivalents). Most respondents reported leftover opioids (657 of 982 responding [66.9%]). Conclusions and Relevance In this cohort study of opioid-naive patients with acute pain, opioid use was generally low dose and of short duration, although some patients reported prolonged opioid use; most reported achieving pain resolution within 3 weeks, with longer times for surgical and low back pain. The findings suggest current guidelines for multimodal treatment and for short-duration opioid prescriptions if needed will serve many but not all patients, and treatment should be tailored to address individual patients’ needs.

Objective:. To compare racial–sex differences in postoperative mortality by dementia status. Background:. Because patients with dementia often find it harder to advocate for themselves, racial–sex differences in postoperative mortality may be greater for patients with dementia versus without dementia. Methods:. Among Medicare fee-for-service beneficiaries aged 65 to 99 years who underwent one of 12 common surgical procedures in 2016 to 2019, we compared 30-day postoperative mortality (death during the index hospitalization or within 30 days of surgery) across 4 race–sex groups (Black men [reference group], White men, White women, and Black women) stratified by dementia status. Elective and nonelective surgeries were examined separately. Results:. Among 888,391 patients undergoing elective surgery, 65,450 (7.4%) had dementia. Postoperative mortality was highest among Black men, both with dementia (adjusted mortality, 3.99%) and without dementia (2.11%). Racial–sex differences were generally greater among patients with dementia. For example, the mortality difference between White women versus Black men was significantly larger among patients with dementia (adjusted difference, −2.38 percentage points [pp]; 95% confidence interval [CI], −3.34 to −1.41) than among those without dementia (−0.75 pp; 95% CI, −0.96 to −0.54) (P-for-interaction = 0.001). In contrast, among 394,554 patients undergoing nonelective surgery, 56,273 (14.3%) had dementia, and we found no evidence that mortality was highest among Black men or that racial–sex differences meaningfully varied by dementia status. Conclusions:. Among patients undergoing elective surgery, racial–sex differences in postoperative mortality were greater among patients with dementia than among those without dementia, highlighting the need for targeted strategies to ensure consistent surgical care.

Abstract Background The burden of urinary incontinence (UI) on the American public is great. The impact of this condition will only continue to rise as the population ages, yet the quality of care provided at the primary care level has been inadequate to date. The Optimizing Primary Care Tools for Incontinence MAnagement (OPTIMA) study has been designed as a four-pronged, practice-based incontinence intervention aimed at improving the management of UI by primary care providers (PCP). Methods In this pragmatic cluster randomized controlled trial, providers across four Southern California healthcare systems are randomized at the office level to receive incontinence intervention (n = 24 offices; 72 providers) vs. a non-intervention routine primary care cohort (n = 24 offices; 72 providers). The intervention includes (i) academic detailing with physician education and individual performance feedback; (ii) clinical decision support with note templates, order sets, and pop-up EHR alerts; (iii) access to co-management with a dedicated advanced practice provider; and (iv) implementation of an electronic referral service in which a specialist screens referrals for appropriateness. To achieve adequate power, the study will require 720 patients (360 patients per arm, average of 15 patients per office). The primary provider outcome is the quality of UI care, as measured by adherence to a set of 13 quality indicators (QIs) on a 6-month chart review. Secondary provider outcomes include specialty referral rates (overall specialist referrals and presence of appropriate delay of referral) and disease-specific knowledge measured by the Pelvic Floor Awareness and Knowledge Survey (PFAKS). Patient self-reported outcomes include disease-specific knowledge measured by PFAKS, UI severity measured by the International Consultation on Incontinence Questionnaire (ICIQ-SF) and Urinary Distress Inventory (UDI-6), UI response to therapy measured by Patient Global Impression of Improvement (PGI-I), and patient-perceived shared decision making via the 9-item Shared Decision Making Questionnaire (SDM-Q-9). Patient outcomes are measured at baseline, 3-, and 6-month timepoints post-appointment with the study provider. Discussion We expect this study to determine the efficacy and impact of comprehensive practice-based interventions on provider quality for UI care. Trial registration The study is registered at ClinicalTrials.gov (NCT05534412). Registered on August 1, 2022.

Background Critical care guidelines recommend that clinicians provide emotional support to families of critically ill patients during family meetings. Little is known about how family member race impacts how emotions are expressed and supported in meetings. Research Question Are there differences in family members' expression of emotion and clinicians' provision of empathy in ICU family meetings involving Black and White family members? Study Design and Methods We conducted a directed content analysis of 40 audio-recorded meetings, matching 20 meetings with Black families and 20 meetings with White families on key characteristics including meeting length. Meetings included Black or White family members of patients receiving prolonged mechanical ventilation and critical care clinicians. We used an established coding scheme to code family expressions of negative emotion and clinician empathic statements. Two analysts, unaware of patient and family race, independently coded all meetings. After coding completion, we unmasked the data, compared code frequencies by family race, and calculated the percent of expressions of negative emotions followed by an empathic response. Results Family members were mostly middle-aged (mean [SD], 50 [10] years) and women (n = 29 [73%]). Physicians leading meetings were mostly young (mean [SD], 38 [7] years), men (n = 27 [68%]), and White (n = 36 [90%]); none were Black. Black families expressed fewer negative emotions than White families (median, 1 [interquartile range, 0-3] vs 4 [interquartile range, 2.5-7.5] expressions of emotions per meeting; P < .001). When families expressed negative emotions, clinicians infrequently responded with empathy to all families and did so less frequently with Black families compared with White families (15% vs 30% of family expressions; P = .099). Interpretation Our results indicate that racial differences exist in family expression of emotion and potentially in clinician empathic responses in ICU family meetings. Empathic communication warrants improvement, with greater improvement needed with Black families. Future interventions may be needed to enhance clinician provision of equitable emotional support.

Rationale Critical care guidelines recommend that ICU teams provide emotional support to families of critically ill patients. Yet, families often receive little emotional support from ICU clinicians. We sought to determine the acceptability and feasibility of the multicomponent Emotional Support in ICU (ES-ICU) intervention. Methods We conducted an open-label pilot study of ES-ICU in the medical ICU of a quaternary academic medical center. We enrolled patients requiring invasive mechanical ventilation, their primary surrogate decision maker, and their ICU physicians and medical team. ES-ICU consists of: (1) early chaplain meetings with families, and (2) relaying family perspectives on the ICU experience to ICU clinicians in standardized reports before scheduled family meetings. Chaplains elicit family perspectives and generate reports that include perspective taking prompts. Fidelity was defined as the proportion of families who met with a chaplain and had a report generated and reviewed by clinicians before a routine family meeting. Chaplains completed the acceptability of intervention measure (AIM) and feasibility of intervention measure (FIM) after chaplain-family meetings. Families completed AIM and clinicians completed AIM and FIM after family meetings. Results We enrolled 9 patients and their family member. All families met with a chaplain (called an “ICU support counselor”). Initial chaplain-family meetings occurred a median of 4.1 days (25th-75th3.7-5.1) after ICU admission and lasted a median of 55 minutes (25th-75th30-60). Chaplains completed surveys after every meeting and reported that in 8 of 9 (89%) meetings families “opened up and offered deep insights into their perspectives”. A structured report was created for all families. Routine family meetings occurred for 7 patients and the report was reviewed by physicians prior to all meetings. Family meetings occurred a median of 4.8 days (25th-75th4.7-7.6) after ICU admission and lasted a median of 40 minutes (25th-75th31-44). All physicians completed post-meeting surveys and rated 71% of reports as quite a bit or extremely helpful. Six families completed post-meeting surveys, and all completely agreed that they felt “supported by the ICU support counselor” and “would recommend the ICU support counselor”. Three families had follow-up visits with chaplains and 3 updated reports were created. Follow-up family meetings occurred for 2 of these families and physicians reviewed reports before both. All participants found ES-ICU acceptable and feasible (Table). Conclusions In a small open-label pilot study, ES-ICU was implemented with fidelity and was acceptable and feasible to participants. A larger pilot randomized trial of ES-ICU is warranted.

Background: In high-risk industries, the primary purpose of incident reporting is to obtain insights into contributing factors. Incident reporting systems in hospitals receive numerous reports from nurses but often lack detailed, actionable information. Enriching the information captured by incident reports would facilitate local efforts to improve patient safety. Methods: The authors developed the Systems Approach For Event Reporting (SAFER) educational program to train nurses to (1) write detailed narratives and (2) describe contributing factors. To achieve these objectives, the research team incorporated the Situation, Background, Assessment, Recommendation (SBAR) model and the Systems Engineering Initiative for Patient Safety (SEIPS) model. The authors conducted pilot tests with nurses, made iterative refinements, then deployed SAFER on eight nursing units at an academic medical center. Results: An online learning module provides background information, a detailed curriculum leveraging SBAR and SEIPS models, interactive exercises, real-world examples of enhanced reports, and concluding information on how enhanced reporting benefits both nursing practice and patient safety. Nurses received a badge buddy-a laminated, double-sided reminder card to hang behind identification badges that reinforces key elements of SBAR and SEIPS models. In pilot testing, nurses reported that completing the module took 10 to 20 minutes, the material was clear and easy to understand, and they understood its purpose and objectives. The completion rate for implementation of SAFER online training was 88.7% (809/912 eligible nurses). Conclusion: SAFER is an innovative program that introduces human factors principles to nurses and trains them to incorporate SBAR and SEIPS into incident reporting. SAFER is acceptable and feasible. Ongoing work includes testing the impact of SAFER on improving the utility of incident reports.