Daniel Tawfik

All Publications

• Physician perspectives of clinical performance feedback and impact on well-being: a qualitative exploration. BMJ open Levoy, E., Vilendrer, S., Dang, R., Nasr, A. S., Luu, J., Tawfik, D., Shanafelt, T. 2024; 14 (11): e082726

  Abstract

  Providing clinical performance feedback to physicians is an established method to improve care, but the impact on physician well-being is unclear. This evaluation aimed to better understand physician perspectives on clinical feedback and its potential impact on well-being.A qualitative design using semi-structured interviews was undertaken. Data were analysed via consensus coding using an inductive-deductive approach informed by Clinical Performance Feedback Intervention Theory. Findings were used to develop a novel framework describing the relationship between feedback and well-being.Interviews were conducted in a large academic medical centre from June-September 2021.We conducted 25 semi-structured interviews with general outpatient and inpatient paediatricians and internists.Physicians felt that feedback supported well-being based on its perceived purpose (intended to promote professional growth vs serving an alternative purpose), which they discerned based on feedback content (aligned with physician priorities vs not aligned), validity (accurate vs inaccurate), actionability (specific vs not, within a physician's sphere of control vs not) and delivery (supportive vs punitive). The Clinical Performance Feedback Well-Being Model is presented to understand how feedback and recipient variables impact well-being.Attention to the process and content of physician clinical performance feedback may advance both the quality of care and physician well-being.

  View details for DOI 10.1136/bmjopen-2023-082726

  View details for PubMedID 39521465

• Evaluating the implementation of the Pediatric Acute Care Education (PACE) program in northwestern Tanzania: a mixed-methods study guided by normalization process theory. BMC health services research Mwanga, J. R., Hokororo, A., Ndosi, H., Masenge, T., Kalabamu, F. S., Tawfik, D., Mediratta, R. P., Rozenfeld, B., Berg, M., Smith, Z. H., Chami, N., Mkopi, N. P., Mwanga, C., Diocles, E., Agweyu, A., Meaney, P. A. 2024; 24 (1): 1066

  Abstract

  In low- and middle-income countries (LMICs), such as Tanzania, the competency of healthcare providers critically influences the quality of pediatric care. To address this issue, we introduced Pediatric Acute Care Education (PACE), an adaptive learning program to enhance provider competency in Tanzania's guidelines for managing seriously ill children. Adaptive learning is a promising alternative to current in-service education, yet optimal implementation strategies in LMIC settings are unknown.(1) To evaluate the initial PACE implementation in Mwanza, Tanzania, using the construct of normalization process theory (NPT); (2) To provide insights into its feasibility, acceptability, and scalability potential.Mixed-methods study involving healthcare providers at three facilities. Quantitative data was collected using the Normalization MeAsure Development (NoMAD) questionnaire, while qualitative data was gathered through in-depth interviews (IDIs) and focus groups discussions (FGDs).Eighty-two healthcare providers completed the NoMAD survey. Additionally, 24 senior providers participated in IDIs, and 79 junior providers participated in FGDs. Coherence and cognitive participation were high, demonstrating that PACE is well understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practices, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly those affecting collective action, were noted. Early indicators point toward the potential for long-term sustainability of the PACE, but assessment of reflexive monitoring was limited due to the study's focus on PACE's initial implementation.This study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges as well as conducting a longer-term study to assess reflexive monitoring is crucial for its successful implementation. Furthermore, the study underscores the value of the NPT as a framework for guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs.

  View details for DOI 10.1186/s12913-024-11554-3

  View details for PubMedID 39272036

  View details for PubMedCentralID PMC11401409

• Unit-based Pathways to Reduce InequitieS for familiEs speaking languages other than English (UPRISE). Hospital pediatrics Magana-Soto, J. N., Ruiz, M. O., Tawfik, D. S., Rey-Ardila, D., Bonillas, A., Persoglia-Bell, M., Su, F., Anand, K. J. 2024

  Abstract

  Health care inequities are common among individuals who speak languages other than English (LOE). Within our PICU, LOE families prefer communication via in-person interpreters (IPI). Spanish-speaking patient families are our largest LOE population; therefore, we sought to increase Spanish IPI utilization for medical updates in the PICU.A quality improvement initiative in a 36-bed PICU included: the addition of a dedicated weekday Spanish-speaking IPI, the creation of communication tools, staff education, optimized identification of LOE families, and development of a language dashboard across multiple Plan, Do, Study, Act cycles. The primary outcome was IPI utilization rates for daily medical updates.Spanish IPI utilization for daily weekday medical updates among 442 Spanish-speaking patient families increased from a median of 39.4% at baseline to a new centerline median of 51.9% during implementation, exhibiting 66.3% (465 of 701) utilization in the final 6 months of implementation. The greatest sustained increases in Spanish IPI utilization occurred after PICU-based IPI implementation, staff education, electronic health record optimization, and a split work week between 2 PICU-based IPIs.This quality improvement initiative increased Spanish IPI utilization for daily weekday medical updates in the PICU across multiple Plan, Do, Study, Act cycles. Future work will adapt these interventions to other languages and other hospital-based units.

  View details for DOI 10.1542/hpeds.2023-007569

  View details for PubMedID 39165244

• Evaluating the Implementation of the Pediatric Acute Care Education (PACE) Program in Northwestern Tanzania: A Mixed-Methods Study Guided by Normalization Process Theory. Research square Mwanga, J. R., Hokororo, A., Ndosi, H., Masenge, T., Kalabamu, F. S., Tawfik, D., Mediratta, R. P., Rozenfeld, B., Berg, M., Smith, Z. H., Chami, N., Mkopi, N. P., Mwanga, C., Diocles, E., Agweyu, A., Meaney, P. A. 2024

  Abstract

  In low- and -middle-income countries (LMICs) like Tanzania, the competency of healthcare providers critically influences the quality of pediatric care. To address this, we introduced PACE (Pediatric Acute Care Education), an adaptive e-learning program tailored to enhance provider competency in line with Tanzania's national guidelines for managing seriously ill children. Adaptive e-learning presents a promising alternative to traditional in-service education, yet optimal strategies for its implementation in LMIC settings remain to be fully elucidated.This study aimed to (1) evaluate the initial implementation of PACE in Mwanza, Tanzania, using the constructs of Normalization Process Theory (NPT), and (2) provide insights into its feasibility, acceptability, and scalability potential.A mixed-methods approach was employed across three healthcare settings in Mwanza: a zonal hospital and two health centers. NPT was utilized to navigate the complexities of implementing PACE. Data collection involved a customized NoMAD survey, focus groups and in-depth interviews with healthcare providers.The study engaged 82 healthcare providers through the NoMAD survey and 79 in focus groups and interviews. Findings indicated high levels of coherence and cognitive participation, demonstrating that PACE is well-understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practice, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly affecting collective action, were noted. The short duration of the study limited the assessment of reflexive monitoring, though early indicators point towards the potential for PACE's long-term sustainability.This study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges is crucial for its successful and sustainable implementation. Furthermore, the study underscores the value of NPT as a framework in guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs.

  View details for DOI 10.21203/rs.3.rs-4432440/v1

  View details for PubMedID 38854141

  View details for PubMedCentralID PMC11160918

• "WISER" intervention to reduce healthcare worker burnout - 1 year follow up. Journal of perinatology : official journal of the California Perinatal Association Profit, J., Cui, X., Tawfik, D., Adair, K. C., Sexton, J. B. 2024

  Abstract

  Test sustainability of Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention efficacy in reducing healthcare worker (HCW) emotional exhaustion (EE), a key component of burnout.One-year follow-up of WISER RCT using two cohorts (one waitlist control with shortened intervention period) of HCWs of four NICUs each, to improve HCW well-being (primary outcome: EE).In Cohorts 1 and 2, 194 and 312 WISER initiators were identified by 1-year, and 99 and 80 completed 1-year follow-up, respectively. Combined cohort results showed that relative to baseline, at 1-year WISER decreased EE (-7.07 (95%CI: -10.22, -3.92), p < 0.001), depression (-4.49 (-6.81, -2.16), p = <0.001), and improved work-life integration (6.08 (4.25, 7.90), p = <0.001). EE continued to decline between 6-month and 1-year follow-up (p = 0.022). The percentage of HCWs reporting concerning outcomes was significantly decreased for EE (-10.9% (95%CI: -17.9%, -4.9%); p < 0.001), and secondary outcomes depression and work-life integration.WISER improves HCW well-being for at least 1 year.NCT02603133; https://clinicaltrials.gov/ct2/show/NCT02603133.

  View details for DOI 10.1038/s41372-024-01993-5

  View details for PubMedID 38734802

  View details for PubMedCentralID 3509207

• Predicting Primary Care Physician Burnout From Electronic Health Record Use Measures. Mayo Clinic proceedings Tawfik, D., Bayati, M., Liu, J., Nguyen, L., Sinha, A., Kannampallil, T., Shanafelt, T., Profit, J. 2024

  Abstract

  To evaluate the ability of routinely collected electronic health record (EHR) use measures to predict clinical work units at increased risk of burnout and potentially most in need of targeted interventions.In this observational study of primary care physicians, we compiled clinical workload and EHR efficiency measures, then linked these measures to 2 years of well-being surveys (using the Stanford Professional Fulfillment Index) conducted from April 1, 2019, through October 16, 2020. Physicians were grouped into training and confirmation data sets to develop predictive models for burnout. We used gradient boosting classifier and other prediction modeling algorithms to quantify the predictive performance by the area under the receiver operating characteristics curve (AUC).Of 278 invited physicians from across 60 clinics, 233 (84%) completed 396 surveys. Physicians were 67% women with a median age category of 45 to 49 years. Aggregate burnout score was in the high range (≥3.325/10) on 111 of 396 (28%) surveys. Gradient boosting classifier of EHR use measures to predict burnout achieved an AUC of 0.59 (95% CI, 0.48 to 0.77) and an area under the precision-recall curve of 0.29 (95% CI, 0.20 to 0.66). Other models' confirmation set AUCs ranged from 0.56 (random forest) to 0.66 (penalized linear regression followed by dichotomization). Among the most predictive features were physician age, team member contributions to notes, and orders placed with user-defined preferences. Clinic-level aggregate measures identified the top quartile of clinics with 56% sensitivity and 85% specificity.In a sample of primary care physicians, routinely collected EHR use measures demonstrated limited ability to predict individual burnout and moderate ability to identify high-risk clinics.

  View details for DOI 10.1016/j.mayocp.2024.01.005

  View details for PubMedID 38573301

• High Variability in the Duration of Chest Compression Interruption is Associated With Poor Outcomes in Pediatric Extracorporeal Cardiopulmonary Resuscitation. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Han, P., Rasmussen, L., Su, F., Dacre, M., Knight, L., Berg, M., Tawfik, D., Haileselassie, B. 2024

  Abstract

  To determine the association between chest compression interruption (CCI) patterns and outcomes in pediatric patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR).Cardiopulmonary resuscitation (CPR) data were collected using defibrillator-electrode and bedside monitor waveforms from pediatric ECPR cases between 2013 and 2021. Duration and variability of CCI during cannulation for ECPR was determined and compared with survival to discharge using Fishers exact test and logistic regressions with cluster-robust ses for adjusted analyses.Quaternary care children's hospital.Pediatric patients undergoing ECPR.None.Of 41 ECPR events, median age was 0.7 years (Q1, Q3: 0.1, 5.4), 37% (15/41) survived to hospital discharge with 73% (11/15) of survivors having a favorable neurologic outcome. Median duration of CPR from start of ECPR cannulation procedure to initiation of extracorporeal membrane oxygenation (ECMO) flow was 21 minutes (18, 30). Median duration of no-flow times associated with CCI during ECMO cannulation was 11 seconds (5, 28). Following planned adjustment for known confounders, survival to discharge was inversely associated with maximum duration of CCI (odds ratio [OR] 0.91 [0.86-0.95], p = 0.04) as well as the variability in the CCI duration (OR 0.96 [0.93-0.99], p = 0.04). Cases with both above-average CCI duration and higher CCI variability (sd> 30 s) were associated with lowest survival (12% vs. 54%, p = 0.009). Interaction modeling suggests that lower variability in CCI is associated with improved survival, especially in cases where average CCI durations are higher.Shorter duration of CCI and lower variability in CCI during cannulation for ECPR were associated with survival following refractory pediatric cardiac arrest.

  View details for DOI 10.1097/PCC.0000000000003461

  View details for PubMedID 38299932

• EXCESS DAILY BLOOD COUNT SAMPLING IN CHILDREN: A PICU DATA COLLABORATIVE STUDY Shah, S., Dziorny, A., Flynn, A., Aczon, M., Farris, R., Horvat, C., Tawfik, D., Bennett, T., Cornell, T., Nishisaki, A., Kennedy, C., Sanchez-Pinto, L., Wetzel, R. LIPPINCOTT WILLIAMS & WILKINS. 2024

  View details for Web of Science ID 001131541101762

• Altered profiles of extracellular mitochondrial DNA in immunoparalyzed pediatric patients after thermal injury. Shock (Augusta, Ga.) Tetri, L. H., Penatzer, J. A., Tsegay, K. B., Tawfik, D. S., Burk, S., Lopez, I., Thakkar, R. K., Haileselassie, B. 2023

  Abstract

  Thermal injury is a major cause of morbidity and mortality in the pediatric population world-wide with secondary infection being the most common acute complication. Suppression of innate and adaptive immune function is predictive of infection in pediatric burn patients, but little is known about the mechanisms causing these effects. Circulating mtDNA which induces a proinflammatory signal, has been described in multiple disease states, but has not been studied in pediatric burn injuries. This study examined the quantity of circulating mtDNA and mtDNA mutations in immunocompetent (IC) and immunoparalyzed (IP) pediatric burn patients.Circulating DNA was isolated from plasma of pediatric burn patients treated at Nationwide Children's Hospital Burn Center at early (1-3 days) and late (4-7 days) time points post-injury. These patients were categorized as IP or IC based on previously established immune function testing and secondary infection. Three mitochondrial genes, D loop, ND1, and ND4, were quantified by multiplexed qPCR to assess both mtDNA quantity and mutation load.At the early timepoint, there were no differences in plasma mtDNA quantity, however IC patients had a progressive increase in mtDNA over time when compared to IP patients (change in ND1 copy number over time 3880 vs 87 copies/day, p = 0.0004). Conversely, the IP group had an increase in mtDNA mutation burden over time.IC patients experienced a significant increase in circulating mtDNA quantity over time, demonstrating an association between increased mtDNA release, and proinflammatory phenotype in the burn patients. IP patients had significant increases in mtDNA mutation load likely representative of degree of oxidative damage. Together, these data provide further insight into the inflammatory and immunological mechanisms following pediatric thermal injury.

  View details for DOI 10.1097/SHK.0000000000002253

  View details for PubMedID 38010095

• Prevalence of burnout and its relation to the neuroendocrine system among pediatric residents during the early Covid-19 pandemic: A pilot feasibility study. Comprehensive psychoneuroendocrinology Tawfik, D. S., Rovnaghi, C., Profit, J., Cornell, T. T., Anand, K. J. 2023; 14: 100174

  Abstract

  Background: Measuring burnout relies on infrequent and subjective surveys, which often do not reflect the underlying factors or biological mechanisms that promote or prevent it. Burnout correlates with cortisol levels and dysregulation of the hypothalamic-pituitary-adrenal axis, but the chronology and strength of this relationship are unknown.Objective: To determine the prevalence and feasibility of studying burnout in pediatric residents using hair cortisol and hair oxytocin concentrations.Design: /Methods: Longitudinal observational cohort study of pediatric residents. We assessed burnout using the Stanford Professional Fulfillment Index and hair cortisol (HCC), and hair oxytocin concentrations (HOC) at four 3-month intervals from January 2020-January 2021. We evaluated test-retest reliability, sensitivity to change using Pearson product-moment correlations, and relationships between burnout and hair biomarkers using hierarchical mixed-effects linear regression.Results: 17 Pediatrics residents provided 78 wellness surveys and 54 hair samples. Burnout symptoms were present in 39 (50%) of the surveys, with 14 (82%) residents reporting burnout in at least one time point. The lowest (41%) and highest (60%) burnout prevalence occurred in 04/2020 and 01/2021, respectively. No significant associations between burnout scores and HCC (beta -0.01, 95%CI: 0.14-0.13), HOC (beta 0.06, 95%CI: 0.06-0.19), or the HCC:HOC ratio (beta -0.04, 95%CI: 0.09-0.02) were noted in separate analyses. Intra-individual changes in hair cortisol concentration were not associated with changes in burnout score.Conclusions: Burnout was prevalent among Pediatrics residents, with highest prevalence noted in January 2021. This pilot longitudinal study demonstrates the feasibility of evaluating burnout with stress and resilience biomarkers in Pediatrics residents.

  View details for DOI 10.1016/j.cpnec.2023.100174

  View details for PubMedID 36742128

• Performance of a Provider-Assigned Functional Outcome Score in Critically Ill Children. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Wilson, N. E., Su, F., DaCar, A., Chang, N., Kapphahn, K., Schroeder, A. R., Tawfik, D. S., Knight, L., Rasmussen, L. 2023

  Abstract

  OBJECTIVES: Determine agreement between Pediatric Cerebral Performance Category (PCPC) scores integrated into clinical workflow and traditional investigator-assigned scores.DESIGN: Longitudinal study.SETTING: A single-center quaternary-care academic institution.SUBJECTS: Children admitted to the PICU between November 2019 and April 2020.INTERVENTIONS: Providers assigned PCPC scores as part of daily workflow. Investigators assigned scores using retrospective chart review.MEASUREMENTS AND MAIN RESULT: s: Of 803 patients admitted to the PICU, 782 survived and were included. Admission and discharge scores were recorded in 95% and 90% of patients, respectively. Agreement between provider- and investigator-assigned scores was excellent, with a weighted kappa of 0.87 (95% CI, 0.84-0.90) and 0.80 (95% CI, 0.76-0.84) for admission and discharge.CONCLUSIONS: Provider-assigned PCPC scores, documented as standard of care, are largely concordant with retrospective investigator-assigned scores. Measurement of cognitive functional status can be successfully integrated into daily provider workflow for use in the clinical, quality improvement, and research arenas.

  View details for DOI 10.1097/PCC.0000000000003234

  View details for PubMedID 37098780

• Assessing Leadership Behavior in Health Care: Introducing the Local Leadership Scale of the SCORE Survey JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Adair, K. C., Levoy, E., Tawfik, D. S., Palassof, S., Profit, J., Frankel, A., Leonard, M., Proulx, J., Sexton, B. 2023; 49 (3): 166-173

  Abstract

  Engaged and accessible leadership is a key component of care excellence. However, the field lacks brief, reliable, and actionable measures of feedback and coaching-related behaviors of local leaders (for example, provides frequent feedback). The current study introduces a five-item Local Leadership (LL) scale by examining its psychometric properties, providing benchmarking across demographic factors and work settings, assessing its association with psychological safety, and testing whether LL predicts reports of restricted activities and absenteeism.In this cross-sectional study, 23,853 questionnaires were distributed across 31 Midwestern US hospitals. The survey included the LL scale, as well as safety culture and well-being scales. Psychometric analyses (Cronbach's α, confirmatory factor analysis [CFA] fit: root square mean error of the approximation [RMSEA], comparative fit index [CFI], Tucker-Lewis index [TLI]), Spearman correlations, t-tests, and analyses of variance (ANOVAs) were used to test the properties of the LL scale and differences by health care worker and work setting characteristics.A total of 16,797 surveys were returned (70.4% response rate). The LL scale exhibited strong psychometric properties (Cronbach's α = 0.94; RMSEA = 0.079; CFI = 0.99; TLI = 0.98). LL scores differed by role, shift, shift length, and years in specialty. Of all roles, leaders (for example, managers) rated leaders most favorably. Nonclinical (vs. clinical) and nonsurgical (vs. surgical) work settings reported higher LL. LL scores correlated positively with psychological safety, absenteeism, and activities restricted due to illness.The LL scale exhibits strong psychometric properties, convergent validity with psychological safety, and variation by work setting, work setting type, role, shift, shift length, and specialty. The study indicates that assessing leadership behaviors with the LL scale is useful and offers actionable behaviors for leaders to improve safety culture within teams.

  View details for DOI 10.1016/j.jcjq.2022.12.007

  View details for Web of Science ID 000965658900001

  View details for PubMedID 36717344

• Leadership Behavior Associations with Domains of Safety Culture, Engagement, and Health Care Worker Well-Being JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Tawfik, D. S., Adair, K. C., Palassof, S., Sexton, B. J., Levoy, E., Frankel, A., Leonard, M., Proulx, J., Profit, J. 2023; 49 (3): 156-165

  Abstract

  Leadership is a key driver of health care worker well-being and engagement, and feedback is an essential leadership behavior. Methods for evaluating interaction norms of local leaders are not well developed. Moreover, associations between local leadership and related domains are poorly understood. This study sought to evaluate health care worker leadership behaviors in relation to burnout, safety culture, and engagement using the Local Leadership scale of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey.The SCORE survey was administered to 31 Midwestern hospitals as part of a broad effort to measure care context, with domains including Local Leadership, Emotional Exhaustion/Burnout, Safety Climate, and Engagement. Mixed-effects hierarchical logistic regression was used to evaluate the relationships between local leadership scores and related domains, adjusted for role and work-setting characteristics.Of the 23,853 distributed surveys, 16,797 (70.4%) were returned. Local leadership scores averaged 68.8 ± 29.1, with 7,338 (44.2%) reporting emotional exhaustion, 9,147 (55.9%) reporting concerning safety climate, 10,974 (68.4%) reporting concerning teamwork climate, 7,857 (47.5%) reporting high workload, and 3,436 (20.7%) reporting intentions to leave. Each 10-point increase in local leadership score was associated with odds ratios of 0.72 (95% confidence interval [CI] 0.71-0.73) for burnout, 0.48 (95% CI 0.47-0.49) for concerning safety climate, 0.64 (95% CI 0.63-0.66) for concerning teamwork climate, 0.90 (95% CI 0.89-0.92) for high workload, and 0.80 (95% CI 0.78-0.81) for intentions to leave, after adjustment for unit and provider characteristics.Local leadership behaviors are readily measurable using a five-item scale and strongly associate with established domains of health care worker well-being, safety culture, and engagement.

  View details for DOI 10.1016/j.jcjq.2022.12.006

  View details for Web of Science ID 000991813200001

  View details for PubMedID 36658090

  View details for PubMedCentralID PMC9974844

• Creating Conversion Factors from EHR Event Log Data: A Comparison of Investigator-Derived and Vendor-Derived Metrics for Primary Care Physicians. AMIA ... Annual Symposium proceedings. AMIA Symposium Magon, H. S., Helkey, D., Shanafelt, T., Tawfik, D. 2023; 2023: 1115-1124

  Abstract

  Physicians spend a large amount of time with the electronic health record (EHR), which the majority believe contributes to their burnout. However, there are limitedstandardized measures of physician EHR time. Vendor-derived metrics are standardized but may underestimate real-world EHR experience. Investigator-derived metrics may be more reliable but not standardized, particularly with regard to timeout thresholds defining inactivity. This study aimed to enable standardized investigator-derived metrics using conversion factors between raw event log-derived metrics and Signal (Epic System's standardized metric) for primary care physicians. This was an observational, retrospective longitudinal study of EHR raw event logs and Signal data from a quaternary academic medical center and its community affiliates in California, over a 6-month period. The study evaluated 242 physicians over 1370 physician-months, comparing 53.7 million event logs to 6850 Signal metrics, in five different time based metrics. Results show that inactivity thresholds for event log metric derivation that most closely approximate Signal metrics ranged from 90 seconds (Visit Navigator) to 360 seconds ("Pajama time") depending on the metric. Based on this data, conversion factors for investigator-derived metrics across a wide range of inactivity thresholds, via comparison with Signal metrics, are provided which may allow researchers to consistently quantify EHR experience.

  View details for PubMedID 38222350

  View details for PubMedCentralID PMC10785859

• MEASURING ASSOCIATIONS BETWEEN ELECTRONIC HEALTH RECORD USE AND INPATIENT PEDIATRIC PROVIDER BURNOUT Stevens, L., Su, F., Pageler, N., Tawfik, D., Sinha, A. LIPPINCOTT WILLIAMS & WILKINS. 2023: 40

  View details for Web of Science ID 000921450900081

• Prediction of Difficult Laryngoscopy Using Ultrasound: A Systematic Review and Meta-Analysis. Critical care medicine Bhargava, V., Rockwell, N. A., Tawfik, D., Haileselassie, B., Petrisor, C., Su, E. 2023; 51 (1): 117-126

  Abstract

  OBJECTIVES: Evaluate associations between ultrasound measures and difficult laryngoscopy.DATA SOURCES: MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library were searched using MeSH terms and keywords.STUDY SELECTION: Studies published in English describing the use of airway ultrasound for identifying difficult laryngoscopy, with sufficient data to calculate sensitivity and specificity using 2*2 tables.DATA EXTRACTION: We assigned the described indices of airway dimension to one of three domains based on methodology characteristics: anterior tissue thickness domain, anatomical position domain, and oral space domain. We then performed a bivariate random-effects meta-analysis, deriving pooled sensitivity, specificity, diagnostic odds ratio, positive likelihood ratio, and negative likelihood ratio estimates. We assessed risks of bias using Quality Assessment of Diagnostic Accuracy Studies-2 analysis.DATA SYNTHESIS: Thirty-three studies evaluating 27 unique indices were included in the meta-analysis. The ultrasound protocols of the included studies were heterogeneous. Anterior tissue thickness demonstrated a pooled sensitivity of 76% (95% CI, 71-81%), specificity of 77% (95% CI, 72-81%), and an area under the receiver operating characteristic curve (AUROC) of 0.83 (95% CI, 0.80-0.86). Anatomical position demonstrated a pooled sensitivity of 74% (95% CI, 61-84%), specificity of 86% (95% CI, 78-91%), and an AUROC of 0.87 (95% CI, 0.84-0.90). Oral space demonstrated a pooled sensitivity of 53% (95% CI, 0.36-0.69), specificity of 77% (95% CI, 0.67-0.85), and an AUROC of 0.73 (95% CI, 0.69-0.77).CONCLUSIONS: Airway ultrasound metrics associate with difficult laryngoscopy in three domains: anterior tissue thickness, anatomic position, and oral space. An assessment instrument combining clinical and ultrasound assessments may be an accurate screening tool for difficult laryngoscopy.

  View details for DOI 10.1097/CCM.0000000000005711

  View details for PubMedID 36519985

• Physician Health and Wellness. Pediatrics McClafferty, H. H., Hubbard, D. K., Foradori, D., Brown, M. L., Profit, J., Tawfik, D. S., SECTION ON INTEGRATIVE MEDICINE, SECTION ON INTEGRATIVE MEDICINE, Brown, M. L., Breuner, C. C., Esparham, A., Gold, M. A., Misra, S. M., Morris, C. R., Tsai, S., Weydert, J. A., Bhakta, H. C., Salus, T. 2022

  Abstract

  Physician health and wellness is a complex topic relevant to all pediatricians. Survey studies have established that pediatricians experience burnout at comparable rates to colleagues across medical specialties. Prevalence of burnout increased for all pediatric disciplines from 2011 to 2014. During that time, general pediatricians experienced a more than 10% increase in burnout, from 35.3% to 46.3%. Pediatric medical subspecialists and pediatric surgical specialists experienced slightly higher baseline rates of burnout in 2011 and similarly increased to just under 50%. Women currently constitute a majority of pediatricians, and surveys report a 20% to 60% higher prevalence of burnout in women physicians compared with their male counterparts. The purpose of this report is to update the reader and explore approaches to pediatrician well-being and reduction of occupational burnout risk throughout the stages of training and practice. Topics covered include burnout prevalence and diagnosis; overview of national progress in physician wellness; update on physician wellness initiatives at the American Academy of Pediatrics; an update on pediatric-specific burnout and well-being; recognized drivers of burnout (organizational and individual); a review of the intersection of race, ethnicity, gender, and burnout; protective factors; and components of wellness (organizational and individual). The development of this clinical report has inevitably been shaped by the social, cultural, public health, and economic factors currently affecting our communities. The coronavirus disease 2019 (COVID-19) pandemic has layered new and significant stressors onto medical practice with physical, mental, and logistical challenges and effects that cannot be ignored.

  View details for DOI 10.1542/peds.2022-059665

  View details for PubMedID 36278292

• Evolution of Thromboelastography Parameters During Pediatric Liver Transplantation Damian, M. I., Tawfik, D., Mendoza, J., Gallo, A., Esquivel, C. LIPPINCOTT WILLIAMS & WILKINS. 2022: S452-S453

  View details for Web of Science ID 000889117001070

• EHR USABILITY AND BARRIERS TO EFFICIENT INFORMATION GATHERING ON THE EHR IN THE PICU: CURRENT STATE Sinha, A., Tawfik, D., Steffen, K. LIPPINCOTT WILLIAMS & WILKINS. 2022: 640

  View details for Web of Science ID 000777939301512

• Effectiveness of a bite-sized web-based intervention to improve healthcare worker wellbeing: A randomized clinical trial of WISER. Frontiers in public health Sexton, J. B., Adair, K. C., Cui, X., Tawfik, D. S., Profit, J. 2022; 10: 1016407

  Abstract

  Importance: Problems with the wellbeing of healthcare workers (HCWs) are widespread and associated with detrimental consequences for the workforce, organizations, and patients.Objective: This study tested the effectiveness of the Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention, a positive psychology program, to improve six dimensions of the wellbeing of HCWs.Design: We conducted a randomized controlled trial of HCWs between 1 April 2018 and 22 July 2019. Cohort 1 received WISER daily for 10 days. Cohort 2 acted as a waitlist control before receiving WISER.Setting: Web-based intervention for actively employed HCWs across the United States.Participants: Eligibility criteria included being ≥18 years old and working as a HCW. Each participant was randomized to start the intervention or serve as a waitlist control for 14 days before starting the intervention.Interventions: Cohorts received links via 10 texts exposing them to introductory videos and positive psychology exercises (3 good things, cultivating awe, random acts of kindness, cultivating relationships, and gratitude letters).Main outcomes and measures: The primary outcome was emotional exhaustion; secondary outcomes included depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. All outcomes were assessed at baseline, 1-week post-intervention (primary endpoint), and 1, 6, and 12-month post-intervention. Outcomes were measured using six validated wellbeing instruments, rescaled to 100-point scales for comparison. Six items assessed participants' WISER experience. The analysis employed mixed-effects models.Results: In cohorts 1 and 2, 241 and 241 initiated WISER, and 178 (74%) and 186 (77%) completed the 6-month follow-up, respectively. Cohort populations were similar at baseline, mostly female (81; 76%) and nurses (34; 32%) or physicians (22; 23%), with 1-10 years of experience in their current position (54; 52%). Relative to control, WISER significantly improved depressive symptoms [-7.5 (95%CI: -11.0, -4.0), p < 0.001], work-life integration [6.5 (95%CI: 4.1, 8.9), p < 0.001], happiness [5.7 (95%CI: 3.0, 8.4), p < 0.001], emotional thriving [6.4 (95%CI: 2.5, 10.3), p = 0.001], and emotional recovery [5.3 (95%CI: 1.7, 8.9), p = 0.004], but not emotional exhaustion [-3.7 (95%CI: -8.2, 0.8), p = 0.11] at 1 week. Combined cohort results at 1, 6, and 12 months showed that all six wellbeing outcomes were significantly improved relative to baseline (p < 0.05 for all). Favorable impressions of WISER were reported by 87% of participants at the 6-month post-assessment.Conclusion and relevance: WISER improved HCW depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. Improvements in all HCW wellbeing outcomes endured at the 1-, 6-, and 12-month follow-ups. HCW's impressions of WISER were positive.Clinical trials number: https://clinicaltrials.gov/ct2/show/, identifier: NCT02603133. Web-based Implementation for the Science of Enhancing Resilience Study (WISER).

  View details for DOI 10.3389/fpubh.2022.1016407

  View details for PubMedID 36568789

• Laryngeal Ultrasound Detects Vocal Fold Immobility in Adults: A Systematic Review. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine Su, E., Hamilton, C., Tawfik, D. S., Mariano, K., Ginsburg, S., Conlon, T., Veten, A., Fernandez, E., Wong, K., Sidell, D. R., Haileselassie, B., Pediatric Research Collaborative for Critical Ultrasound 2021

  Abstract

  Laryngeal ultrasound (US) is becoming widely accepted for assessing true vocal fold immobility (TVFI), a potential complication of laryngeal and thyroid surgery. The objective of this project is to perform a systematic review and meta-analysis of pooled evidence surrounding laryngeal US as a modality for diagnosing TVFI in adults at risk for the condition in comparison to laryngoscopy as a gold standard. Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations from January 1, 2000, to June 30, 2020. Studies were included if they involved patients 16years and older, where laryngeal US was compared to laryngoscopy for TVFI. Studies were excluded if there were insufficient data to compute a sensitivity/specificity table after attempting to contact the authors. Case reports, and case series were also excluded. The initial search returned 1357 citations. Of these, 109 were selected for review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty citations describing 6033 patients were included in the final meta-analysis. A bivariate random effects meta-analysis was performed, revealing a pooled sensitivity for laryngeal US of 0.95 (95% confidence interval [CI] 0.88-0.98), a specificity of 0.99 (95% CI 0.97-0.99), and a diagnostic odds ratio of 1328.2 (95% CI 294.0-5996.5). The area under the curve of the hierarchical summary receiver operating characteristic curve was 0.99 (95% CI 0.98-1.00). Laryngeal US demonstrates high sensitivity and specificity for detecting VFI in the hands of clinicians directly providing care to patients.

  View details for DOI 10.1002/jum.15884

  View details for PubMedID 34837415

• Contributions of Systolic and Diastolic Blood Pressures to Cardiovascular Outcomes in the ALLHAT Study. Journal of the American College of Cardiology Itoga, N. K., Tawfik, D. S., Montez-Rath, M. E., Chang, T. I. 2021; 78 (17): 1671-1678

  Abstract

  BACKGROUND: SBP and DBP have important associations with cardiovascular events, but are seldom considered simultaneously.OBJECTIVES: This study sought to simultaneously analyze systolic blood pressure (SBP) and diastolic blood pressure (DBP) measurements on the associated risk of a primary composite outcome of all-cause mortality, myocardial infarction (MI), congestive heart failure (CHF), or stroke.METHODS: This study analyzed ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) data, which randomized adults to chlorthalidone, amlodipine, or lisinopril. The authors evaluated the simultaneous association of repeated SBP and DBP measurements on the primary composite outcome, and each outcome using proportional hazards regression. The authors report hazard ratios using a "heat map" to represent high and low risk according to SBP and DBP combinations.RESULTS: During a median follow-up of 4.4 years (interquartile range: 3.6-5.4 years), 33,357 participants experienced 2,636 MIs, 866 CHF events, 936 strokes, and 3,700 deaths; 8,138 patients (24.4%) had at least 1 event. For the composite outcome, all-cause mortality, MI, and CHF, a U-shaped association was observed with SBP and DBP, but the SBP and DBP associated with the lowest hazards differed for each outcome. For example, SBP/DBP of 140-155/70-80mmHg was associated with the lowest HR for all-cause mortality, compared with 110-120/85-90mmHg for MI and 125-135/70-75mmHg for CHF. In contrast, the association of SBP and stroke was linear.CONCLUSIONS: The risk pattern of SBP and DBP differs by clinical outcomes, and the SBP and DBP associated with the lowest risk. Our results suggest individualization of blood pressure targets may depend in part on the cardiovascular event for which the patient is most at risk.

  View details for DOI 10.1016/j.jacc.2021.08.035

  View details for PubMedID 34674811

• Randomized controlled trial of the "WISER" intervention to reduce healthcare worker burnout. Journal of perinatology : official journal of the California Perinatal Association Profit, J., Adair, K. C., Cui, X., Mitchell, B., Brandon, D., Tawfik, D. S., Rigdon, J., Gould, J. B., Lee, H. C., Timpson, W. L., McCaffrey, M. J., Davis, A. S., Pammi, M., Matthews, M., Stark, A. R., Papile, L., Thomas, E., Cotten, M., Khan, A., Sexton, J. B. 2021

  Abstract

  OBJECTIVE: Test web-based implementation for the science of enhancing resilience (WISER) intervention efficacy in reducing healthcare worker (HCW) burnout.DESIGN: RCT using two cohorts of HCWs of four NICUs each, to improve HCW well-being (primary outcome: burnout). Cohort 1 received WISER while Cohort 2 acted as a waitlist control.RESULTS: Cohorts were similar, mostly female (83%) and nurses (62%). In Cohorts 1 and 2 respectively, 182 and 299 initiated WISER, 100 and 176 completed 1-month follow-up, and 78 and 146 completed 6-month follow-up. Relative to control, WISER decreased burnout (-5.27 (95% CI: -10.44, -0.10), p=0.046). Combined adjusted cohort results at 1-month showed that the percentage of HCWs reporting concerning outcomes was significantly decreased for burnout (-6.3% (95%CI: -11.6%, -1.0%); p=0.008), and secondary outcomes depression (-5.2% (95%CI: -10.8, -0.4); p=0.022) and work-life integration (-11.8% (95%CI: -17.9, -6.1); p<0.001). Improvements endured at 6 months.CONCLUSION: WISER appears to durably improve HCW well-being.CLINICAL TRIALS NUMBER: NCT02603133; https://clinicaltrials.gov/ct2/show/NCT02603133.

  View details for DOI 10.1038/s41372-021-01100-y

  View details for PubMedID 34366432

• Randomized controlled trial of the "WISER" intervention to reduce healthcare worker burnout JOURNAL OF PERINATOLOGY Profit, J., Adair, K. C., Cui, X., Mitchell, B., Brandon, D., Tawfik, D. S., Rigdon, J., Gould, J. B., Lee, H. C., Timpson, W. L., McCaffrey, M. J., Davis, A. S., Pammi, M., Matthews, M., Stark, A. R., Papile, L., Thomas, E., Cotten, M., Khan, A., Sexton, J. 2021

  View details for DOI 10.1038/541372-021-01100-y

  View details for Web of Science ID 000682814300001

• Frustration With Technology and its Relation to Emotional Exhaustion Among Health Care Workers: Cross-sectional Observational Study. Journal of medical Internet research Tawfik, D. S., Sinha, A., Bayati, M., Adair, K. C., Shanafelt, T. D., Sexton, J. B., Profit, J. 2021; 23 (7): e26817

  Abstract

  BACKGROUND: New technology adoption is common in health care, but it may elicit frustration if end users are not sufficiently considered in their design or trained in their use. These frustrations may contribute to burnout.OBJECTIVE: This study aimed to evaluate and quantify health care workers' frustration with technology and its relationship with emotional exhaustion, after controlling for measures of work-life integration that may indicate excessive job demands.METHODS: This was a cross-sectional, observational study of health care workers across 31 Michigan hospitals. We used the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey to measure work-life integration and emotional exhaustion among the survey respondents. We used mixed-effects hierarchical linear regression to evaluate the relationship among frustration with technology, other components of work-life integration, and emotional exhaustion, with adjustment for unit and health care worker characteristics.RESULTS: Of 15,505 respondents, 5065 (32.7%) reported that they experienced frustration with technology on at least 3-5 days per week. Frustration with technology was associated with higher scores for the composite Emotional Exhaustion scale (r=0.35, P<.001) and each individual item on the Emotional Exhaustion scale (r=0.29-0.36, P<.001 for all). Each 10-point increase in the frustration with technology score was associated with a 1.2-point increase (95% CI 1.1-1.4) in emotional exhaustion (both measured on 100-point scales), after adjustment for other work-life integration items and unit and health care worker characteristics.CONCLUSIONS: This study found that frustration with technology and several other markers of work-life integration are independently associated with emotional exhaustion among health care workers. Frustration with technology is common but not ubiquitous among health care workers, and it is one of several work-life integration factors associated with emotional exhaustion. Minimizing frustration with health care technology may be an effective approach in reducing burnout among health care workers.

  View details for DOI 10.2196/26817

  View details for PubMedID 34255674

• Personal and Professional Factors Associated With Work-Life Integration Among US Physicians. JAMA network open Tawfik, D. S., Shanafelt, T. D., Dyrbye, L. N., Sinsky, C. A., West, C. P., Davis, A. S., Su, F., Adair, K. C., Trockel, M. T., Profit, J., Sexton, J. B. 2021; 4 (5): e2111575

  Abstract

  Importance: Poor work-life integration (WLI) occurs when career and personal responsibilities come in conflict and may contribute to the ongoing high rates of physician burnout. The characteristics associated with WLI are poorly understood.Objective: To identify personal and professional factors associated with WLI in physicians and identify factors that modify the association between gender and WLI.Design, Setting, and Participants: This cross-sectional study was based on electronic and paper surveys administered October 2017 to March 2018 at private, academic, military, and veteran's practices across the US. It used a population-based sample of US physicians across all medical specialties. Data analysis was performed from November 2019 to July 2020.Main Outcomes and Measures: WLI was assessed using an 8-item scale (0-100 point scale, with higher scores indicating favorable WLI), alongside personal and professional factors. Multivariable linear regressions evaluated independent associations with WLI as well as factors that modify the association between gender and WLI.Results: Of 5197 physicians completing surveys, 4370 provided complete responses. Of the physicians who provided complete responses, 2719 were men, 3491 were White/Caucasian (80.8%), 3560 were married (82.4%), and the mean (SD) age was 52.3 (12.0) years. The mean (SD) WLI score was 55 (23). Women reported lower (worse) mean (SD) WLI scores than men overall (52 [22] vs 57 [23]; mean difference, -5 [-0.2 SDs]; P<.001). In multivariable regression, lower WLI was independently associated with being a woman (linear regression coefficient, -6; SE, 0.7; P<.001) as well as being aged 35 years or older (eg, aged 35 to 44 years: linear regression coefficient, -7; SE, 1.4; P<.001), single (linear regression coefficient, -3 vs married; SE, 1.1; P=.003), working more hours (eg, 50 to 59 hours per week vs less than 40 hours per week: linear regression coefficient, -9; SE, 1.0; P<.001) and call nights (linear regression coefficient, -1 for each call night per week; SE, 0.2; P<.001), and being in emergency medicine (linear regression coefficient, -18; SE, 1.6, P<.001), urology (linear regression coefficient, -11; SE, 4.0; P=.009), general surgery (linear regression coefficient, -4; SE, 2.0; P=.04), anesthesiology (linear regression coefficient, -4; SE, 1.7; P=.03), or family medicine (linear regression coefficient, -3; SE, 1.4; P=.04) (reference category, internal medicine subspecialties). In interaction modeling, physician age, youngest child's age, and hours worked per week modified the associations between gender and WLI, such that the largest gender disparities were observed in physicians who were aged 45 to 54 years (estimated WLI score for women, 49; 95% CI, 47-51; estimated WLI score for men, 57, 95% CI, 55-59; P<.001), had youngest child aged 23 years or older (estimated WLI score for women, 51; 95% CI, 48-54; estimated WLI score for men, 60; 95% CI, 58-62; P<.001), and were working less than 40 hours per week (estimated WLI score for women, 61; 95% CI, 59-63; estimated WLI score for men; 70; 95% CI, 68-72; P<.001).Conclusions and Relevance: This study found that lower WLI was reported by physicians who are women, single, aged 35 years or older, and who work more hours and call nights. These findings suggest that systemic change is needed to improve WLI among physicians.

  View details for DOI 10.1001/jamanetworkopen.2021.11575

  View details for PubMedID 34042994

• Maternal and neonatal health care worker well-being and patient safety climate amid the COVID-19 pandemic. Journal of perinatology : official journal of the California Perinatal Association Haidari, E., Main, E. K., Cui, X., Cape, V., Tawfik, D. S., Adair, K. C., Sexton, B. J., Profit, J. 2021

  Abstract

  OBJECTIVE: To assess maternal and neonatal healthcare workers (HCWs) perspectives on well-being and patient safety amid the COVID-19 pandemic.STUDY DESIGN: Anonymous survey of HCW well-being, burnout, and patient safety over the prior conducted in June 2020. Results were analyzed by job position and burnout status.RESULT: We analyzed 288 fully completed surveys. In total, 66% of respondents reported symptoms of burnout and 73% felt burnout among their co-workers had significantly increased. Workplace strategies to address HCW well-being were judged by 34% as sufficient. HCWs who were "burned out" reported significantly worse well-being and patient safety attributes. Compared to physicians, nurses reported higher rates of unprofessional behavior (37% vs. 14%, p=0.027) and difficulty focusing on work (59% vs. 36%, p=0.013).CONCLUSION: Three months into the COVID-19 pandemic, HCW well-being was substantially compromised, with negative ramifications for patient safety.

  View details for DOI 10.1038/s41372-021-01014-9

  View details for PubMedID 33727700

• Assessment of Vocal Cord Motion Using Laryngeal Ultrasound in Children: A Systematic Review and Meta-Analysis. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Hamilton, C. E., Su, E. n., Tawfik, D. n., Fernandez, E. n., Veten, A. n., Conlon, T. n., Ginsburg, S. n., Mariano, K. n., Sidell, D. n., Haileselassie, B. n. 2021

  Abstract

  Laryngeal ultrasound is a nonirradiating, noninvasive method for assessing the upper airway in children. This systematic review and meta-analysis examine available evidence for accuracy of laryngeal ultrasound in diagnosing vocal cord immobility in infants and children after surgery and trauma affecting the vocal cords.Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations. Publications from January 1, 2000, to June 30, 2020 were included in the search strategy. Study inclusion criteria consisted of randomized control trials and nonrandomized retrospective or prospective observational studies where vocal cord motion was evaluated by laryngeal ultrasound and compared with a reference test. Studies were excluded if there was insufficient data to compute a sensitivity/specificity table. Case reports, case series less than 10, and manuscripts not published in English were also excluded.Studies which included subjects younger than or equal to 18 years were considered for full article review.No restrictions on study settings were imposed in this systematic review.The initial search returned 1,357 citations. After de-duplication, abstract, and full review, eight citations were included in the final meta-analysis. A bivariate random-effects meta-analysis was performed, which revealed a pooled sensitivity for laryngeal ultrasound in detecting vocal cord immobility of 91% (95% CI, 83-95%), specificity of 97% (95% CI, 82-100%), diagnostic odds ratio 333.56 (95% CI, 34.00-3,248.71), positive likelihood ratio 31.58 (95% CI, 4.50-222.05), and negative likelihood ratio 0.09 (95% CI, 0.05-0.19).Laryngeal ultrasound demonstrates high sensitivity and specificity for detecting vocal cord motion in children in a wide range of clinical settings. Laryngeal ultrasound offers a low-risk imaging option for assessing vocal cord function in children compared with the current gold standard of laryngoscopy.

  View details for DOI 10.1097/PCC.0000000000002734

  View details for PubMedID 33833204

• Pain Assessment and Management in Pediatric Intensive Care Units Around the World, an International, Multicenter Study. Frontiers in pediatrics Grunauer, M., Mikesell, C., Bustamante, G., Cobo, G., Sánchez, S., Román, A. M., Icaza-Freire, A. P., Gavilanes, A. W., Wang, N. E. 2021; 9: 746489

  Abstract

  The adequate assessment and management of pain remains a challenging task in the Pediatric Intensive Care Unit (PICU). Our goal is to describe how pain is assessed and managed in PICUs around the world and to examine how human and material resources impact achievement of this goal. An international multicenter cross-sectional observational study was designed with the participation of 34 PICUs located in urban, suburban, and rural areas of 18 countries. We evaluated how PICUs around the world assessed and managed pain according to the Initiative for Pediatric Palliative Care recommendations, and how human and material resources impacted achievement of this goal. Data was collected for this study from 2016 to 2018 using questionnaires completed by medical doctors and nurses. In this paper, we focus on the indicators related to how pain is managed and assessed. The average achievement of the goal of pain relief across all centers was 72.2% (SD: 21.1). We found a statistically significant trend of more effective pain management scores, routine assessment, proper documentation, and involvement of pain management experts by increasing country income. While there are efforts being made worldwide to improve the knowledge in pain assessment and management, there is a lack of resources to do so appropriately in low-middle-income countries. There is a mismatch between the existing guidelines and policies, which are mainly designed in high income countries, and the resources available in lower resourced environments.

  View details for DOI 10.3389/fped.2021.746489

  View details for PubMedID 34778135

  View details for PubMedCentralID PMC8581242

• Measuring Electronic Health Record Use in the Pediatric ICU Using Audit-Logs and Screen Recordings. Applied clinical informatics Sinha, A., Stevens, L. A., Su, F., Pageler, N. M., Tawfik, D. S. 2021; 12 (4): 737-744

  Abstract

   Time spent in the electronic health record (EHR) has been identified as an important unit of measure for health care provider clinical activity. The lack of validation of audit-log based inpatient EHR time may have resulted in underuse of this data in studies focusing on inpatient patient outcomes, provider efficiency, provider satisfaction, etc. This has also led to a dearth of clinically relevant EHR usage metrics consistent with inpatient provider clinical activity. The aim of our study was to validate audit-log based EHR times using observed EHR-times extracted from screen recordings of EHR usage in the inpatient setting. This study was conducted in a 36-bed pediatric intensive care unit (PICU) at Lucile Packard Children's Hospital Stanford between June 11 and July 14, 2020. Attending physicians, fellow physicians, hospitalists, and advanced practice providers with ≥0.5 full-time equivalent (FTE) for the prior four consecutive weeks and at least one EHR session recording were included in the study. Citrix session recording player was used to retrospectively review EHR session recordings that were captured as the provider interacted with the EHR. EHR use patterns varied by provider type. Audit-log based total EHR time correlated strongly with both observed total EHR time (r = 0.98, p < 0.001) and observed active EHR time (r = 0.95, p < 0.001). Each minute of audit-log based total EHR time corresponded to 0.95 (0.87-1.02) minutes of observed total EHR time and 0.75 (0.67-0.83) minutes of observed active EHR time. Results were similar when stratified by provider role. Our study found inpatient audit-log based EHR time to correlate strongly with observed EHR time among pediatric critical care providers. These findings support the use of audit-log based EHR-time as a surrogate measure for inpatient provider EHR use, providing an opportunity for researchers and other stakeholders to leverage EHR audit-log data in measuring clinical activity and tracking outcomes of workflow improvement efforts longitudinally and across provider groups.

  View details for DOI 10.1055/s-0041-1733851

  View details for PubMedID 34380167

• PEDIATRIC ICU ELECTRONIC HEALTH RECORD USAGE AS MEASURED BY AUDIT LOGS AND SCREEN RECORDINGS Sinha, A., Stevens, L., Su, F., Pageler, N., Tawfik, D. LIPPINCOTT WILLIAMS & WILKINS. 2021: 156

  View details for Web of Science ID 000672597100301

• The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care JOURNAL OF PATIENT SAFETY Profit, J., Sharek, P. J., Cui, X., Nisbet, C. C., Thomas, E. J., Tawfik, D. S., Lee, H. C., Draper, D., Sexton, J. 2020; 16 (4): E310–E316

  View details for DOI 10.1097/PTS.0000000000000546

  View details for Web of Science ID 000595177300033

• Changing safety culture. Journal of perinatology : official journal of the California Perinatal Association Ravi, D., Tawfik, D. S., Sexton, J. B., Profit, J. 2020

  Abstract

  Safety culture, an aspect of organizational culture, that reflects work place norms toward safety, is foundational to high-quality care. Improvements in safety culture are associated with improved operational and clinical outcomes. In the neonatal intensive care unit (NICU), where fragile infants receive complex, coordinated care over prolonged time periods, it is critically important that unit norms reflect the high priority placed on safety. Changing the safety culture of the NICU involves a systematic process of measurement, identifying strengths and weaknesses, deploying targeted interventions, and learning from the results, to set the stage for an iterative process of improvement. Successful change efforts require: effective partnerships with key stakeholders including management, clinicians, staff, and families; using data to make the case for improvement; and leadership actions that motivate change, channel resources, and support active problem- solving. Sustainable change requires buy-in from NICU staff and management, resources, and long-term institutional commitment.

  View details for DOI 10.1038/s41372-020-00839-0

  View details for PubMedID 33024255

• Provider burnout: Implications for our perinatal patients. Seminars in perinatology Tawfik, D. S., Profit, J. 2020: 151243

  Abstract

  OBJECTIVE: To describe the syndrome of physician burnout within neonatology, its relation to neonatal quality of care, and outline potential solutions.FINDINGS: Burnout affects up to half of physicians, including up to one-third of neonatologists, at any given time. It is linked to suicidality, substance abuse, and intent to leave practice, and it is strongly associated with reduced quality of care in the published literature. Resilience and mindfulness interventions rooted in positive psychology may reduce burnout among individual providers. Because burnout is largely driven by organizational factors, system-level attention to leadership, teamwork, and practice efficiency can reduce burnout at the level of the organization.CONCLUSIONS: Burnout is common among neonatologists and consistently relates to decreased quality of patient care in a variety of dimensions. Personal resilience training and system-wide organizational interventions are needed to reverse burnout and promote high-quality neonatal care.

  View details for DOI 10.1016/j.semperi.2020.151243

  View details for PubMedID 32248955

• Health and Economic Outcomes of Posterior Spinal Fusion for Children With Neuromuscular Scoliosis. Hospital pediatrics Lin, J. L., Tawfik, D. S., Gupta, R., Imrie, M., Bendavid, E., Owens, D. K. 2020

  Abstract

  OBJECTIVES: Neuromuscular scoliosis (NMS) can result in severe disability. Nonoperative management minimally slows scoliosis progression, but operative management with posterior spinal fusion (PSF) carries high risks of morbidity and mortality. In this study, we compare health and economic outcomes of PSF to nonoperative management for children with NMS to identify opportunities to improve care.METHODS: We performed a cost-effectiveness analysis. Our decision analytic model included patients aged 5 to 20 years with NMS and a Cobb angle ≥50°, with a base case of 15-year-old patients. We estimated costs, life expectancy, quality-adjusted life-years (QALYs), and incremental cost-effectiveness from published literature and conducted sensitivity analyses on all model inputs.RESULTS: We estimated that PSF resulted in modestly decreased discounted life expectancy (10.8 years) but longer quality-adjusted life expectancy (4.84 QALYs) than nonoperative management (11.2 years; 3.21 QALYs). PSF costs $75400 per patient. Under base-case assumptions, PSF costs $50100 per QALY gained. Our findings were sensitive to quality of life (QoL) and life expectancy, with PSF favored if it significantly increased QoL.CONCLUSIONS: In patients with NMS, whether PSF is cost-effective depends strongly on the degree to which QoL improved, with larger improvements when NMS is the primary cause of debility, but limited data on QoL and life expectancy preclude a definitive assessment. Improved patient-centered outcome assessments are essential to understanding the effectiveness of NMS treatment alternatives. Because the degree to which PSF influences QoL substantially impacts health outcomes and varies by patient, clinicians should consider shared decision-making during PSF-related consultations.

  View details for DOI 10.1542/hpeds.2019-0153

  View details for PubMedID 32079619

• Ultrasonographic Optic Nerve Sheath Diameter Measurement to Detect Intracranial Hypertension in Children With Neurological Injury: A Systematic Review. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Bhargava, V. n., Tawfik, D. n., Tan, Y. J., Dunbar, T. n., Haileselassie, B. n., Su, E. n. 2020

  Abstract

  Ultrasound measured optic nerve sheath diameter is a noninvasive, nonirradiating tool for estimating intracranial hypertension. The objective of this systematic review and meta-analysis is summarization of the current evidence for accuracy of ultrasound measured optic nerve sheath diameter in detecting intracranial hypertension in pediatric patients.Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations. Publications from January 1, 2000, to June 30, 2019, were included in the search strategy.Studies were included if they involved patients less than 18 years, where ultrasound measured optic nerve sheath diameter was compared to conventional, nonophthalmic tests for intracranial hypertension. Studies were excluded if there was insufficient data to compute a sensitivity/specificity table. Case reports, case series, and manuscripts not published in English were also excluded.The initial search returned 573 citations. Of these, 57 were selected for review.Eleven citations were included in the final meta-analysis. A bivariate random-effects meta-analysis was performed, which revealed a pooled sensitivity for ultrasound measured optic nerve sheath diameter of 93% (95% CI, 74-99%), a specificity of 74% (95% CI, 52-88%), and a diagnostic odds ratio of 39.00 (95% CI, 4.16-365.32). The area under the curve of the hierarchical summary receiver operating characteristic curve was 0.90 (95% CI, 0.87-0.93). Subgroup analyses of the test's performance evaluating new-onset intracranial hypertension and in comparison to invasively measured intracranial pressure were performed. The test performance in these instances was similar to findings in the primary analysis.We are unable to identify a threshold value in ultrasound measured optic nerve sheath diameter for the determination of intracranial hypertension in children. Even though the ultrasound measured optic nerve sheath diameter measurement is highly sensitive to the presence of increased intracranial pressure, the test has only moderate specificity. Therefore, other confirmatory methods and further investigation is necessary in the clinical care of children. The technique is likely not sufficiently precise for clinical use in the absence of other confirmatory methods, and further investigation is necessary to determine clinical protocols for its use in children.

  View details for DOI 10.1097/PCC.0000000000002453

  View details for PubMedID 32796395

• Organizational factors affecting physician well-being. Current treatment options in pediatrics Tawfik, D. S., Profit, J., Webber, S., Shanafelt, T. D. 2019; 5 (1): 11–25

  Abstract

  Purpose of review: Symptoms of burnout affect approximately half of pediatricians and pediatric subspecialists at any given time, with similarly concerning prevalence of other aspects of physician distress, including fatigue, depressive symptoms, and suicidal ideation. Physician well-being affects quality of care, patient satisfaction, and physician turnover. Organizational factors influence well-being, stressing the need for organizations to address this epidemic.Recent findings: Organizational characteristics, policies, and culture influence physician well-being, and specific strategies may support an environment where physicians thrive. We highlight four organizational opportunities to improve physician well-being: developing leaders, cultivating community and organizational culture, improving practice efficiency, and optimizing administrative policies. Leaders play a key role in aligning organizational and individual values, promoting professional fulfillment, and fostering a culture of collegiality and social support among physicians. Reducing documentation burden and improving practice efficiency may help balance job demands and resources. Finally, reforming administrative policies may reduce work-home conflict, support physician's efforts to attend to their own well-being, and normalize use of supportive resources.Summary: Physician well-being is critical to organizational success, sustainment of an adequate workforce, and optimal patient outcomes. Because burnout is primarily influenced by organizational factors, organizational interventions are key to promoting well-being. Developing supportive leadership, fostering a culture of wellness, optimizing practice efficiency, and improving administrative policies are worthy of organizational action and further research.

  View details for DOI 10.1007/s40746-019-00147-6

  View details for PubMedID 31632895

• Perinatal Risk Factors and Outcome Coding in Clinical and Administrative Databases. Pediatrics Tawfik, D. S., Gould, J. B., Profit, J. 2019

  Abstract

  BACKGROUND AND OBJECTIVES: Administrative databases may allow true population-based studies and quality improvement endeavors, but the accuracy of billing codes for capturing key risk factors and outcomes needs to be assessed. We sought to describe the performance of a statewide administrative database and the clinical database from the California Perinatal Quality Care Collaborative (CPQCC).METHODS: This population-based retrospective cohort study linked key perinatal risk factors and outcomes from the 133-unit CPQCC database to relevant billing codes from administrative maternal and newborn inpatient discharge records, for 50631 infants born from 2006 to 2012. Using the CPQCC record as the gold standard, we calculated the positive predictive value, negative predictive value, and Matthews correlation coefficient for each item, then evaluated comparative performance across units.RESULTS: The Matthews correlation coefficient was highest (>0.7; strong positive correlation) for multiple delivery, Cesarean delivery, very low birth weight, maternal hypertension, maternal diabetes, patent ductus arteriosus, in-hospital death, patent ductus arteriosus and retinopathy of prematurity surgeries, extracorporeal life support, and intraventricular hemorrhage. Maternal chorioamnionitis, fetal distress, retinopathy of prematurity staging, chronic lung disease, and pneumothorax were the least reliably coded. Maternal factors and delivery details were more reliably coded in the maternal inpatient record than the newborn inpatient record.CONCLUSIONS: Several important perinatal risk factors and outcomes are highly congruent between these administrative and clinical databases. Several subjective risk factors and outcomes are appropriate targets for data improvement initiatives. The ability for timely extraction of administrative inpatient data will be key to their usefulness in quality metrics.

  View details for PubMedID 30626622

• Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit. Health services research Tawfik, D. S., Profit, J. n., Lake, E. T., Liu, J. B., Sanders, L. M., Phibbs, C. S. 2019

  Abstract

  To develop a nurse staffing prediction model and evaluate deviation from predicted nurse staffing as a contributor to patient outcomes.Secondary data collection conducted 2017-2018, using the California Office of Statewide Health Planning and Development and the California Perinatal Quality Care Collaborative databases. We included 276 054 infants born 2008-2016 and cared for in 99 California neonatal intensive care units (NICUs).Repeated-measures observational study. We developed a nurse staffing prediction model using machine learning and hierarchical linear regression and then quantified deviation from predicted nurse staffing in relation to health care-associated infections, length of stay, and mortality using hierarchical logistic and linear regression.We linked NICU-level nurse staffing and organizational data to patient-level risk factors and outcomes using unique identifiers for NICUs and patients.An 11-factor prediction model explained 35 percent of the nurse staffing variation among NICUs. Higher-than-predicted nurse staffing was associated with decreased risk-adjusted odds of health care-associated infection (OR: 0.79, 95% CI: 0.63-0.98), but not with length of stay or mortality.Organizational and patient factors explain much of the variation in nurse staffing. Higher-than-predicted nurse staffing was associated with fewer infections. Prospective studies are needed to determine causality and to quantify the impact of staffing reforms on health outcomes.

  View details for DOI 10.1111/1475-6773.13249

  View details for PubMedID 31869865

• Safety climate, safety climate strength, and length of stay in the NICU. BMC health services research Tawfik, D. S., Thomas, E. J., Vogus, T. J., Liu, J. B., Sharek, P. J., Nisbet, C. C., Lee, H. C., Sexton, J. B., Profit, J. n. 2019; 19 (1): 738

  Abstract

  Safety climate is an important marker of patient safety attitudes within health care units, but the significance of intra-unit variation of safety climate perceptions (safety climate strength) is poorly understood. This study sought to examine the standard safety climate measure (percent positive response (PPR)) and safety climate strength in relation to length of stay (LOS) of very low birth weight (VLBW) infants within California neonatal intensive care units (NICUs).Observational study of safety climate from 2073 health care providers in 44 NICUs. Consistent perceptions among a NICU's respondents, i.e., safety climate strength, was determined via intra-unit standard deviation of safety climate scores. The relation between safety climate PPR, safety climate strength, and LOS among VLBW (< 1500 g) infants was evaluated using log-linear regression. Secondary outcomes were infections, chronic lung disease, and mortality.NICUs had safety climate PPRs of 66 ± 12%, intra-unit standard deviations 11 (strongest) to 23 (weakest), and median LOS 60 days. NICUs with stronger climates had LOS 4 days shorter than those with weaker climates. In interaction modeling, NICUs with weak climates and low PPR had the longest LOS, NICUs with strong climates and low PPR had the shortest LOS, and NICUs with high PPR (both strong and weak) had intermediate LOS. Stronger climates were associated with lower odds of infections, but not with other secondary outcomes.Safety climate strength is independently associated with LOS and moderates the association between PPR and LOS among VLBW infants. Strength and PPR together provided better prediction than PPR alone, capturing variance in outcomes missed by PPR. Evaluations of NICU safety climate consider both positivity (PPR) and consistency of responses (strength) across individuals.

  View details for DOI 10.1186/s12913-019-4592-1

  View details for PubMedID 31640679

• Evidence Relating Health Care Provider Burnout and Quality of Care: A Systematic Review and Meta-analysis. Annals of internal medicine Tawfik, D. S., Scheid, A. n., Profit, J. n., Shanafelt, T. n., Trockel, M. n., Adair, K. C., Sexton, J. B., Ioannidis, J. P. 2019

  Abstract

  Whether health care provider burnout contributes to lower quality of patient care is unclear.To estimate the overall relationship between burnout and quality of care and to evaluate whether published studies provide exaggerated estimates of this relationship.MEDLINE, PsycINFO, Health and Psychosocial Instruments (EBSCO), Mental Measurements Yearbook (EBSCO), EMBASE (Elsevier), and Web of Science (Clarivate Analytics), with no language restrictions, from inception through 28 May 2019.Peer-reviewed publications, in any language, quantifying health care provider burnout in relation to quality of patient care.2 reviewers independently selected studies, extracted measures of association of burnout and quality of care, and assessed potential bias by using the Ioannidis (excess significance) and Egger (small-study effect) tests.A total of 11 703 citations were identified, from which 123 publications with 142 study populations encompassing 241 553 health care providers were selected. Quality-of-care outcomes were grouped into 5 categories: best practices (n = 14), communication (n = 5), medical errors (n = 32), patient outcomes (n = 17), and quality and safety (n = 74). Relations between burnout and quality of care were highly heterogeneous (I2 = 93.4% to 98.8%). Of 114 unique burnout-quality combinations, 58 indicated burnout related to poor-quality care, 6 indicated burnout related to high-quality care, and 50 showed no significant effect. Excess significance was apparent (73% of studies observed vs. 62% predicted to have statistically significant results; P = 0.011). This indicator of potential bias was most prominent for the least-rigorous quality measures of best practices and quality and safety.Studies were primarily observational; neither causality nor directionality could be determined.Burnout in health care professionals frequently is associated with poor-quality care in the published literature. The true effect size may be smaller than reported. Future studies should prespecify outcomes to reduce the risk for exaggerated effect size estimates.Stanford Maternal and Child Health Research Institute.

  View details for DOI 10.7326/M19-1152

  View details for PubMedID 31590181

• The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care. Journal of patient safety Profit, J., Sharek, P. J., Cui, X., Nisbet, C. C., Thomas, E. J., Tawfik, D. S., Lee, H. C., Draper, D., Sexton, J. B. 2018

  Abstract

  OBJECTIVES: Key validated clinical metrics are being used individually and in aggregate (Baby-MONITOR) to monitor the performance of neonatal intensive care units (NICUs). The degree to which perceptions of key components of safety culture, safety climate, and teamwork are related to aspects of NICU quality of care is poorly understood. The objective of this study was to test whether NICU performance on key clinical metrics correlates with caregiver perceptions of safety culture.STUDY DESIGN: Cross-sectional study of 6253 very low-birth-weight infants in 44 NICUs. We measured clinical quality via the Baby-MONITOR and its nine risk-adjusted and standardized subcomponents (antenatal corticosteroids, hypothermia, pneumothorax, healthcare-associated infection, chronic lung disease, retinopathy screen, discharge on any human milk, growth velocity, and mortality). A voluntary sample of 2073 of 3294 eligible professional caregivers provided ratings of safety and teamwork climate using the Safety Attitudes Questionnaire. We examined NICU-level variation across clinical and safety culture ratings and conducted correlation analysis of these dimensions.RESULTS: We found significant variation in clinical and safety culture metrics across NICUs. Neonatal intensive care unit teamwork and safety climate ratings were correlated with absence of healthcare-associated infection (r = 0.39 [P = 0.01] and r = 0.29 [P = 0.05], respectively). None of the other clinical metrics, individual or composite, were significantly correlated with teamwork or safety climate.CONCLUSIONS: Neonatal intensive care unit teamwork and safety climate were correlated with healthcare-associated infections but not with other quality metrics. Linkages to clinical measures of quality require additional research.This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

  View details for PubMedID 30407963

• Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clinic proceedings Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C. A., Dyrbye, L. N., Tutty, M. A., West, C. P., Shanafelt, T. D. 2018

  Abstract

  OBJECTIVE: To evaluate physician burnout, well-being, and work unit safety grades in relationship to perceived major medical errors.PARTICIPANTS AND METHODS: From August 28, 2014, to October 6, 2014, we conducted a population-based survey of US physicians in active practice regarding burnout, fatigue, suicidal ideation, work unit safety grade, and recent medical errors. Multivariate logistic regression and mixed-effects hierarchical models evaluated the associations among burnout, well-being measures, work unit safety grades, and medical errors.RESULTS: Of 6695 responding physicians in active practice, 6586 provided information on the areas of interest: 3574 (54.3%) reported symptoms of burnout, 2163 (32.8%) reported excessive fatigue, and 427 (6.5%) reported recent suicidal ideation, with 255 of 6563 (3.9%) reporting a poor or failing patient safety grade in their primary work area and 691 of 6586 (10.5%) reporting a major medical error in the prior 3 months. Physicians reporting errors were more likely to have symptoms of burnout (77.6% vs 51.5%; P<.001), fatigue (46.6% vs 31.2%; P<.001), and recent suicidal ideation (12.7% vs 5.8%; P<.001). In multivariate modeling, perceived errors were independently more likely to be reported by physicians with burnout (odds ratio [OR], 2.22; 95% CI, 1.79-2.76) or fatigue (OR, 1.38; 95% CI, 1.15-1.65) and those with incrementally worse work unit safety grades (OR, 1.70; 95% CI, 1.36-2.12; OR, 1.92; 95% CI, 1.48-2.49; OR, 3.12; 95% CI, 2.13-4.58; and OR, 4.37; 95% CI, 2.06-9.28 for grades of B, C, D, and F, respectively), adjusted for demographic and clinical characteristics.CONCLUSION: In this large national study, physician burnout, fatigue, and work unit safety grades were independently associated with major medical errors. Interventions to reduce rates of medical errors must address both physician well-being and work unit safety.

  View details for PubMedID 30001832

• Association of Blood Pressure Measurements with Peripheral Arterial Disease Events: A Reanalysis of the ALLHAT Data. Circulation Itoga, N. K., Tawfik, D. S., Lee, C. K., Maruyama, S., Leeper, N. J., Chang, T. I. 2018

  Abstract

  Background -Current guidelines recommend treating hypertension in patients with peripheral arterial disease (PAD) to reduce the risk of cardiac events and stroke, but the effect of reducing blood pressure on lower extremity PAD events is largely unknown. We investigated the association of blood pressure with lower extremity PAD events using data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Methods -ALLHAT investigated the effect of different antihypertensive medication classes (chlorthalidone, amlodipine, lisinopril, or doxazosin) on cardiovascular events. Using these data, the primary outcome in our analysis was time to first lower extremity PAD event, defined as PAD-related hospitalization, procedures, medical treatment, or PAD-related death. Given the availability of longitudinal standardized blood pressure measurements, we analyzed systolic blood pressure (SBP), diastolic blood pressure (DBP) and pulse pressure (PP) as time-varying categorical variables (reference categories 120-129 mm Hg for SBP, 70-79 mm Hg for DBP, and 45-54 mm Hg for PP) in separate models. We used extended Cox regression with death as a competing risk to calculate the association of each BP component with PAD events, and report the results as sub-distribution hazard ratios (HR) and 95% confidence intervals (CI). Results -The present analysis included 33,357 patients with an average age of 67.4 years, 53.1% men, 59.7% white race, and 36.2% with diabetes mellitus. The median baseline blood pressure was 146/84 mm Hg. Participants were followed for a median of 4.3 (IQR 3.6-5.3) years, during which time 1,489 (4.5%) had a lower extremity PAD event, and 4,148 (12.4%) died. In models adjusted for demographic and clinical characteristics, SBP <120 mm Hg was associated with a 26% (CI 5-52%, P=0.015) higher hazard and SBP≥160 mm Hg was associated with a 21% (CI 0-48%, P=0.050) higher hazard for a PAD event, compared with SBP 120-129 mm Hg. In contrast, lower, but not higher, DBP was associated with higher hazard of PAD events: for DBP <60 mm Hg HR = 1.72 (CI 1.38 - 2.16). PP had a U-shaped association with PAD events. Conclusions -In this re-analysis of data from ALLHAT, we found a higher rate of lower extremity PAD events with higher and lower SBP and PP, and with lower DBP. Given the recent revised blood pressure guidelines advocating lower SBP targets for overall cardiovascular risk reduction, further refinement of optimal blood pressure targets specific to PAD is needed. Clinical Trial Registration -URL: www.clinicaltrials.gov Unique identifier: NCT00000542.

  View details for PubMedID 29930023

• Group A Streptococcal Pyomyositis in a Previously Healthy Six-year-old Girl. Cureus Tawfik, D., Hobson, W. L. 2018; 10 (2): e2168

  Abstract

  A six-year-old previously healthy girl was seen in an outpatient pediatric clinic in the western United States for thigh pain. The pain was accompanied by an initial fever and was most severe after periods of prolonged rest. During the evaluation, her exam rapidly progressed with severe episodic pain and tenderness of the right anteromedial thigh. Magnetic resonance imaging (MRI) demonstrated signal enhancement at the insertion of the right obturator externus muscle. Blood culture was positive for Group A Streptococcus. She was diagnosed with pyomyositis of the right obturator externus and was successfully treated with antimicrobials. This case demonstrates a rare case of streptococcal pyomyosits, in a temperate climate, without known predisposing factor or injury. We review the epidemiology of streptococcal pyomyositis in temperate climates and discuss the presentation of pyomyositis in children.

  View details for PubMedID 29644156

• Context in Quality of Care: Improving Teamwork and Resilience. Clinics in perinatology Tawfik, D. S., Sexton, J. B., Adair, K. C., Kaplan, H. C., Profit, J. 2017; 44 (3): 541-552

  Abstract

  Quality improvement in health care is an ongoing challenge. Consideration of the context of the health care system is of paramount importance. Staff resilience and teamwork climate are key aspects of context that drive quality. Teamwork climate is dynamic, with well-established tools available to improve teamwork for specific tasks or global applications. Similarly, burnout and resilience can be modified with interventions such as cultivating gratitude, positivity, and awe. A growing body of literature has shown that teamwork and burnout relate to quality of care, with improved teamwork and decreased burnout expected to produce improved patient quality and safety.

  View details for DOI 10.1016/j.clp.2017.04.004

  View details for PubMedID 28802338

• Factors Associated With Provider Burnout in the NICU PEDIATRICS Tawfik, D. S., Phibbs, C. S., Sexton, J. B., Kan, P., Sharek, P. J., Nisbet, C. C., Rigdon, J., Trockel, M., Profit, J. 2017; 139 (5)

  Abstract

  NICUs vary greatly in patient acuity and volume and represent a wide array of organizational structures, but the effect of these differences on NICU providers is unknown. This study sought to test the relation between provider burnout prevalence and organizational factors in California NICUs.Provider perceptions of burnout were obtained from 1934 nurse practitioners, physicians, registered nurses, and respiratory therapists in 41 California NICUs via a validated 4-item questionnaire based on the Maslach Burnout Inventory. The relations between burnout and organizational factors of each NICU were evaluated via t-test comparison of quartiles, univariable regression, and multivariable regression.Overall burnout prevalence was 26.7% ± 9.8%. Highest burnout prevalence was found among NICUs with higher average daily admissions (32.1% ± 6.4% vs 17.2% ± 6.7%, P < .001), higher average occupancy (28.1% ± 8.1% vs 19.9% ± 8.4%, P = .02), and those with electronic health records (28% ± 11% vs 18% ± 7%, P = .03). In sensitivity analysis, nursing burnout was more sensitive to organizational differences than physician burnout in multivariable modeling, significantly associated with average daily admissions, late transfer proportion, nursing hours per patient day, and mortality per 1000 infants. Burnout prevalence showed no association with proportion of high-risk patients, teaching hospital distinction, or in-house attending presence.Burnout is most prevalent in NICUs with high patient volume and electronic health records and may affect nurses disproportionately. Interventions to reduce burnout prevalence may be of greater importance in NICUs with ≥10 weekly admissions.

  View details for DOI 10.1542/peds.2016-4134

  View details for Web of Science ID 000400371500040

  View details for PubMedID 28557756

• Teamwork in the NICU Setting and Its Association with Health Care-Associated Infections in Very Low-Birth-Weight Infants. American journal of perinatology Profit, J., Sharek, P. J., Kan, P., Rigdon, J., Desai, M., Nisbet, C. C., Tawfik, D. S., Thomas, E. J., Lee, H. C., Sexton, J. B. 2017

  Abstract

  Background and Objective Teamwork may affect clinical care in the neonatal intensive care unit (NICU) setting. The objective of this study was to assess teamwork climate across NICUs and to test scale-level and item-level associations with health care-associated infection (HAI) rates in very low-birth-weight (VLBW) infants. Methods Cross-sectional study of the association between HAI rates, defined as any bacterial or fungal infection during the birth hospitalization, among 6,663 VLBW infants cared for in 44 NICUs between 2010 and 2012. NICU HAI rates were correlated with teamwork climate ratings obtained in 2011 from 2,073 of 3,294 eligible NICU health professionals (response rate 63%). The relation between HAI rates and NICU teamwork climate was assessed using logistic regression models including NICU as a random effect. Results Across NICUs, 36 to 100% (mean 66%) of respondents reported good teamwork. HAI rates were significantly and independently associated with teamwork climate (odds ratio, 0.82; 95% confidence interval, 0.73-0.92, p = 0.005), such that the odds of an infant contracting a HAI decreased by 18% with each 10% rise in NICU respondents reporting good teamwork. Conclusion Improving teamwork may be an important element in infection control efforts.

  View details for DOI 10.1055/s-0037-1601563

  View details for PubMedID 28395366

• Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections. Journal of perinatology Tawfik, D. S., Sexton, J. B., Kan, P., Sharek, P. J., Nisbet, C. C., Rigdon, J., Lee, H. C., Profit, J. 2017; 37 (3): 315-320

  Abstract

  To examine burnout prevalence among California neonatal intensive care units (NICUs) and to test the relation between burnout and healthcare-associated infection (HAI) rates in very low birth weight (VLBW) neonates.Retrospective observational study of provider perceptions of burnout from 2073 nurse practitioners, physicians, registered nurses and respiratory therapists, using a validated four-item questionnaire based on the Maslach Burnout Inventory. The relation between burnout and HAI rates among VLBW (<1500 g) neonates from each NICU was evaluated using multi-level logistic regression analysis with patient-level factors as fixed effects.We found variable prevalence of burnout across the NICUs surveyed (mean 25.2±10.1%). Healthcare-associated infection rates were 8.3±5.1% during the study period. Highest burnout prevalence was found among nurses, nurse practitioners and respiratory therapists (non-physicians, 28±11% vs 17±19% physicians), day shift workers (30±3% vs 25±4% night shift) and workers with 5 or more years of service (29±2% vs 16±6% in fewer than 3 years group). Overall burnout rates showed no correlation with risk-adjusted rates of HAIs (r=-0.133). Item-level analysis showed positive association between HAIs and perceptions of working too hard (odds ratio 1.15, 95% confidence interval 1.04-1.28). Sensitivity analysis of high-volume NICUs suggested a moderate correlation between burnout prevalence and HAIs (r=0.34).Burnout is most prevalent among non-physicians, daytime workers and experienced workers. Perceptions of working too hard associate with increased HAIs in this cohort of VLBW infants, but overall burnout prevalence is not predictive.Journal of Perinatology advance online publication, 17 November 2016; doi:10.1038/jp.2016.211.

  View details for DOI 10.1038/jp.2016.211

  View details for PubMedID 27853320

• Near-Fatal Gastrointestinal Hemorrhage in a Child with Medulloblastoma on High Dose Dexamethasone. Cureus Yecies, D. n., Tawfik, D. n., Damman, J. n., Thorson, C. n., Hong, D. S., Grant, G. A., Bensen, R. n., Damian, M. n. 2017; 9 (7): e1442

  Abstract

  A four-year-old female was admitted to a university-based children's hospital with a newly-diagnosed posterior fossa tumor. She was started on famotidine and high-dose dexamethasone and underwent gross total resection of a medulloblastoma. She was continued on dexamethasone and famotidine. She exhibited postoperative posterior fossa syndrome and was started on enteral feeds via the nasoduodenal tube. She had small gastrointestinal bleeds on postoperative days eight, 11, and 18, and was found to have a well-circumscribed posterior duodenal ulcer. On postoperative day 19, she suffered a massive life-threatening gastrointestinal bleed requiring aggressive resuscitation with blood products. She required an emergent laparotomy due to ongoing blood loss and she was found to have posterior duodenal wall erosion into her gastroduodenal artery. She recovered and subsequently began delayed chemotherapy. This case demonstrates a rare and life-threatening complication of high-dose dexamethasone therapy in the setting of posterior fossa pathology despite stress ulcer prophylaxis. We present a historical perspective with the review of the association between duodenal and intracranial pathology and the usage of high-dose dexamethasone in such cases.

  View details for PubMedID 28924528