Clinical Focus


  • Internal Medicine

Academic Appointments


  • Clinical Professor, Medicine

Administrative Appointments


  • Hospitalist, Division of GIM, Stanford University (1999 - Present)
  • Medical Director, B3/C3 Inpatient Unit, Stanford Healthcare (2006 - Present)
  • Medical Director for Quality, Department of Medicine, Stanford University School of Medicine (2011 - Present)

Honors & Awards


  • Fellowship, National Science Foundation Fellowship (1989-1992)
  • Fellowship, Tau Beta Pi Engineering Fellowship (1989)
  • Fellowship, DuPont Fellowship in Chemical Engineering (1989)
  • Most Outstanding Senior Women in Engineering, Purdue University (1989)
  • Purdue Alumni Foundation Award, Purdue University (1989)
  • Purdue Outstanding Chemical Engineering Senior, Purdue University (1989)
  • Award for Service and Leadership, Omega Chi Epsilon (1989)

Professional Education


  • Residency:Stanford University Internal Medicine Residency (1999) CA
  • Medical Education:Harvard Medical School (1996) MA
  • Board Certification: Internal Medicine, American Board of Internal Medicine (1999)
  • Residency, Stanford Univ Medical Center, Internal Medicine (1999)
  • MD, Harvard University, Medicine (1996)
  • PhD, MIT, Medical Engineering (1995)
  • BS, Purdue University, Chemical Engineering (1989)

Stanford Advisees


  • Med Scholar Project Advisor
    Nicholas Zehner

All Publications


  • Reducing Telemetry Use Is Safe: A Retrospective Analysis of Rapid Response Team and Code Events After a Successful Intervention to Reduce Telemetry Use AMERICAN JOURNAL OF MEDICAL QUALITY Xie, L., Garg, T., Svec, D., Hom, J., Kaimal, R., Ahuja, N., Barnes, J., Shieh, L. 2019; 34 (4): 398–401
  • How Much Time are Physicians and Nurses Spending Together at the Patient Bedside? Journal of hospital medicine Sang, A. X., Tisdale, R. L., Nielsen, D., Loica-Mersa, S., Miller, T., Chong, I., Shieh, L. 2019; 14: E1–E6

    Abstract

    BACKGROUND: Bedside rounding involving both nurses and physicians has numerous benefits for patients and staff. However, precise quantitative data on the current extent of physician-nurse (MD-RN) overlap at the patient bedside are lacking.OBJECTIVE: This study aimed to examine the frequency of nurse and physician overlap at the patient beside and what factors affect this frequency.DESIGN: This is a prospective, observational study of time-motion data generated from wearable radio frequency identification (RFID)-based locator technology.SETTING: Single-institution academic hospital.MEASUREMENTS: The length of physician rounds, frequency of rounds that include nurses simultaneously at the bedside, and length of MD-RN overlap were measured and analyzed by ward, day of week, and distance between patient room and nursing station.RESULTS: A total of 739 MD rounding events were captured over 90 consecutive days. Of these events, 267 took place in single-bed patient rooms. The frequency of MD-RN overlap was 30.0%, and there was no statistical difference between the three wards studied. Overall, the average length of all MD rounds was 7.31 ± 0.58 minutes, but rounding involving a bedside nurse lasted longer than rounds with MDs alone (9.56 vs 5.68 minutes, P < .05). There was no difference in either the length of rounds or the frequency of MD-RN overlap between weekdays and weekends. Finally, patient rooms located farther away from the nursing station had a lower likelihood of MD-RN overlap (Pearson's r = -0.67, P < .05).CONCLUSION: RFID-based technology provides precise, automated, and high-throughput time-motion data to capture nurse and physician activity. At our institution, 30.0% of rounds involve a bedside nurse, highlighting a potential barrier to bedside interdisciplinary rounding.

    View details for DOI 10.12788/jhm.3204

    View details for PubMedID 31112496

  • Electronic health record-based clinical decision support alert for severe sepsis: a randomised evaluation. BMJ quality & safety Downing, N. L., Rolnick, J., Poole, S. F., Hall, E., Wessels, A. J., Heidenreich, P., Shieh, L. 2019

    Abstract

    BACKGROUND: Sepsis remains the top cause of morbidity and mortality of hospitalised patients despite concerted efforts. Clinical decision support for sepsis has shown mixed results reflecting heterogeneous populations, methodologies and interventions.OBJECTIVES: To determine whether the addition of a real-time electronic health record (EHR)-based clinical decision support alert improves adherence to treatment guidelines and clinical outcomes in hospitalised patients with suspected severe sepsis.DESIGN: Patient-level randomisation, single blinded.SETTING: Medical and surgical inpatient units of an academic, tertiary care medical centre.PATIENTS: 1123 adults over the age of 18 admitted to inpatient wards (intensive care units (ICU) excluded) at an academic teaching hospital between November 2014 and March 2015.INTERVENTIONS: Patients were randomised to either usual care or the addition of an EHR-generated alert in response to a set of modified severe sepsis criteria that included vital signs, laboratory values and physician orders.MEASUREMENTS AND MAIN RESULTS: There was no significant difference between the intervention and control groups in primary outcome of the percentage of patients with new antibiotic orders at 3hours after the alert (35% vs 37%, p=0.53). There was no difference in secondary outcomes of in-hospital mortality at 30 days, length of stay greater than 72hours, rate of transfer to ICU within 48hours of alert, or proportion of patients receiving at least 30mL/kg of intravenous fluids.CONCLUSIONS: An EHR-based severe sepsis alert did not result in a statistically significant improvement in several sepsis treatment performance measures.

    View details for PubMedID 30872387

  • An Evaluation of Barriers to Inpatient Medication Allergy Documentation Chollet, M. B., Shieh, L., Liu, A. Y. MOSBY-ELSEVIER. 2019: AB280
  • Patient vs provider perspectives of 30-day hospital readmissions. BMJ open quality Smeraglio, A., Heidenreich, P. A., Krishnan, G., Hopkins, J., Chen, J., Shieh, L. 2019; 8 (1): e000264

    Abstract

    Objective: To compare patients' and providers' views on contributors to 30-day hospital readmissions.Design: Analysis of a qualitative interview survey between 18 May-30 June 2015.Setting: Interviews were conducted during the 30-day readmission hospitalisation at a single tertiary care academic hospital.Participants: We conducted 178 interviews of readmitted patients.Measures: We queried opinions of what factors patients believed contributed to their rehospitalisation and compared this with the perspective of the index admission provider. The primary outcome was the view that the readmission was preventable. A review by a RN (nurse) case manager also provided an assessment based on patient report, provider report and chart review.Results: Patients were more likely to view a readmission as preventable compared with physicians (p<0.0001). Patients identified system issues (defined as factors controlled by the hospital discharge process) as contributors to their readmission in 58% (103/178) of cases while providers identified system issues as the contributor to a patients' readmission in 2% (2/101) of cases. Patients with poor functional status were more likely to feel the cause of their readmission was due to system issues than patients with better functional status (p=0.03). A RN case manager review determined that in 48% (86/178) of cases the system had some amount of contribution to a patient's readmission. There was no significant difference in belief that the readmission was preventable between the RN case manager and the patient (p=0.47).Conclusions: Readmitted patients often feel that the hospital system contributed to their readmission. Providers did not recognise patient and RN case manager identified issues as contributors to hospital readmissions.

    View details for PubMedID 30687798

  • Waiting it out: Consultation delays prolong in-patient length of stay Postgraduate Medical Journal Rahman, A. S., Shi, S., Meza, P. K., Jia, J. L., Svec, D., Shieh, L. 2019
  • Waiting it out: consultation delays prolong in-patient length of stay. Postgraduate medical journal Rahman, A. S., Shi, S., Meza, P. K., Jia, J. L., Svec, D., Shieh, L. 2019

    Abstract

    Decreasing delays for hospitalised patients results in improved hospital efficiency, increased quality of care and decreased healthcare expenditures. Delays in subspecialty consultations and procedures can cause increased length of stay due to reasons outside of necessary medical care.To quantify, describe and record reasons for delays in consultations and procedures for patients on the general medicine wards.We conducted weekly audits of all admitted patients on five Internal Medicine teams over 8 weeks. A survey was reviewed with attending physicians and residents on five internal medicine teams to identify patients with a delay due to consultation or procedure, quantify length of delay and record reason for delay.During the study period, 316 patients were reviewed and 48 were identified as experiencing a total of 53 delays due to consultations or procedures. The average delay was 1.8 days for a combined total of 83 days. Top reasons for delays included scheduling, late response to page and a busy service. The frequency in length of consult delays vary among different specialties. The highest frequency of delays was clustered in procedure-heavy specialties.This report highlights the importance of reviewing system barriers that lead to delayed service in hospitals. Addressing these delays could lead to reductions in length of stay for inpatients.

    View details for PubMedID 30674619

  • Analysis of a Potential Automated Sepsis Alert Based on Quick Sequential Organ Failure Assessment (qSOFA) Among Hospitalized Floor Patients Swenson, K., Rogers, A., Krishnan, G., Shieh, L. AMER THORACIC SOC. 2019
  • A long wait: barriers to discharge for long length of stay patients. Postgraduate medical journal Zhao, E. J., Yeluru, A., Manjunath, L., Zhong, L. R., Hsu, H., Lee, C. K., Wong, A. C., Abramian, M., Manella, H., Svec, D., Shieh, L. 2018

    Abstract

    INTRODUCTION: Reducing long length of stay (LLOS, or inpatient stays lasting over 30 days) is an important way for hospitals to improve cost efficiency, bed availability and health outcomes. Discharge delays can cost hundreds to thousands of dollars per patient, and LLOS represents a burden on bed availability for other potential patients. However, most research studies investigating discharge barriers are not LLOS-specific. Of those that do, nearly all are limited by further patient subpopulation focus or small sample size. To our knowledge, our study is the first to describe LLOS discharge barriers in an entire Department of Medicine.METHODS: We conducted a chart review of 172 LLOS patients in the Department of Medicine at an academic tertiary care hospital and quantified the most frequent causes of delay as well as factors causing the greatest amount of delay time. We also interviewed healthcare staff for their perceptions on barriers to discharge.RESULTS: Discharge site coordination was the most frequent cause of delay, affecting 56% of patients and accounting for 80% of total non-medical postponement days. Goals of care issues and establishment of follow-up care were the next most frequent contributors to delay.CONCLUSION: Together with perspectives from interviewed staff, these results highlight multiple different areas of opportunity for reducing LLOS and maximising the care capacity of inpatient hospitals.

    View details for PubMedID 30301835

  • Reducing Telemetry Use Is Safe: A Retrospective Analysis of Rapid Response Team and Code Events After a Successful Intervention to Reduce Telemetry Use. American journal of medical quality : the official journal of the American College of Medical Quality Xie, L., Garg, T., Svec, D., Hom, J., Kaimal, R., Ahuja, N., Barnes, J., Shieh, L. 2018: 1062860618805189

    Abstract

    Interventions guiding appropriate telemetry utilization have successfully reduced use at many hospitals, but few studies have examined their possible adverse outcomes. The authors conducted a successful intervention to reduce telemetry use in 2013 on a hospitalist service using educational modules, routine review, and financial incentives. The association of reduced telemetry use with the incidence of rapid response team (RRT) and code activations was assessed in a retrospective cohort study of 210 patients who experienced a total of 233 RRT and code events on the inpatient internal medicine services from January 2012 through March 2015 at a tertiary care center. The incidence of adverse events for the hospitalist service was not significantly different during the intervention and postintervention period as compared to the preintervention period. Reducing inappropriate telemetry use was not associated with an increase in the incidence rates of RRT and code events.

    View details for PubMedID 30293436

  • An Electronic Best Practice Alert Based on Choosing Wisely Guidelines Reduces Thrombophilia Testing in the Outpatient Setting. Journal of general internal medicine Jun, T., Kwang, H., Mou, E., Berube, C., Bentley, J., Shieh, L., Hom, J. 2018

    View details for PubMedID 30215176

  • Shared Decision-Making During Inpatient Rounds: Opportunities for Improvement in Patient Engagement and Communication. Journal of hospital medicine Blankenburg, R., Hilton, J. F., Yuan, P., Rennke, S., Monash, B., Harman, S. M., Sakai, D. S., Hosamani, P., Khan, A., Chua, I., Huynh, E., Shieh, L., Xie, L. 2018

    Abstract

    BACKGROUND: Shared decision-making (SDM) improves patient engagement and may improve outpatient health outcomes. Little is known about inpatient SDM.OBJECTIVE: To assess overall quality, provider behaviors, and contextual predictors of SDM during inpatient rounds on medicine and pediatrics hospitalist services.DESIGN: A 12-week, cross-sectional, single-blinded observational study of team SDM behaviors during rounds, followed by semistructured patient interviews.SETTING: Two large quaternary care academic medical centers.PARTICIPANTS: Thirty-five inpatient teams (18 medicine, 17 pediatrics) and 254 unique patient encounters (117 medicine, 137 pediatrics).INTERVENTION: Observational study.MEASUREMENTS: We used a 9-item Rochester Participatory Decision-Making Scale (RPAD) measured team-level SDM behaviors. Same-day interviews using a modified RPAD assessed patient perceptions of SDM.RESULTS: Characteristics associated with increased SDM in the multivariate analysis included the following: service, patient gender, timing of rounds during patient's hospital stay, and amount of time rounding per patient (P < .05). The most frequently observed behaviors across all services included explaining the clinical issue and matching medical language to the patient's level of understanding. The least frequently observed behaviors included checking understanding of the patient's point of view, examining barriers to follow-through, and asking if the patient has any questions. Patients and guardians had substantially higher ratings for SDM quality compared to peer observers (7.2 vs 4.4 out of 9).CONCLUSIONS: Important opportunities exist to improve inpatient SDM. Team size, number of learners, patient census, and type of decision being made did not affect SDM, suggesting that even large, busy services can perform SDM if properly trained.

    View details for PubMedID 29401211

  • Night-time communication at Stanford University Hospital: perceptions, reality and solutions BMJ QUALITY & SAFETY Sun, A., Wang, L., Go, M., Eggers, Z., Deng, R., Maggio, P., Shieh, L. 2018; 27 (2): 156–62

    Abstract

    Resident work hour restrictions have led to the creation of the 'night float' to care for the patients of multiple primary teams after hours. These residents are often inundated with acute issues in the numerous patients they cover and are less able to address non-urgent issues that arise at night. Further, non-urgent pages may contribute to physician alarm fatigue and negatively impact patient outcomes.To delineate the burden of non-urgent paging at night and propose solutions.We performed a resident review and categorisation of 1820 pages to night floats between September 2014 and December 2014. Both attending and nursing review of 10% of pages was done and compared.Of reviewed pages, 62.1% were urgent and 27.7% were non-urgent. Attending review of random page samples correlated well with resident review. Common reasons for non-urgent pages were non-urgent patient status updates, low-priority order requests and non-critical lab values.A significant number of non-urgent pages are sent at night. These pages likely distract from acute issues that arise at night and place an unnecessary burden on night floats. Both behavioural and systemic adjustments are needed to address this issue. Possible interventions include integrating low-priority messaging into the electronic health record system and use of charge nurses to help determine urgency of issues and batch non-urgent pages.

    View details for PubMedID 29055898

  • EMR-based handoff tool improves completeness of internal medicine residents' handoffs. BMJ open quality Tisdale, R. L., Eggers, Z., Shieh, L. 2018; 7 (3): e000188

    Abstract

    Background: The majority of adverse events in healthcare involve communication breakdown. Physician-to-physician handoffs are particularly prone to communication errors, yet have been shown to be more complete when systematised according to a standardised bundle. Interventions that improve thoroughness of handoffs have not been widely studied.Aim: To measure the effect of an electronic medical record (EMR)-based handoff tool on handoff completeness.Intervention: This EMR-based handoff tool included a radio button prompting users to classify patients as stable, a 'watcher' or unstable. It automatically pulled in EMR data on the patient's 24-hour vitals, common lab tests and code status. Finally, it provided text boxes labelled 'Active Issues', 'Action List (To-Dos)' and 'If/Then' to fill in.Implementation and evaluation: Written handoffs from general and specialty (haematology, oncology, cardiology) Internal Medicine resident-run inpatient wards were evaluated on a randomly chosen representative sample of days in April and May 2015 at Stanford University Medical Center, focusing on a predefined set of content elements. The intervention was then implemented in June 2015 with postintervention data collected in an identical fashion in August to September 2016.Results: Handoff completeness improved significantly (p<0.0001). Improvement in inclusion of illness severity was notable for its magnitude and its importance in establishing a consistent mental model of a patient. Elements that automatically pulled in data and those prompting users to actively fill in data both improved.Conclusion: A simple EMR-based handoff tool providing a mix of frameworks for completion and automatic pull-in of objective data improved handoff completeness. This suggests that EMR-based interventions may be effective at improving handoffs, possibly leading to fewer medical errors and better patient care.

    View details for DOI 10.1136/bmjoq-2017-000188

    View details for PubMedID 30019013

  • Prediction of Acute Kidney Injury With a Machine Learning Algorithm Using Electronic Health Record Data. Canadian journal of kidney health and disease Mohamadlou, H., Lynn-Palevsky, A., Barton, C., Chettipally, U., Shieh, L., Calvert, J., Saber, N. R., Das, R. 2018; 5: 2054358118776326

    Abstract

    A major problem in treating acute kidney injury (AKI) is that clinical criteria for recognition are markers of established kidney damage or impaired function; treatment before such damage manifests is desirable. Clinicians could intervene during what may be a crucial stage for preventing permanent kidney injury if patients with incipient AKI and those at high risk of developing AKI could be identified.In this study, we evaluate a machine learning algorithm for early detection and prediction of AKI.We used a machine learning technique, boosted ensembles of decision trees, to train an AKI prediction tool on retrospective data taken from more than 300 000 inpatient encounters.Data were collected from inpatient wards at Stanford Medical Center and intensive care unit patients at Beth Israel Deaconess Medical Center.Patients older than the age of 18 whose hospital stays lasted between 5 and 1000 hours and who had at least one documented measurement of heart rate, respiratory rate, temperature, serum creatinine (SCr), and Glasgow Coma Scale (GCS).We tested the algorithm's ability to detect AKI at onset and to predict AKI 12, 24, 48, and 72 hours before onset.We tested AKI detection and prediction using the National Health Service (NHS) England AKI Algorithm as a gold standard. We additionally tested the algorithm's ability to detect AKI as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. We compared the algorithm's 3-fold cross-validation performance to the Sequential Organ Failure Assessment (SOFA) score for AKI identification in terms of area under the receiver operating characteristic (AUROC).The algorithm demonstrated high AUROC for detecting and predicting NHS-defined AKI at all tested time points. The algorithm achieves AUROC of 0.872 (95% confidence interval [CI], 0.867-0.878) for AKI detection at time of onset. For prediction 12 hours before onset, the algorithm achieves an AUROC of 0.800 (95% CI, 0.792-0.809). For 24-hour predictions, the algorithm achieves AUROC of 0.795 (95% CI, 0.785-0.804). For 48-hour and 72-hour predictions, the algorithm achieves AUROC values of 0.761 (95% CI, 0.753-0.768) and 0.728 (95% CI, 0.719-0.737), respectively.Because of the retrospective nature of this study, we cannot draw any conclusions about the impact the algorithm's predictions will have on patient outcomes in a clinical setting.The results of these experiments suggest that a machine learning-based AKI prediction tool may offer important prognostic capabilities for determining which patients are likely to suffer AKI, potentially allowing clinicians to intervene before kidney damage manifests.

    View details for PubMedID 30094049

  • Attitudes and Perceptions of Medical Trainees Towards an Electronic Medical Alert System for Sepsis Swenson, K., Ferguson, J., Shieh, L., Rogers, A. AMER THORACIC SOC. 2018
  • Impact of problem-based charting on the utilization and accuracy of the electronic problem list. Journal of the American Medical Informatics Association : JAMIA Li, R. C., Garg, T., Cun, T., Shieh, L., Krishnan, G., Fang, D., Chen, J. H. 2018

    Abstract

    Problem-based charting (PBC) is a method for clinician documentation in commercially available electronic medical record systems that integrates note writing and problem list management. We report the effect of PBC on problem list utilization and accuracy at an academic intensive care unit (ICU).An interrupted time series design was used to assess the effect of PBC on problem list utilization, which is defined as the number of new problems added to the problem list by clinicians per patient encounter, and of problem list accuracy, which was determined by calculating the recall and precision of the problem list in capturing 5 common ICU diagnoses.In total, 3650 and 4344 patient records were identified before and after PBC implementation at Stanford Hospital. An increase of 2.18 problems (>50% increase) in the mean number of new problems added to the problem list per patient encounter can be attributed to the initiation of PBC. There was a significant increase in recall attributed to the initiation of PBC for sepsis (β = 0.45, P < .001) and acute renal failure (β = 0.2, P = .007), but not for acute respiratory failure, pneumonia, or venous thromboembolism.The problem list is an underutilized component of the electronic medical record that can be a source of clinician-structured data representing the patient's clinical condition in real time. PBC is a readily available tool that can integrate problem list management into physician workflow.PBC improved problem list utilization and accuracy at an academic ICU.

    View details for PubMedID 29360995

  • Lean-Based Redesign of Multidisciplinary Rounds on General Medicine Service. Journal of hospital medicine Kane, M., Rohatgi, N., Heidenreich, P., Thakur, A., Winget, M., Shum, K., Hereford, J., Shieh, L., Lew, T., Horn, J., Chi, J., Weinacker, A., Seay-Morrison, T., Ahuja, N. 2018

    Abstract

    Multidisciplinary rounds (MDR) facilitate timely communication amongst the care team and with patients. We used Lean techniques to redesign MDR on the teaching general medicine service.To examine if our Lean-based new model of MDR was associated with change in the primary outcome of length of stay (LOS) and secondary outcomes of discharges before noon, documentation of estimated discharge date (EDD), and patient satisfaction.This is a pre-post study. The preperiod (in which the old model of MDR was followed) comprised 4000 patients discharged between September 1, 2013, and October 22, 2014. The postperiod (in which the new model of MDR was followed) comprised 2085 patients between October 23, 2014, and April 30, 2015.Lean-based redesign of MDR.LOS, discharges before noon, EDD, and patient satisfaction.There was no change in the mean LOS. Discharges before noon increased from 6.9% to 10.7% (P < .001). Recording of EDD increased from 31.4% to 41.3% (P < .001). There was no change in patient satisfaction.Lean-based redesign of MDR was associated with an increase in discharges before noon and in recording of EDD.

    View details for PubMedID 29394300

  • Multicentre validation of a sepsis prediction algorithm using only vital sign data in the emergency department, general ward and ICU BMJ OPEN Mao, Q., Jay, M., Hoffman, J. L., Calvert, J., Barton, C., Shimabukuro, D., Shieh, L., Chettipally, U., Fletcher, G., Kerem, Y., Zhou, Y., Das, R. 2018; 8 (1): e017833

    Abstract

    We validate a machine learning-based sepsis-prediction algorithm (InSight) for the detection and prediction of three sepsis-related gold standards, using only six vital signs. We evaluate robustness to missing data, customisation to site-specific data using transfer learning and generalisability to new settings.A machine-learning algorithm with gradient tree boosting. Features for prediction were created from combinations of six vital sign measurements and their changes over time.A mixed-ward retrospective dataset from the University of California, San Francisco (UCSF) Medical Center (San Francisco, California, USA) as the primary source, an intensive care unit dataset from the Beth Israel Deaconess Medical Center (Boston, Massachusetts, USA) as a transfer-learning source and four additional institutions' datasets to evaluate generalisability.684 443 total encounters, with 90 353 encounters from June 2011 to March 2016 at UCSF.None.Area under the receiver operating characteristic (AUROC) curve for detection and prediction of sepsis, severe sepsis and septic shock.For detection of sepsis and severe sepsis, InSight achieves an AUROC curve of 0.92 (95% CI 0.90 to 0.93) and 0.87 (95% CI 0.86 to 0.88), respectively. Four hours before onset, InSight predicts septic shock with an AUROC of 0.96 (95% CI 0.94 to 0.98) and severe sepsis with an AUROC of 0.85 (95% CI 0.79 to 0.91).InSight outperforms existing sepsis scoring systems in identifying and predicting sepsis, severe sepsis and septic shock. This is the first sepsis screening system to exceed an AUROC of 0.90 using only vital sign inputs. InSight is robust to missing data, can be customised to novel hospital data using a small fraction of site data and retains strong discrimination across all institutions.

    View details for PubMedID 29374661

  • Real-Time Clinical Decision Support Decreases Inappropriate Plasma Transfusion AMERICAN JOURNAL OF CLINICAL PATHOLOGY Shah, N., Baker, S. A., Spain, D., Shieh, L., Shepard, J., Hadhazy, E., Maggio, P., Goodnough, L. T. 2017; 148 (2): 154–60

    Abstract

    To curtail inappropriate plasma transfusions, we instituted clinical decision support as an alert upon order entry if the patient's recent international normalized ratio (INR) was 1.7 or less.The alert was suppressed for massive transfusion and within operative or apheresis settings. The plasma order was automatically removed upon alert acceptance while clinical exception reasons allowed for continued transfusion. Alert impact was studied comparing a 7-month control period with a 4-month intervention period.Monthly plasma utilization decreased 17.4%, from a mean ± SD of 3.40 ± 0.48 to 2.82 ± 0.6 plasma units per hundred patient days (95% confidence interval [CI] of difference, -0.1 to 1.3). Plasma transfused below an INR of 1.7 or less decreased from 47.6% to 41.6% (P = .0002; odds ratio, 0.78; 95% CI, 0.69-0.89). The alert recommendation was accepted 33% of the time while clinical exceptions were chosen in the remaining cases (active bleeding, 31%; other clinical indication, 33%; and apheresis, 2%). Alert acceptance rate varied significantly among different provider specialties.Clinical decision support can help curtail inappropriate plasma use but needs to be part of a comprehensive strategy including audit and feedback for comprehensive, long-term changes.

    View details for PubMedID 28898990

  • Barriers to timely discharge from the general medicine service at an academic teaching hospital. Postgraduate medical journal Ragavan, M. V., Svec, D., Shieh, L. 2017

    Abstract

    Reducing delays for patients who are safe to be discharged is important for minimising complications, managing costs and improving quality. Barriers to discharge include placement, multispecialty coordination of care and ineffective communication. There are a few recent studies that describe barriers from the perspective of all members of the multidisciplinary team.To identify the barriers to discharge for patients from our medicine service who had a discharge delay of over 24 hours.We developed and implemented a biweekly survey that was reviewed with attending physicians on each of the five medicine services to identify patients with an unnecessary delay. Separately, we conducted interviews with staff members involved in the discharge process to identify common barriers they observed on the wards.Over the study period from 28 October to 22 November 2013, out of 259 total discharges, 87 patients had a delay of over 24 hours (33.6%) and experienced a total of 181 barriers. The top barriers from the survey included patient readiness, prolonged wait times for procedures or results, consult recommendations and facility placement. A total of 20 interviews were conducted, from which the top barriers included communication both between staff members and with the patient, timely notification of discharge and lack of discharge standardisation.There are a number of frequent barriers to discharge encountered in our hospital that may be avoidable with planning, effective communication methods, more timely preparation and tools to standardise the discharge process.

    View details for DOI 10.1136/postgradmedj-2016-134529

    View details for PubMedID 28450581

  • Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical care medicine Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., Kumar, A., Sevransky, J. E., Sprung, C. L., Nunnally, M. E., Rochwerg, B., Rubenfeld, G. D., Angus, D. C., Annane, D., Beale, R. J., Bellinghan, G. J., Bernard, G. R., Chiche, J., Coopersmith, C., De Backer, D. P., French, C. J., Fujishima, S., Gerlach, H., Hidalgo, J. L., Hollenberg, S. M., Jones, A. E., Karnad, D. R., Kleinpell, R. M., Koh, Y., Lisboa, T. C., Machado, F. R., Marini, J. J., Marshall, J. C., Mazuski, J. E., McIntyre, L. A., McLean, A. S., Mehta, S., Moreno, R. P., Myburgh, J., Navalesi, P., Nishida, O., Osborn, T. M., Perner, A., Plunkett, C. M., Ranieri, M., Schorr, C. A., Seckel, M. A., Seymour, C. W., Shieh, L., Shukri, K. A., Simpson, S. Q., Singer, M., Thompson, B. T., Townsend, S. R., van der Poll, T., Vincent, J., Wiersinga, W. J., Zimmerman, J. L., Dellinger, R. P. 2017; 45 (3): 486-552

    Abstract

    To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012."A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions.Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

    View details for DOI 10.1097/CCM.0000000000002255

    View details for PubMedID 28098591

  • Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive care medicine Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., Kumar, A., Sevransky, J. E., Sprung, C. L., Nunnally, M. E., Rochwerg, B., Rubenfeld, G. D., Angus, D. C., Annane, D., Beale, R. J., Bellinghan, G. J., Bernard, G. R., Chiche, J., Coopersmith, C., De Backer, D. P., French, C. J., Fujishima, S., Gerlach, H., Hidalgo, J. L., Hollenberg, S. M., Jones, A. E., Karnad, D. R., Kleinpell, R. M., Koh, Y., Lisboa, T. C., Machado, F. R., Marini, J. J., Marshall, J. C., Mazuski, J. E., McIntyre, L. A., McLean, A. S., Mehta, S., Moreno, R. P., Myburgh, J., Navalesi, P., Nishida, O., Osborn, T. M., Perner, A., Plunkett, C. M., Ranieri, M., Schorr, C. A., Seckel, M. A., Seymour, C. W., Shieh, L., Shukri, K. A., Simpson, S. Q., Singer, M., Thompson, B. T., Townsend, S. R., van der Poll, T., Vincent, J., Wiersinga, W. J., Zimmerman, J. L., Dellinger, R. P. 2017; 43 (3): 304-377

    Abstract

    To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012".A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions.Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

    View details for DOI 10.1007/s00134-017-4683-6

    View details for PubMedID 28101605

  • A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback. Postgraduate medical journal Hom, J., Kumar, A., Evans, K. H., Svec, D., Richman, I., Fang, D., Smeraglio, A., Holubar, M., Johnson, T., Shah, N., Renault, C., Ahuja, N., Witteles, R., Harman, S., Shieh, L. 2017

    Abstract

    Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns.Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments.The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001).We successfully implemented a novel high value care curriculum that specifically targets intern physicians.

    View details for PubMedID 28663352

  • Magnitude of Potentially Inappropriate Thrombophilia Testing in the Inpatient Hospital Setting. Journal of hospital medicine Mou, E., Kwang, H., Hom, J., Shieh, L., Kumar, A., Richman, I., Berube, C. 2017; 12 (9): 735–38

    Abstract

    Laboratory costs of thrombophilia testing exceed an estimated $650 million (in US dollars) annually. Quantifying the prevalence and financial impact of potentially inappropriate testing in the inpatient hospital setting represents an integral component of the effort to reduce healthcare expenditures. We conducted a retrospective analysis of our electronic medical record to evaluate 2 years' worth of inpatient thrombophilia testing measured against preformulated appropriateness criteria. Cost data were obtained from the Centers for Medicare and Medicaid Services 2016 Clinical Laboratory Fee Schedule. Of the 1817 orders analyzed, 777 (42.7%) were potentially inappropriate, with an associated cost of $40,422. The tests most frequently inappropriately ordered were Factor V Leiden, prothrombin gene mutation, protein C and S activity levels, antithrombin activity levels, and the lupus anticoagulant. Potentially inappropriate thrombophilia testing is common and costly. These data demonstrate a need for institution-wide changes in order to reduce unnecessary expenditures and improve patient care.

    View details for PubMedID 28914278

  • The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital. Journal of hospital medicine Rennke, S., Yuan, P., Monash, B., Blankenburg, R., Chua, I., Harman, S., Sakai, D. S., Khan, A., Hilton, J. F., Shieh, L., Satterfield, J. 2017; 12 (12): 1001–8

    Abstract

    Patient engagement through shared decision-making (SDM) is increasingly seen as a key component for patient safety, patient satisfaction, and quality of care. Current SDM models do not adequately account for medical and environmental contexts, which may influence medical decisions in the hospital. We identified leading SDM models and reviews to inductively construct a novel SDM model appropriate for the inpatient setting. A team of medicine and pediatric hospitalists reviewed the literature to integrate core SDM concepts and processes and iteratively constructed a synthesized draft model. We then solicited broad SDM expert feedback on the draft model for validation and further refinement. The SDM 3 Circle Model identifies 3 core categories of variables that dynamically interact within an "environmental frame." The resulting Venn diagram includes overlapping circles for (1) patient/family, (2) provider/team, and (3) medical context. The environmental frame includes all external, contextual factors that may influence any of the 3 circles. Existing multistep SDM process models were then rearticulated and contextualized to illustrate how a shared decision might be made. The SDM 3 Circle Model accounts for important environmental and contextual characteristics that vary across settings. The visual emphasis generated by each "circle" and by the environmental frame direct attention to often overlooked interactive forces and has the potential to more precisely define, promote, and improve SDM. This model provides a framework to develop interventions to improve quality and patient safety through SDM and patient engagement for hospitalists.

    View details for PubMedID 29073314

  • Prediction of Sepsis in the Intensive Care Unit With Minimal Electronic Health Record Data: A Machine Learning Approach. JMIR medical informatics Desautels, T., Calvert, J., Hoffman, J., Jay, M., Kerem, Y., Shieh, L., Shimabukuro, D., Chettipally, U., Feldman, M. D., Barton, C., Wales, D. J., Das, R. 2016; 4 (3)

    Abstract

    Sepsis is one of the leading causes of mortality in hospitalized patients. Despite this fact, a reliable means of predicting sepsis onset remains elusive. Early and accurate sepsis onset predictions could allow more aggressive and targeted therapy while maintaining antimicrobial stewardship. Existing detection methods suffer from low performance and often require time-consuming laboratory test results.To study and validate a sepsis prediction method, InSight, for the new Sepsis-3 definitions in retrospective data, make predictions using a minimal set of variables from within the electronic health record data, compare the performance of this approach with existing scoring systems, and investigate the effects of data sparsity on InSight performance.We apply InSight, a machine learning classification system that uses multivariable combinations of easily obtained patient data (vitals, peripheral capillary oxygen saturation, Glasgow Coma Score, and age), to predict sepsis using the retrospective Multiparameter Intelligent Monitoring in Intensive Care (MIMIC)-III dataset, restricted to intensive care unit (ICU) patients aged 15 years or more. Following the Sepsis-3 definitions of the sepsis syndrome, we compare the classification performance of InSight versus quick sequential organ failure assessment (qSOFA), modified early warning score (MEWS), systemic inflammatory response syndrome (SIRS), simplified acute physiology score (SAPS) II, and sequential organ failure assessment (SOFA) to determine whether or not patients will become septic at a fixed period of time before onset. We also test the robustness of the InSight system to random deletion of individual input observations.In a test dataset with 11.3% sepsis prevalence, InSight produced superior classification performance compared with the alternative scores as measured by area under the receiver operating characteristic curves (AUROC) and area under precision-recall curves (APR). In detection of sepsis onset, InSight attains AUROC = 0.880 (SD 0.006) at onset time and APR = 0.595 (SD 0.016), both of which are superior to the performance attained by SIRS (AUROC: 0.609; APR: 0.160), qSOFA (AUROC: 0.772; APR: 0.277), and MEWS (AUROC: 0.803; APR: 0.327) computed concurrently, as well as SAPS II (AUROC: 0.700; APR: 0.225) and SOFA (AUROC: 0.725; APR: 0.284) computed at admission (P<.001 for all comparisons). Similar results are observed for 1-4 hours preceding sepsis onset. In experiments where approximately 60% of input data are deleted at random, InSight attains an AUROC of 0.781 (SD 0.013) and APR of 0.401 (SD 0.015) at sepsis onset time. Even with 60% of data missing, InSight remains superior to the corresponding SIRS scores (AUROC and APR, P<.001), qSOFA scores (P=.0095; P<.001) and superior to SOFA and SAPS II computed at admission (AUROC and APR, P<.001), where all of these comparison scores (except InSight) are computed without data deletion.Despite using little more than vitals, InSight is an effective tool for predicting sepsis onset and performs well even with randomly missing data.

    View details for PubMedID 27694098

  • Hand hygiene of medical students and resident physicians: predictors of attitudes and behaviour. Postgraduate medical journal Barroso, V., Caceres, W., Loftus, P., Evans, K. H., Shieh, L. 2016; 92 (1091): 497-500

    Abstract

    We measured medical students' and resident trainees' hand hygiene behaviour, knowledge and attitudes in order to identify important predictors of hand hygiene behaviour in this population.An anonymous, web-based questionnaire was distributed to medical students and residents at Stanford University School of Medicine in August of 2012. The questionnaire included questions regarding participants' behaviour, knowledge, attitude and experiences about hand hygiene. Behaviour, knowledge and attitude indices were scaled from 0 to 1, with 1 representing superior responses. Using multivariate regression, we identified positive and negative predictors of superior hand hygiene behaviour. We investigated effectiveness of interventions, barriers and comfort reminding others.280 participants (111 students and 169 residents) completed the questionnaire (response rate 27.8%). Residents and medical students reported hand hygiene behaviour compliance of 0.45 and 0.55, respectively (p=0.02). Resident and medical student knowledge was 0.80 and 0.73, respectively (p=0.001). The attitude index for residents was 0.56 and 0.55 for medical students. Regression analysis identified experiences as predictors of hand hygiene behaviour (both positive and negative influence). Knowledge was not a significant predictor of behaviour, but a working gel dispenser and observing attending physicians with good hand hygiene practices were reported by both groups as the most effective strategy in influencing trainees.Medical students and residents have similar attitudes about hand hygiene, but differ in their level of knowledge and compliance. Concerns about hierarchy may have a significant negative impact on hand hygiene advocacy.

    View details for DOI 10.1136/postgradmedj-2015-133509

    View details for PubMedID 26912501

  • Validation of Test Performance and Clinical Time Zero for an Electronic Health Record Embedded Severe Sepsis Alert. Applied clinical informatics Rolnick, J., Downing, N. L., Shepard, J., Chu, W., Tam, J., Wessels, A., Li, R., Dietrich, B., Rudy, M., Castaneda, L., Shieh, L. 2016; 7 (2): 560-572

    Abstract

    Increasing use of EHRs has generated interest in the potential of computerized clinical decision support to improve treatment of sepsis. Electronic sepsis alerts have had mixed results due to poor test characteristics, the inability to detect sepsis in a timely fashion and the use of outside software limiting widespread adoption. We describe the development, evaluation and validation of an accurate and timely severe sepsis alert with the potential to impact sepsis management.To develop, evaluate, and validate an accurate and timely severe sepsis alert embedded in a commercial EHR.The sepsis alert was developed by identifying the most common severe sepsis criteria among a cohort of patients with ICD 9 codes indicating a diagnosis of sepsis. This alert requires criteria in three categories: indicators of a systemic inflammatory response, evidence of suspected infection from physician orders, and markers of organ dysfunction. Chart review was used to evaluate test performance and the ability to detect clinical time zero, the point in time when a patient develops severe sepsis.Two physicians reviewed 100 positive cases and 75 negative cases. Based on this review, sensitivity was 74.5%, specificity was 86.0%, the positive predictive value was 50.3%, and the negative predictive value was 94.7%. The most common source of end-organ dysfunction was MAP less than 70 mm/Hg (59%). The alert was triggered at clinical time zero in 41% of cases and within three hours in 53.6% of cases. 96% of alerts triggered before a manual nurse screen.We are the first to report the time between a sepsis alert and physician chart-review clinical time zero. Incorporating physician orders in the alert criteria improves specificity while maintaining sensitivity, which is important to reduce alert fatigue. By leveraging standard EHR functionality, this alert could be implemented by other healthcare systems.

    View details for DOI 10.4338/ACI-2015-11-RA-0159

    View details for PubMedID 27437061

    View details for PubMedCentralID PMC4941860

  • Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost JOURNAL OF HOSPITAL MEDICINE Svec, D., Ahuja, N., Evans, K. H., Hom, J., Garg, T., Loftus, P., Shieh, L. 2015; 10 (9): 627-632

    View details for DOI 10.1002/jhm.2411

    View details for Web of Science ID 000360836000012

  • Improving and sustaining a reduction in iatrogenic pneumothorax through a multifaceted quality-improvement approach JOURNAL OF HOSPITAL MEDICINE Shieh, L., Go, M., Gessner, D., Chen, J. H., Hopkins, J., Maggio, P. 2015; 10 (9): 599-607

    Abstract

    The Agency for Healthcare Research and Quality has adopted iatrogenic pneumothorax (IAP) as a Patient Safety Indicator. In 2006, in response to a low performance ranking for IAP rate from the University Healthsystem Consortium (UHC), the authors established a multidisciplinary team to reduce our institution's IAP rate. Root-cause analysis found that subclavian insertion of central venous catheterization (CVC) was the most common procedure associated with IAP OBJECTIVE: Our short-term goal was a 50% reduction of both CVC-associated and all-cause IAP rates within 18 months, with long-term goals of sustained reduction.Observational study.Academic tertiary care hospital.Consecutive inpatients from 2006 to 2014.Our multifaceted intervention included: (1) clinical and documentation standards based on evidence, (2) cognitive aids, (3) simulation training, (4) purchase and deployment of ultrasound equipment, and (5) feedback to clinical services.CVC-associated IAP, all-cause IAP rate.We achieved both a short-term (years 2006 to 2008) and long-term (years 2006 to 2008-2014) reduction in our CVC-associated and all-cause IAP rates. Our short-term reduction in our CVC-associated IAP was 53% (P = 0.088), and our long-term reduction was 85% (P < 0.0001). Our short-term reduction in the all-cause IAP rate was 26% (P < 0.0001), and our long-term reduction was 61% (P < 0.0001).A multidisciplinary team, focused on evidence, patient safety, and standardization, can use a set of multifaceted interventions to sustainably improve patient outcomes for several years after implementation. Our hospital was in the highest performance UHC quartile for all-cause IAP in 2012 to 2014. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine.

    View details for DOI 10.1002/jhm.2388

    View details for Web of Science ID 000360836000007

  • Pending Studies at Hospital Discharge: A Pre-post Analysis of an Electronic Medical Record Tool to Improve Communication at Hospital Discharge. Journal of general internal medicine Kantor, M. A., Evans, K. H., Shieh, L. 2015; 30 (3): 312-318

    Abstract

    Achieving safe transitions of care at hospital discharge requires accurate and timely communication. Both the presence of and follow-up plan for diagnostic studies that are pending at hospital discharge are expected to be accurately conveyed during these transitions, but this remains a challenge.To determine the prevalence, characteristics, and communication of studies pending at hospital discharge before and after the implementation of an electronic medical record (EMR) tool that automatically generates a list of pending studies.Pre-post analysis.260 consecutive patients discharged from inpatient general medicine services from July to August 2013.Development of an EMR-based tool that automatically generates a list of studies pending at discharge.The main outcomes were prevalence and characteristics of pending studies and communication of studies pending at hospital discharge. We also surveyed internal medicine house staff on their attitudes about communication of pending studies.Pre-intervention, 70 % of patients had at least one pending study at discharge, but only 18 % of these were communicated in the discharge summary. Most studies were microbiology cultures (68 %), laboratory studies (16 %), or microbiology serologies (10 %). The majority of study results were ultimately normal (83 %), but 9 % were newly abnormal. Post-intervention, communication of studies pending increased to 43 % (p < 0.001).Most patients are discharged from the hospital with pending studies, but in usual practice, the presence of these studies has rarely been communicated to outpatient providers in the discharge summary. Communication significantly increased with the implementation of an EMR-based tool that automatically generated a list of pending studies from the EMR and allowed users to import this list into the discharge summary. This is the first study to our knowledge to introduce an automated EMR-based tool to communicate pending studies.

    View details for DOI 10.1007/s11606-014-3064-x

    View details for PubMedID 25416599

  • Septris: a novel, mobile, online, simulation game that improves sepsis recognition and management. Academic medicine Evans, K. H., Daines, W., Tsui, J., Strehlow, M., Maggio, P., Shieh, L. 2015; 90 (2): 180-184

    Abstract

    Annually affecting over 18 million people worldwide, sepsis is common, deadly, and costly. Despite significant effort by the Surviving Sepsis Campaign and other initiatives, sepsis remains underrecognized and undertreated.Research indicates that educating providers may improve sepsis diagnosis and treatment; thus, the Stanford School of Medicine has developed a mobile-accessible, case-based, online game entitled Septris (http://med.stanford.edu/septris/). Septris, launched online worldwide in December 2011, takes an innovative approach to teaching early sepsis identification and evidence-based management. The free gaming platform leverages the massive expansion over the past decade of smartphones and the popularity of noneducational gaming.The authors sought to assess the game's dissemination and its impact on learners' sepsis-related knowledge, skills, and attitudes. In 2012, the authors trained Stanford pregraduate (clerkship) and postgraduate (resident) medical learners (n = 156) in sepsis diagnosis and evidence-based practices via 20 minutes of self-directed game play with Septris. The authors administered pre- and posttests.By October 2014, Septris garnered over 61,000 visits worldwide. After playing Septris, both pre- and postgraduate groups improved their knowledge on written testing in recognizing and managing sepsis (P < .001). Retrospective self-reporting on their ability to identify and manage sepsis also improved (P < .001). Over 85% of learners reported that they would or would maybe recommend Septris.Future evaluation of Septris should assess its effectiveness among different providers, resource settings, and cultures; generate information about how different learners make clinical decisions; and evaluate the correlation of game scores with sepsis knowledge.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

    View details for DOI 10.1097/ACM.0000000000000611

    View details for PubMedID 25517703

  • A nurse-driven screening tool for the early identification of sepsis in an intermediate care unit setting. Journal of hospital medicine Gyang, E., Shieh, L., Forsey, L., Maggio, P. 2015; 10 (2): 97-103

    Abstract

    Use of a screening tool as a decision support mechanism for early detection of sepsis has been widely advocated, yet studies validating tool performance are scarce, especially in non-intensive care unit settings.For this pilot study we prospectively screened consecutive patients admitted to a medical/surgical intermediate care unit at an academic medical center over a 1-month period and retrospectively analyzed their clinical data. Patients were screened with a 3-tiered, paper-based, nurse-driven sepsis assessment tool every 8 hours. For patients screening positive for sepsis or severe sepsis, the primary treatment team was notified and the team's clinical actions were recorded. Results of the screening test were then compared to patient International Classification of Diseases, Ninth Revision (ICD-9) codes for sepsis, severe sepsis, and septic shock identified during the study time period, and performance of the screening test was assessed.A total of 2143 screening tests were completed in 245 patients (169 surgical, 76 medical). ICD-9 codes confirmed sepsis incidence was 9%. Of the 39 patients who screened positive, 51% were positive for sepsis, and 49% screened positive for severe sepsis. Screening tool sensitivity and specificity were 95% and 92%, respectively. Negative predictive value was 99% and positive predictive value was 54%. Overall test accuracy was 92%. There was no statistically significant difference in tool performance between medical and surgical patients.A simple screening tool for sepsis utilized as part of nursing assessment may be a useful way of identifying early sepsis in both medical and surgical patients in an intermediate care unit setting. Journal of Hospital Medicine 2014. © 2014 Society of Hospital Medicine.

    View details for DOI 10.1002/jhm.2291

    View details for PubMedID 25425449

  • Why Providers Transfuse Blood Products Outside Recommended Guidelines in Spite of Integrated Electronic Best Practice Alerts JOURNAL OF HOSPITAL MEDICINE Chen, J. H., Fang, D. Z., Goodnough, L. T., Evans, K. H., Porter, M. L., Shieh, L. 2015; 10 (1): 1-7

    Abstract

    Best practice alerts (BPAs) provide clinical decision support (CDS) at the point of care to reduce unnecessary blood product transfusions, yet substantial transfusions continue outside of recommended guidelines.To understand why providers order blood transfusions outside of recommended guidelines despite interruptive alerts.Retrospective review.Tertiary care hospital.Inpatient healthcare providers.Provider-BPA interaction data were collected from January 2011 to August 2012 from the hospital electronic medical record.Provider (free-text) responses to blood transfusion BPA prompts were independently reviewed and categorized by 2 licensed physicians, with agreement assessed by χ(2) analysis and kappa scoring.Rationale for overriding blood transfusion BPAs was highly diverse, acute bleeding being the most common (>34%), followed by protocolized behaviors on specialty services (up to 26%), to "symptomatic" anemia (11%-12%). Many providers transfused in anticipation of surgical or procedural intervention (10%-15%) or imminent hospital discharge (2%-5%). Resident physicians represented the majority (55%) of providers interacting with BPAs.Providers interacting with BPAs (primarily residents and midlevel providers) often do not have the negotiating power to change ordering behavior. Protocolized behaviors, unlikely to be influenced by BPAs, are among the most commonly cited reasons for transfusing outside of guidelines. Symptomatic anemia is a common, albeit subjective, indication cited for blood transfusion. With a wide swath of individually uncommon rationales for transfusion behavior, secondary use of electronic medical record databases and integrated CDS tools are important to efficiently analyze common practice behaviors. Journal of Hospital Medicine 2014. © 2014 The Authors Journal of Hospital Medicine published by Wiley Periodicals, Inc. on behalf of Society of Hospital Medicine.

    View details for DOI 10.1002/jhm.2236

    View details for Web of Science ID 000347516300001

  • Septris: A Novel, Mobile, Online, Simulation Game That Improves Sepsis Recognition and Management Academic Medicine Evans, K. H., Daines, W. P., Tsui, J., Strehlow, M., Maggio, P., Shieh, L. 2015; Vol. 90, No. 2 (February 2015)

    Abstract

    Annually affecting over 18 million people worldwide, sepsis is common, deadly, and costly. Despite significant effort by the Surviving Sepsis Campaign and other initiatives, sepsis remains underrecognized and undertreated.Research indicates that educating providers may improve sepsis diagnosis and treatment; thus, the Stanford School of Medicine has developed a mobile-accessible, case-based, online game entitled Septris (http://med.stanford.edu/septris/). Septris, launched online worldwide in December 2011, takes an innovative approach to teaching early sepsis identification and evidence-based management. The free gaming platform leverages the massive expansion over the past decade of smartphones and the popularity of noneducational gaming.The authors sought to assess the game's dissemination and its impact on learners' sepsis-related knowledge, skills, and attitudes. In 2012, the authors trained Stanford pregraduate (clerkship) and postgraduate (resident) medical learners (n = 156) in sepsis diagnosis and evidence-based practices via 20 minutes of self-directed game play with Septris. The authors administered pre- and posttests.By October 2014, Septris garnered over 61,000 visits worldwide. After playing Septris, both pre- and postgraduate groups improved their knowledge on written testing in recognizing and managing sepsis (P < .001). Retrospective self-reporting on their ability to identify and manage sepsis also improved (P < .001). Over 85% of learners reported that they would or would maybe recommend Septris.Future evaluation of Septris should assess its effectiveness among different providers, resource settings, and cultures; generate information about how different learners make clinical decisions; and evaluate the correlation of game scores with sepsis knowledge.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

    View details for DOI 10.1097/ACM.0000000000000611

  • Development and evaluation of an electronic health record-based best-practice discharge checklist for hospital patients. Joint Commission journal on quality and patient safety / Joint Commission Resources Garg, T., Lee, J. Y., Evans, K. H., Chen, J., Shieh, L. 2015; 41 (3): 126-121

    Abstract

    Checklists may help reduce discharge errors; however, current paper checklists have limited functionality. In 2013 a best-practice discharge checklist using the electronic health record (EHR) was developed and evaluated at Stanford University Medical Center (Stanford, California) in a cluster randomized trial to evaluate its usage, user satisfaction, and impact on physicians' work flow.The study was divided into four phases.In Phase I, on the survey (N = 76), most of the participants (54.0%) reported using memory to remember discharge tasks. On a 0-100 scale, perception of checklists as being useful was strong (mean, 66.4; standard deviation [SD], 21.2), as was interest in EHR checklists (64.5, 26.6). In Phase II, the checklist consisted of 15 tasks categorized by admission, hospitalization, and discharge-planning. In Phase III, the checklist was implemented as an EHR "smart-phrase" allowing for automatic insertion. In Phase IV, in a trial with 60 participating physicians, 23 EHR checklist users reported higher usage than 12 paper users (28.5 versus 7.67, p = .019), as well as higher checklist integration with work flow (22.6 versus 1.67, p = .014), usefulness of checklist (33.7 versus. 8.92, p = .041), discharge confidence (30.8 versus 5.00, p = .029), and discharge efficiency (25.5 versus 6.67, p = .056). Increasing EHR checklist use was correlated with usefulness ( r = .85, p < .001), confidence (r = .81, p < .001), and efficiency (r = .87, p < .001).The EHR checklist reminded physicians to complete discharge tasks, improved confidence, and increased process efficiency. This is the first study to show that medicine residents use "memory" as the most common method for remembering discharge tasks. These data reinforce the need for a formalized tool, such as a checklist, that residents can rely on to complete important discharge tasks.

    View details for PubMedID 25977128

  • Cost and turn-around time display decreases inpatient ordering of reference laboratory tests: a time series BMJ QUALITY & SAFETY Fang, D. Z., Sran, G., Gessner, D., Loftus, P. D., Folkins, A., Christopher, J. Y., Shieh, L. 2014; 23 (12): 994-1000

    Abstract

    Reference tests, also known as send-out tests, are commonly ordered laboratory tests with variable costs and turn-around times. We aim to examine the effects of displaying reference laboratory costs and turn-around times during computerised physician order entry (CPOE) on inpatient physician ordering behaviour.We conducted a prospective observational study at a tertiary care hospital involving inpatient attending physicians and residents. Physician ordering behaviour was prospectively observed between September 2010 and December 2012. An intervention was implemented to display cost and turn-around time for reference tests within our CPOE. We examined changes in the mean number of monthly physician orders per inpatient day at risk, the mean cost per order, and the average turn-around time per order.After our intervention, the mean number of monthly physician orders per inpatient day at risk decreased by 26% (51 vs 38, p<0.0001) with a decrease in mean cost per order (US$146.50 vs US$134.20, p=0.0004). There were no significant differences in mean turn-around time per order (5.6 vs 5.7 days, p=0.057). A stratified analysis of both cost and turn-around time showed significant decreases in physician ordering. The intervention projected a mean annual savings of US$330 439. Reference test cost and turn-around time variables were poorly correlated (r=0.2). These findings occurred in the setting of non-significant change to physician ordering in a control cohort of non-reference laboratory tests.Display of reference laboratory cost and turn-around time data during real-time ordering may result in significant decreases in ordering of reference laboratory tests with subsequent cost savings.

    View details for DOI 10.1136/bmjqs-2014-003053

    View details for Web of Science ID 000345318300009

  • Cost and turn-around time display decreases inpatient ordering of reference laboratory tests: a time series. BMJ quality & safety Fang, D. Z., Sran, G., Gessner, D., Loftus, P. D., Folkins, A., Christopher, J. Y., Shieh, L. 2014; 23 (12): 994-1000

    Abstract

    Reference tests, also known as send-out tests, are commonly ordered laboratory tests with variable costs and turn-around times. We aim to examine the effects of displaying reference laboratory costs and turn-around times during computerised physician order entry (CPOE) on inpatient physician ordering behaviour.We conducted a prospective observational study at a tertiary care hospital involving inpatient attending physicians and residents. Physician ordering behaviour was prospectively observed between September 2010 and December 2012. An intervention was implemented to display cost and turn-around time for reference tests within our CPOE. We examined changes in the mean number of monthly physician orders per inpatient day at risk, the mean cost per order, and the average turn-around time per order.After our intervention, the mean number of monthly physician orders per inpatient day at risk decreased by 26% (51 vs 38, p<0.0001) with a decrease in mean cost per order (US$146.50 vs US$134.20, p=0.0004). There were no significant differences in mean turn-around time per order (5.6 vs 5.7 days, p=0.057). A stratified analysis of both cost and turn-around time showed significant decreases in physician ordering. The intervention projected a mean annual savings of US$330 439. Reference test cost and turn-around time variables were poorly correlated (r=0.2). These findings occurred in the setting of non-significant change to physician ordering in a control cohort of non-reference laboratory tests.Display of reference laboratory cost and turn-around time data during real-time ordering may result in significant decreases in ordering of reference laboratory tests with subsequent cost savings.

    View details for DOI 10.1136/bmjqs-2014-003053

    View details for PubMedID 25165402

  • Restrictive blood transfusion practices are associated with improved patient outcomes TRANSFUSION Goodnough, L. T., Maggio, P., Hadhazy, E., Shieh, L., Hernandez-Boussard, T., Khari, P., Shah, N. 2014; 54 (10): 2753-2759

    Abstract

    Blood transfusion has been cited as one of the five most overutilized therapeutic procedures in the United States. We assessed the impact of clinical decision support at computerized physician order entry and education on red blood cell (RBC) transfusions and clinical patient outcomes at our institution.Clinical patient outcomes and RBC transfusions were assessed before and after implementation of a best practice alert triggered for transfusions when the hemoglobin level was higher than 7 g/dL for all inpatient discharges from January 2008 through December 2013. Retrospective clinical and laboratory data related to RBC transfusions were extracted: case-mix complexity, patient discharges and selected surgical volumes, and patient outcomes (mortality, 30-day readmissions, length of stay).There was a significant improvement in RBC utilization as assessed by RBC units transfused per 100 patient-days-at-risk. Concurrently, hospital-wide clinical patient outcomes showed improvement (mortality, p = 0.034; length of stay, p = 0.003) or remained stable (30-day readmission rates, p = 0.909). Outcome improvements were even more pronounced in patients who received blood transfusions, with decreased mortality rate (55.2 to 33.0, p < 0.001), length of stay (mean, 10.1 to 6.2 days, p < 0.001), and 30-day readmission rate (136.9 to 85.0, p < 0.001). The mean number of units transfused per patient also declined (3.6 to 2.7, p < 0.001). Acquisition costs of RBC units per 1000 patient discharges decreased from $283,130 in 2009 to $205,050 in 2013 with total estimated savings of $6.4 million and likely far greater impact on total transfusion-related costs.Improved blood utilization is associated with improved clinical patient outcomes.

    View details for DOI 10.1111/trf.12723

    View details for Web of Science ID 000343821100023

  • Smarter hospital communication: Secure smartphone text messaging improves provider satisfaction and perception of efficacy, workflow. Journal of hospital medicine Przybylo, J. A., Wang, A., Loftus, P., Evans, K. H., Chu, I., Shieh, L. 2014; 9 (9): 573-578

    Abstract

    Though current hospital paging systems are neither efficient (callbacks disrupt workflow), nor secure (pagers are not Health Insurance Portability and Accountability Act [HIPAA]-compliant), they are routinely used to communicate patient information. Smartphone-based text messaging is a potentially more convenient and efficient mobile alternative; however, commercial cellular networks are also not secure.To determine if augmenting one-way pagers with Medigram, a secure, HIPAA-compliant group messaging (HCGM) application for smartphones, could improve hospital team communication.Eight-week prospective, cluster-randomized, controlled trialStanford HospitalThree inpatient medicine teams used the HCGM application in addition to paging, while two inpatient medicine teams used paging only for intra-team communication.Baseline and post-study surveys were collected from 22 control and 41 HCGM team members.When compared with paging, HCGM was rated significantly (P < 0.05) more effective in: (1) allowing users to communicate thoughts clearly (P = 0.010) and efficiently (P = 0.009) and (2) integrating into workflow during rounds (P = 0.018) and patient discharge (P = 0.012). Overall satisfaction with HCGM was significantly higher (P = 0.003). 85% of HCGM team respondents said they would recommend using an HCGM system on the wards.Smartphone-based, HIPAA-compliant group messaging applications improve provider perception of in-hospital communication, while providing the information security that paging and commercial cellular networks do not. Journal of Hospital Medicine 2014;9:573-578. © 2014 The Authors Journal of Hospital Medicine published by Wiley Periodicals, Inc. on behalf of Society of Hospital Medicine.

    View details for DOI 10.1002/jhm.2228

    View details for PubMedID 25110991

  • Improved blood utilization using real-time clinical decision support. Transfusion Goodnough, L. T., Shieh, L., Hadhazy, E., Cheng, N., Khari, P., Maggio, P. 2014; 54 (5): 1358-1365

    Abstract

    We analyzed blood utilization at Stanford Hospital and Clinics after implementing real-time clinical decision support (CDS) and best practice alerts (BPAs) into physician order entry (POE) for blood transfusions.A clinical effectiveness (CE) team developed consensus with a suggested transfusion threshold of a hemoglobin (Hb) level of 7 g/dL, or 8 g/dL for patients with acute coronary syndromes. The CDS was implemented in July 2010 and consisted of an interruptive BPA at POE, a link to relevant literature, and an "acknowledgment reason" for the blood order.The percentage of blood ordered for patients whose most recent Hb level exceeded 8 g/dL ranged at baseline from 57% to 66%; from the education intervention by the CE team August 2009 to July 2010, the percentage decreased to a range of 52% to 56% (p = 0.01); and after implementation of CDS and BPA, by end of December 2010 the percentage of patients transfused outside the guidelines decreased to 35% (p = 0.02) and has subsequently remained below 30%. For the most recent interval, only 27% (767 of 2890) of transfusions occurred in patients outside guidelines. Comparing 2009 to 2012, despite an increase in annual case mix index from 1.952 to 2.026, total red blood cell (RBC) transfusions decreased by 7186 units, or 24%. The estimated net savings for RBC units (at $225/unit) in purchase costs for 2012 compared to 2009 was $1,616,750.Real-time CDS has significantly improved blood utilization. This system of concurrent review can be used by health care institutions, quality departments, and transfusion services to reduce blood transfusions.

    View details for DOI 10.1111/trf.12445

    View details for PubMedID 24117533

  • Patient whiteboards to improve patient-centred care in the hospital. Postgraduate medical journal Tan, M., Hooper Evans, K., Braddock, C. H., Shieh, L. 2013; 89 (1056): 604-609

    Abstract

    Patient whiteboards facilitate communication between patients and hospital providers, but little is known about their impact on patient satisfaction and awareness. Our objectives were to: measure the impact in improving patients' understanding of and satisfaction with care; understand barriers for their use by physicians and how these could be overcome; and explore their impact on staff and patients' families.In 2012, we conducted a 3-week pilot of multidisciplinary whiteboard use with 104 inpatients on the general medicine service at Stanford University Medical Center. A brief, inperson survey was conducted with two groups: (1) 56 patients on two inpatient units with whiteboards and (2) 48 patients on two inpatient units without whiteboards. Questions included understanding of: physician name, goals of care, discharge date and satisfaction with care. We surveyed 25 internal medicine residents regarding challenges of whiteboard use, along with physical therapists, occupational therapists, case managers, consulting physicians and patients' family members (n=40).The use of whiteboards significantly increased the proportion of patients who knew: their physician (p≤=0.0001), goals for admission (p≤=0.0016), their estimated discharge date (p≤=0.049) and improved satisfaction with the hospital stay overall (p≤=0.0242). Physicians, ancillary staff and patient families all found the whiteboards to be helpful. In response, residents were also more likely to integrate whiteboard use into their daily work flow.Inpatient whiteboards help physicians and ancillary staff with communication, improve patients' awareness of their care team, admission plans and duration of admission, and significantly improve patient overall satisfaction.

    View details for DOI 10.1136/postgradmedj-2012-131296

    View details for PubMedID 23922397

  • Teaching evidence-based medicine on a busy hospitalist service: Residents rate a pilot curriculum ACADEMIC MEDICINE Nicholson, L. J., Shieh, L. Y. 2005; 80 (6): 607-609

    Abstract

    To increase evidence-based medicine (EBM) instruction within the confines of reduced resident work hours.In 2001-02, the authors designed and implemented an EBM curriculum for residents on an inpatient medicine service at Stanford University Medical Center. Thirty-six residents were assigned the hospitalist rotation in its pilot year. Attendings introduced EBM concepts and Internet resources. During daily rounds, housestaff presented patient-based EBM literature search results. After the rotation, residents were given a questionnaire on which they were asked to rate the impact of the curriculum on their understanding of 20 EBM terms or practice skills (1 = no effect to 5 = strong effect).Twenty-three residents (64%) completed the questionnaire. The results were very positive with average effect of more than 4 (somewhat strong effect/impact) for 16 of the 20 questions. High-speed Internet access and EBM Web resources were critical to efficient delivery of the curriculum during inpatient care.The pilot curriculum successfully introduced the practice of EBM during active inpatient care without requiring additional hours from housestaff schedules. To further evaluate and expand this project, EBM skills will be tested before and after the rotation, and faculty development will allow consistent delivery in additional clinical settings.

    View details for Web of Science ID 000229386300016

    View details for PubMedID 15917368

  • EROSION OF A NEW FAMILY OF BIODEGRADABLE POLYANHYDRIDES JOURNAL OF BIOMEDICAL MATERIALS RESEARCH Shieh, L., Tamada, J., Chen, I., Pang, J., Domb, A., Langer, R. 1994; 28 (12): 1465-1475

    Abstract

    Studies investigating the erosion mechanism of the newly developed poly (fatty acid dimer: sebacic acid) polyanhydride (p:[FAD:SA]) are described. The overall erosion of different monomer compositions of p(FAD:SA) copolymers was examined to determine whether and to what extent copolymer properties affected polymer erosion. Increasing the hydrophobic monomer (FAD) content up to 50 wt% in the copolymer resulted in longer erosion, whereas further increases up to 70 wt% decreased the erosion period. Polymer crystallinity depended on copolymer FAD content. Copolymer degradation was studied by examining anhydride bond hydrolysis using infrared spectroscopy. Much faster hydrolysis was found in p(FAD:SA) 70:30 compared with more crystalline copolymers of higher SA content. Light microscopy indicates the presence of an erosion zone, a distinct area where mass loss occurs. This erosion zone moves from the outside toward the interior of the polymer matrix. It plays an important role in erosion because any water or monomer must diffuse through this eroded layer.

    View details for Web of Science ID A1994PU33100011

    View details for PubMedID 7876286