At North Shore University Hospital on Long Island, motion sensors, like those used for burglar alarms, go off every time someone enters an intensive care room. The sensor triggers a video camera, which transmits its images halfway around the world to India, where workers are checking to see if doctors and nurses are performing a critical procedure: washing their hands.

This Big Brother-ish approach is one of a panoply of efforts to promote a basic tenet of infection prevention, hand-washing, or as it is more clinically known in the hospital industry, hand-hygiene. With drug-resistant superbugs on the rise, according to a recent report by the federal Centers for Disease Control and Prevention, and with hospital-acquired infections costing $30 billion and leading to nearly 100,000 patient deaths a year, hospitals are willing to try almost anything to reduce the risk of transmission.

Studies have shown that without encouragement, hospital workers wash their hands as little as 30 percent of the time that they interact with patients. So in addition to the video snooping, hospitals across the country are training hand-washing coaches, handing out rewards like free pizza and coffee coupons, and admonishing with “red cards.” They are using radio-frequency ID chips that note when a doctor has passed by a sink, and undercover monitors, who blend in with the other white coats, to watch whether their colleagues are washing their hands for the requisite 15 seconds, as long as it takes to sing the “Happy Birthday” song.

All this effort is to coax workers into using more soap and water, or alcohol-based sanitizers like Purell.

“This is not a quick fix; this is a war,” said Dr. Bruce Farber, chief of infectious disease at North Shore.

But the incentive to do something is strong: under new federal rules, hospitals will lose Medicare money when patients get preventable infections.

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Two out of five medical students have an unconscious bias against obese people, according to a new study by researchers at Wake Forest Baptist Medical Center. The study is published online ahead of print in the Journal of Academic Medicine.

"Bias can affect clinical care and the doctor-patient relationship, and even a patient's willingness or desire to go see their physician, so it is crucial that we try to deal with any bias during medical school," said David Miller, M.D., associate professor of internal medicine at Wake Forest Baptist and lead author of the study.

"Previous research has shown that on average, physicians have a strong anti-fat bias similar to that of the general population. Doctors are more likely to assume that obese individuals won't follow treatment plans, and they are less likely to respect obese patients than average weight patients," Miller said.

Miller and colleagues conducted the study as part of their efforts to update the medical school's curriculum on obesity. The goal was to measure the prevalence of unconscious weight-related biases among medical students and to determine whether the students were aware of those biases.

The three-year study included more than 300 third-year medical students at a medical school in the southeastern United States from 2008 through 2011. The students were geographically diverse, representing at least 25 different states and 12 countries outside the United States.

The researchers used a computer program called the Weight Implicit Association Test (IAT) to measures students' unconscious preferences for "fat" or "thin" individuals. Students also answered a survey assessing their conscious weight-related preferences. The authors determined if the students were aware of their bias by seeing if their IAT results matched their stated preferences.

Overall, 39 percent of medical students had a moderate to strong unconscious anti-fat bias as compared to 17 percent who had a moderate to strong anti-thin bias. Less than 25 percent of students were aware of their biases.

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A study released today by George Washington University School of Public Health and Health Services (SPHHS) researchers offers an in-depth look at hospitals nationwide and admissions to intensive care units (ICU). The study, published in the journal Academic Emergency Medicine, finds a sharp increase—nearly 50 percent—in ICU admissions coming from U.S. emergency departments.

"These findings suggest that emergency physicians are sending more patients on to the ICU," said SPHHS researcher and lead author Peter Mullins. "The increase might be the result of an older, sicker population that needs more care." The larger question, one that this study couldn't answer, is whether there will be enough ICU capacity in the future to accommodate the growing number of patients, particularly the oldest of the old, the authors said.

Mullins and his colleagues conducted the study by using data from the National Hospital Ambulatory Care Survey, a sample of U.S. hospital-based emergency departments during a seven-year period. They found that ICU admissions jumped from 2.79 million in 2002-2003 to 4.14 million in 2008-2009. The study also shows that during the same time frame overall emergency department admissions grew by only 5.8 percent.

Other key findings of the study:
- ICU admissions grew the most among patients aged 85 and older—increasing 25 percent every two years.
- Utilization of tests and services provided to emergency department patients on their way to the ICU also jumped during the study period, with the largest rise occurring in computerized tomography (CT) or magnetic resonance imaging (MRI) tests. In fact, CT and MRI tests provided while still in the emergency department increased from 16.8 percent to 37.4 percent.
- The most common reasons for ICU admissions were symptoms such as chest pain or shortness of breath that can signal life-threatening conditions like heart attacks.
- On average, patients had to wait five hours in the emergency department before getting into the ICU.

Additional research must be done to find ways to keep critically ill patients from facing long waits in crowded emergency departments, said co-author Jesse Pines, MD, MBA, MSCE, a practicing emergency physician and an associate professor of emergency medicine and health policy at SPHHS.

"Studies have shown that the longer ICU patients stay in the emergency department, the more likely they are to die in the hospital," Pines said. "Better coordination between the emergency department and ICU staff might help speed transfers and prevent complications caused by long emergency department waits," he said.

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Over the past decade, in response to public concerns about medical errors arising from fatigue, the Accreditation Council for Graduate Medical Education, the organization responsible for accrediting American medical residency programs, has been progressively limiting the number of hours that trainees can work. The latest mandate, which took effect in 2011, is the most stringent and deals most specifically with interns. These youngest doctors are allowed to work no longer than 16 hours in a day; and residency programs that violate the restriction risk losing their accreditation.

In response to the 16-hour mandate and faced with a Rubik’s-cube conundrum of covering all the work with the same number of interns working fewer hours, training programs across the country came up with several innovative scheduling configurations. Some created complicated and overlapping shifts where outgoing doctors “signed out” their patients, passing off their responsibilities to the incoming shift. Others adopted a “night float” system that meant a resident just a year out of internship had to carry the work of as many as 12 interns at night, looking after more than 100 patients and fielding questions about those patients at best every 20 minutes and at worst every 11 minutes throughout the night.

Now, two years after the 16-hour mandate was established, studies on the outcomes are being published, and the results reveal one thing.

Maybe we should have thought a little harder about the arithmetic.

Contrary to expectations, these studies have shown that interns have not been getting significantly more sleep. Moreover, they are not happier, nor are they studying more. In one national survey, nearly half of all doctors in training disapproved of the regulations altogether. Another study revealed that interns were spending less time in educational activities because the additional time required for such conferences and lectures would push them over the 16-hour limit.

In addition, there has been no significant improvement in the quality of care since the work limits took effect. In one case, doctors had to scrap the night float system because the nurses thought the care offered by trainees on that schedule was so poor. Another study revealed that interns confessed to having more concerns about making serious medical errors after the mandate than before.

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Medical interns spend just 12 percent of their time examining and talking with patients, and more than 40 percent of their time behind a computer, according to a new Johns Hopkins study that closely followed first-year residents at Baltimore's two large academic medical centers. Indeed, the study found, interns spent nearly as much time walking (7 percent) as they did caring for patients at the bedside.

Compared with similar time-tracking studies done before 2003, when hospitals were first required to limit the number of consecutive working hours for trainees, the researchers found that interns since then spend significantly less time in direct contact with patients. Changes to the 2003 rules limited interns to no more than 30 consecutive hours on duty, and further restrictions in 2011 allow them to work only 16 hours in a row.

"One of the most important learning opportunities in residency is direct interaction with patients," says Lauren Block, M.D., M.P.H., a clinical fellow in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine and leader of the study published online in the Journal of General Internal Medicine. "Spending an average of eight minutes a day with each patient just doesn't seem like enough time to me."

"Most of us went into medicine because we love spending time with the patients. Our systems have squeezed this out of medical training," says Leonard Feldman, M.D., the study's senior author and a hospitalist at The Johns Hopkins Hospital (JHH).

For the study, trained observers followed 29 internal medicine interns—doctors in their first year out of medical school—at JHH and the University of Maryland Medical Center for three weeks during January 2012, for a total of 873 hours. The observers used an iPod Touch app to mark down what the interns were doing at every minute of their shifts. If they were multi-tasking, the observers were told to count the activity most closely related to direct patient care.

The researchers found that interns spent 12 percent of their time talking with and examining patients; 64 percent on indirect patient care, such as placing orders, researching patient history and filling out electronic paperwork; 15 percent on educational activities, such as medical rounds; and 9 percent on miscellaneous activities. The researchers acknowledge that it's unclear what proportion of time spent at the bedside is ideal, or whether the interns they studied in the first year of a three-year internal medicine training program make up the time lost with patients later in residency. But 12 percent, Feldman says, "seems shockingly low at face value. Interns spend almost four more times as long reviewing charts than directly engaging patients."

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In reviewing 25 years of U.S. malpractice claim payouts, Johns Hopkins researchers found that diagnostic errors—not surgical mistakes or medication overdoses—accounted for the largest fraction of claims, the most severe patient harm, and the highest total of penalty payouts. Diagnosis-related payments amounted to $38.8 billion between 1986 and 2010, they found.

"This is more evidence that diagnostic errors could easily be the biggest patient safety and medical malpractice problem in the United States," says David E. Newman-Toker, M.D., Ph.D., an associate professor of neurology at the Johns Hopkins University School of Medicine and leader of the study published online in BMJ Quality and Safety. "There's a lot more harm associated with diagnostic errors than we imagined."

While the new study looked only at a subset of claims—those that rose to the level of a malpractice payout—researchers estimate the number of patients suffering misdiagnosis-related, potentially preventable, significant permanent injury or death annually in the United States ranges from 80,000 to 160,000.

Diagnostic error can be defined as a diagnosis that is missed, wrong or delayed, as detected by some subsequent definitive test or finding. The ensuing harm results from the delay or failure to treat a condition present when the working diagnosis was wrong or unknown, or from treatment provided for a condition not actually present. "Overall, diagnostic errors have been underappreciated and under-recognized because they're difficult to measure and keep track of owing to the frequent gap between the time the error occurs and when it's detected," Newman-Toker says. "These are frequent problems that have played second fiddle to medical and surgical errors, which are evident more immediately."

He says experts have often downplayed the scope of diagnostic errors not because they were unaware of the problem, but "because they were afraid to open up a can of worms they couldn't close." He adds: "Progress has been made confronting other types of patient harm, but there's probably not going to be a magic-bullet solution for diagnostic errors because they are more complex and diverse than other patient safety issues. We're going to need a lot more people focusing their efforts on this issue if we're going to successfully tackle it."

For their review, Newman-Toker and his colleagues analyzed medical malpractice payments data from the National Practitioner Data Bank, an electronic repository of all payments made on behalf of practitioners in the United States for malpractice settlements or judgments since 1986.

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"X-rays can look alike, and if one patient's images are confused with another before the radiologist sees them, it can be difficult for the radiologist to determine there is a mismatch," said Dr. Srini Tridandapani, of Emory University and an author of the study.
As part of the study, ten radiologists interpreted 20 pairs of radiographic images with and without photographs. Two to four mismatched pairs were included in each set of 20 pairs of images. When photographs were added, radiologists correctly identified the mismatch 64% of the time. The error detection rate was about 13% when photographs were not included, said Dr. Tridandapani.

The radiologists in the study did not know they could use the photographs as a means to identify mismatched x-ray images, and some said they purposely ignored the photographs because they thought the study was designed to determine if a photograph would distract them. "We did a second study of five radiologists, and we told them to use the photographs. The error detection rate went up to 94% in the second study," said Dr. Tridandapani.

Surprisingly, the interpretation time went down in the first study when the photographs were added to the images, said Dr. Tridandapani. "We're not sure why this happened, but it could be because the photograph provided clinical clues that assisted the radiologist in making the diagnosis," he said.

"I estimate that about 1 out of 10,000 examinations have wrong-patient errors," Dr. Tridandapani said. "It occurred to me that we should be adding a photograph to every medical imaging study as a means to correct this problem after I received a phone call, and a picture of the caller appeared on my phone. The picture immediately identified for me who the caller was," he said.

The study required additional personnel to take the pictures of the patients immediately after the patients' x-ray examination. However, Dr. Tridandapani and his colleagues have developed a prototype system where the camera can be attached to a portable x-ray machine; the picture is taken without additional personnel.

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Medical students at Duke University are using a new virtual game-based tool to learn from their mistakes without a life depending on it.

With the latest in life-like patient simulation labs, healthcare students and professionals can get hands-on experience in making life-saving decisions.

For students without access to those labs, a gaming system simulates the technology.

“So what this type of platform offers is a way to practice no matter where they are,” said Dr. Jeff Taekman, the director of human simulation and patient safety at Duke.

Taekman says this virtual gaming system – developed by Applied Research Associates specifically for Duke – offers scenarios where a patient’s life depends on teamwork, rapid response and good decisions.

“In this particular situation we can have different providers playing different roles. They can be an anesthesiologist, an OB/GYN, or a nurse, learning without any risk to the patient,” Dr. Allen Mask said.

One simulation tests reactions to a patient who suffers bleeding during pregnancy – a problem that kills 140,000 women every year worldwide.

“It’s important to recognize quickly when a patient needs to be transfused under these circumstances,” said Dr. Evelyn Lockhart with Duke Transfusion services.

“You can see actually the blood loss is starting,” said Taekman.

Participants can get patient feedback and choose appropriate drugs.

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For years, medical students who chose a residency in radiology were said to be on the ROAD to happiness. The acronym highlighted the specialties — radiology, ophthalmology, anesthesiology and dermatology — said to promise the best lifestyle for doctors, including the most money for the least grueling work.

Not anymore. Radiologists still make twice as much as family doctors, but are high on the list of specialists whose incomes are in steepest decline. Recent radiology graduates with huge medical school debts are having trouble finding work, let alone the $400,000-and-up dream jobs that beckoned as they signed on for five to seven years of relatively low-paid labor as trainees. On Internet forums, younger radiology residents agonize about whether it is too late to switch tracks.

At St. Barnabas Hospital in the Bronx, a dozen radiologists in training, including Dr. Luke Gerges, 28, are suddenly stranded on an expensive road to nowhere. All received termination notices recently because their hospital is ending their residency program next year as part of a plan to replace its radiologists with a teleradiology company that reads diagnostic images remotely.

“Those days of raking in the dough with radiology are gone,” said Dr. Gerges, who is four years beyond medical school and $300,000 in debt. He said he chose a specialty he loves without caring that big salaries were waning, but never imagined it would be this hard to finish his postgraduate training and get a job.

“No one is going to hire me to be a radiologist without my training,” he said.

Few specialties have been immune to the same factors depressing radiology: deep Medicare cuts, cut-rate competition driven by technology, doubts about the health value of many tests and procedures and new measures to tilt public money to primary care.

The case of St. Barnabas may be extreme, said Dr. Paul H. Ellenbogen, chairman of the American College of Radiology, the principal organization of the nation’s 30,000 radiologists, who called the hospital’s treatment of the residents “unconscionable.” But it is part of a larger pattern that has made radiology the target of a dozen cuts in Medicare reimbursement since 2006, he said, totaling $6 billion.

“We were somewhat victims of our success,” said Dr. Ellenbogen, in Dallas, whose career spans what radiologists call the golden years, when the cost of diagnostic imaging grew faster than other items in health care.

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