Physician Order Research Articles

Development of an automated process for monitoring of amiodarone treatment

Abstract Background Amiodarone treatment requires repeated laboratory evaluations of thyroid and liver function due to risk of side effects during long-term administration. Robotic process automation (RPA) represents the use of software robots to automate repetitive and routine tasks typically performed by humans. Purpose We aimed to develop an RPA using a diagnostic classification algorithm and clinical support system for follow-up of amiodarone treatment. Methods Based on international guidelines and clinical specialist advisory we constructed an RPA which was studied in a test environment in parallel with routine amiodarone treatment. Expert advice was integrated through a series of collaborative workshops, ensuring alignment of the algorithm with current best practices in thyroid and liver disease management. The RPA provided recommendations on the time interval to next laboratory testing and suggestions for patient management to the physician, who was serving as a human-in-the-loop responsible for clinical decisions. Results After iterative improvements the RPA was evaluated against physician orders (n=390 paired orders) without technical failures. The recommended time interval to next follow-up was (mean ± SD) 4.5 ± 2.4 vs. 3.1 ± 1.4 months for RPA vs. physician (p<0.0001). While normal laboratory findings resulted in recommended follow-up in 6 months by the RPA (72.2%) this was only ordered in 9.9% by the physician (Figure). Physicians’ orders clustered between 3-4 months (58.5%). All patients diagnosed with new side effects (n=12) were detected and communicated correctly by the RPA, whereas only 8 were correctly detected and responded to by the physician (Table). Conclusions An automated process constitutes a reliable alternative to the current fully manual management of amiodarone follow-up. It may reduce manual labour, frequency of laboratory testing and detect side effects with increased precision, thereby reducing costs and enhancing patient value. While the RPA shows promise, further research is needed to explore its adaptability to other treatment scenarios.

The practice of defensive medicine among Italian physicians: a cross sectional study in Rome

Abstract Background To identify the perception and the reason of defensive medicine among Italian physicians, and identify the socio-demographic and work-related determinants of the increased practice of defensive medicine. Methods This study is a cross sectional web survey. A questionnaire was sent by e-mail to all the physicians registered to the Order of Physicians and Dentists of the Province of Rome. The collection period was from mar 2024 to may 2024. Descriptive analysis and multivariable linear regression models were conducted to describe differences between groups and to estimate the relationships between variables. Results A total of 291 physicians completed the survey and were included in this analysis. Almost 60% of respondents feel under pressure due to the possibility of legal disputes. 73,8% adopted defensive medicine behaviours during the last year. More than 80% are aware that defensive medicine represents a limitation for their profession and a unfavourable factor for patients. Who answered that they practice defensive medicine think that it is a factor limiting their professional activity (OR: 2.3) and an unfavourable factor for the patient’s health (OR: 1.1). Conclusions Defensive medicine is an important factor in health care costs without increasing the benefits to the patient. The study contributes to a deeper understanding of the perception of defensive medicine among physicians. Defensive medicine practice is common among physicians with concerns about increasing pattern in the future. Key messages • Our study highlights physicians’ awareness of adopting defensive medicine behaviors in their clinical practice. • The study contributes to a deeper understanding of the perception of defensive medicine among physicians.

Evaluation of Intravenous Immunoglobulin Usage in a Teaching Hospital: A Case Series Study in Kerman, Iran

Background: Assessing the utilization of intravenous immunoglobulin (IVIG) is crucial due to its high cost and limited availability. IVIG preparations are utilized in various disorders. This study aimed to investigate the prescribing and consumption patterns of IVIG at Kerman Afzalipour Hospital and to propose strategies for reducing drug expenditures. Materials and Methods: Over one year, physician orders and patient charts of individuals treated with IVIG were reviewed to collect data. Descriptive statistics were employed for data analysis using SPSS software. Results: During the study period, 62 IVIG administrations were documented at the hospital, with 54.1% involving female patients. Of these, 51.4% were prescribed for labeled indications, while 48.6% were for off-label indications. No contraindications were observed, although precaution was warranted in 9.6% of cases, which was not consistently addressed, and laboratory parameters were not evaluated in any case. Conclusion: This study reveals that IVIG infusions for off-label indications were nearly as frequent as those for labeled indications.

Effectiveness of Nurse-Driven Protocols in Reducing Catheter-Associated Urinary Tract Infections: A Systematic Review and Meta-Analysis.

Catheter-associated urinary tract infections (CAUTIs) are common health care-associated infections linked to indwelling urinary catheters. Nurse-driven protocols (NDPs) empower nurses to direct care without physician orders, potentially enhancing patient outcomes and reducing infection rates. This systematic review and meta-analysis aimed to evaluate the effectiveness of NDPs for preventing CAUTIs and reducing catheter utilization rates. Databases searched included Cochrane Library, PubMed, Embase, and others. Ten studies involving 27, 965 NDP-treated patients and 30, 230 controls were reviewed, examining catheter utilization rates and CAUTI incidence. Use of NDPs significantly lowered catheter utilization rates (34.84% vs 49.40%) and CAUTI incidence (2.867% vs 6.503%). Risk ratio analysis revealed a 29.48% decrease in catheter utilization and a 55.91% reduced CAUTI risk with NDP implementation. Using NDPs demonstrate superior efficacy in reducing catheter use and CAUTI occurrence compared to traditional methods. Further research is warranted to solidify evidence-based nursing practices in this area.

A Descriptive Study: Evaluation of Delayed Laboratory Testing in Emergency Room

Precision, accuracy, and short turnaround time (TAT) are important to improve the quality and effectiveness of laboratory services in the Emergency Room (ER). Several studies reported an average of 60% the ratio of anticoagulant to sample is not appropriate, lysis, and clotted samples occurred in the pre-analytical part. This part consisted of the request/registration of laboratory tests, patient preparation, specimen collection, and transportation to the central laboratory. The aim of this research is to evaluate the cause of the long TAT for laboratory research so as to obtain problem solving based on the target. This observational study was conducted in 2021 at the ER laboratory outlet. Observations were made started from the workload carried out by the laboratory technician, sample registration, and data collection from the Laboratory Information System (LIS). The study obtained 14.709 samples from the LIS at the Clinical Pathology Department, Cipto Mangunkusumo Hospital. The highest sample rejection rate was from the ER laboratory outlet due to specimen lysis (2.79%). The average time required for re-collecting specimens was around 2-2.5 hours. This rejection was below the minimum quality standards based on the International Federation of Clinical Chemistry (IFCC). Other problems include the limited number of medical laboratory experts compared to the workload also inefficient Computerized Physician Order Entry (CPOE) registration methods. The main problem of delayed laboratory testing in the emergency department is the pre-analytical part including sample registration and rejection specimens. That rejection mostly comes from lysis specimens, which caused invalid laboratory result.

Preventing Overrides of Severe Drug Allergy Alerts Initiative: an Implemented System Upgrade

Administering medications to patients with documented drug hypersensitivity reactions (DHR) poses a significant risk for adverse events, ranging from mild reactions to life-threatening incidents. Electronic healthcare systems have revolutionized the modern clinical decision-making process, with built in warnings. However, as these alerts become a routine part of healthcare provider’s workflow, alert fatigue becomes a challenge. This study was conducted within the Ministry of National Guard Health Affairs (MNGHA), a government healthcare system in Saudi Arabia. A taskforce of experts was formed to develop an electronic path that would prevent unintentional overrides of severe drug allergy alerts. The system underwent rigorous testing, and monitoring parameters were established. We outline the implementation of a system upgrade designed to trigger an alternative interruption in the computerized physician order entry (CPOE) process, distinct from the regular allergy pop-up alerts. The alternate path is activated upon a CPOE with a drug-to-drug match and a documented severe drug allergy symptom, necessitating co-signature form another prescriber before proceeding. The adopted upgrade is a proactive approach to enhance medication safety in electronic healthcare systems, ensuring that serious allergy-related warnings are not overridden, ultimately enhancing patient safety. Further monitoring will confirm the safety and effectiveness of this measure. This study provides a model for institutions seeking to prevent allergy-related harm within their patient population.

Assessing variations in care delivered to rural out of hospital cardiac arrest patients in the interfacility transfer setting.

There is significant variation in out-of-hospital cardiac arrest (OHCA) outcomes between different regions. We sought to evaluate outcomes of OHCA patients in the interfacility transfer (IFT) setting, between critical care transport (LifeFlight) and community Emergency Medical Services (EMS), in the state of Maine. This was a retrospective analysis of our institution's electronic medical record and the Maine EMS database. Data were collected from January 1, 2019, to December 31, 2021. Only adult OHCA encounters requiring an IFT for definitive post-cardiac-arrest care were included. Demographics, EMS agency, IFT vital signs, targeted temperature management (TTM) medications, cerebral performance category (CPC) scores, survival to discharge, and other descriptive variables were collected. Ninety-three patients met inclusion criteria, with LifeFlight transferring 30 of them (32.3%). LifeFlight was more likely to initiate TTM compared to other EMS agencies (p=0.012), have run-sheets reported (p=0.001), and serve rural areas (p=0.036). LifeFlight was associated with more epinephrine (0.034) and norepinephrine (<0.001) use. Only 37% of IFTs had physician orders, with none (0.0%) of them defining vital sign targets. No difference in survival to discharge or CPC scores was observed between LifeFlight and other EMS agencies. No significant variation in comorbidities or vital signs was observed. There was no difference in survival to discharge or CPC scores between LifeFlight and ad hoc EMS agency. LifeFlight was associated with more TTM and vasopressor utilization during IFT. Most IFT encounters did not have dedicated physician orders, and none of the orders included vital sign targets.

An Audit On Minimising Unnecessary Catheter Use In An Older Population Attending The Emergency Department

Abstract Background Catheter-associated urinary tract infections (CAUTI) pose a great risk of morbidity and mortality to our older population. It is estimated that around 20% of patients admitted to hospital receive an indwelling catheter at some point. Each day that a catheter is in situ increases the risk of urinary tract infection by 5 %. Inappropriate placement of catheters in this population poses an unnecessary and significant risk. Many catheters are inserted in the Emergency Department in older patients, and we wanted to find out if these urinary catheters were inserted in accordance with best practice guidelines. Methods An audit was conducted to look at indwelling catheter use in a cohort of patients over 75 years of age who presented to the Emergency Department of a tertiary hospital over a two-week period in November 2023. Using the software Symphony patient records and Emergency Department physician notes were accessed to look at the following: age, whether catheter insertion was consistent with current best practice evidence, whether the indication for catheter insertion was documented and whether the catheter was removed while in the emergency department. Patients who had long term catheters were also included. Results We included 22 patients in this audit (n=22)- median age was 81 (range 75-90); 11 were male (50%) and 20 had urinary catheterisation consistent with best practice guidelines (91%). 8 patients had clear documentation of indication for the catheter (36%), while no patients had their catheter removed whilst in the emergency department (0%). Conclusion The vast majority of patients had an appropriate indication for urinary catheterisation however clear documentation of a physician order for the urinary catheter was lacking in over half of the cases. A guideline was created showing clear indications for urinary catheterisation in this population and an education session with medical and nursing staff is planned prior to re-auditing.

Missed Opportunities for use of Advanced Care Planning and Palliative Care in Open Aortic Surgery

Major vascular surgery, including open aortic procedures, is associated with having a 30-day mortality rate greater than 6% and a perioperative complication rate greater than 50%. Published literature suggests that patients undergoing high-risk procedures benefit from having a care plan in place to not only maximize quality of life but also to ensure medical interventions align with care goals. Currently, there is a paucity of published data on the prevalence of goals of care conversations, advance care planning documentation, and palliative care evaluations in patients undergoing high-risk vascular operations. A retrospective chart review of all patients who underwent open aortic surgery at a tertiary care academic medical center from July 2014 to March 2023 was performed. Patient demographics, comorbidities, type and timing of advanced care planning (ACP), palliative care evaluations, and clinical outcomes during the periprocedural period were recorded. For patients who died during the study period, the use of palliative care prior to death were noted. Patients who received ACP or palliative care were compared with those who did not. The cohort consisted of 192 patients who underwent major open aortic surgery. The mean age was 63 years (SD 12.3) and the majority of patients were male (73.4%) and white (64.1%). Thirty-nine (20.6%) operations were classified as emergent. At the time of their operation, 16.7% (n=32) of patients had an ACP document on file. Of the 38 documents on file, most were durable power of attorney (DPOA) (86.8%) documents while a smaller percentage were physician orders for life-sustaining treatment (POLST) (13.2%). There were no patients with Do Not Resuscitate and/or Intubate (DNR/DNI), living will, or organ/tissue donation orders noted in their chart prior to surgery. One percent (n=2) of patients had a palliative evaluation prior to their operation. During the perioperative period, an additional 2 (1%) of patients had advanced care planning documentation and 7 (3.7%) of patients underwent palliative care evaluation. Fifteen percent of patients (n=28) died during the perioperative period and an additional 21 patients died by the end of the study period for a total mortality of 25.2% in the study population. Among patients that died during the perioperative period, 28.6% (n=8 out of 28) received palliative care. Overall, 28.6% of all study patients that died (n=14 out of 49) received a palliative care evaluation prior to or during their terminal hospitalization. Patients who had ACP documents or who received palliative care consultations prior to surgery were older (p=0.01), more likely to be on Medicare or Medicaid (p=0.004), and more likely to have a history of solid organ malignancy (p=0.03). The median interval between surgery and receiving palliative care was 20 (IQR 3-71) days. The median interval between palliative care and death was 5 (IQR 2-13) days. Patients who utilized ACP or PC were more likely to die at home (p=0.05). Despite a high mortality and morbidity rate, ACP documentation is poor for patients undergoing major open aortic surgery. Palliative care interventions tend to be performed closer to the end of life, suggesting a missed opportunity to define goals of care.

Abstract A125: A nationwide initiative to expand access to lung cancer screening: Results and impact of the Color/American Cancer Society Lung Screening Access Program

Abstract Lung cancer is a leading health challenge in the United States – it is the third most common cancer and disproportionately impacts people of color. Early detection of lung cancer is possible through routine screenings using low-dose lung CT scans. Despite the efficacy of screening, 80-85% of people eligible for screening are not up-to-date. The underutilization of regular screening has often been attributed to gaps in primary care and insufficient support following an abnormal result. In an effort to improve access, Color and the American Cancer Society (ACS), launched a nationwide initiative to make lung cancer screening readily accessible and free across all 50 states based on ACS guidelines. The program simplifies the screening process by managing all logistical steps from physician orders to finding and booking appointments at local clinics to assisting with next steps if abnormalities are detected.Since the program launched in November 2023, 74 people completed the online health risk assessment. On average participants were 54 years of age (range: 18-81 years), 64% (n=41) female, and 65% (n=48) White. 28% (n=19) respondents currently smoked, 50% (n=34) had a former history of smoking, and average smoking history was 23.0 pack years (range: 0.1 - 66 pack years). While the program primarily supports individuals who meet ACS lung screening guidelines, all participants can speak with a clinician about screening.Of those who completed the health risk assessment, 45.6% (n=31) met ACS eligibility criteria for lung screening. Eligible participants were on average 62 years of age (range: 51 - 77 years), 74% (n=23) were female, and 87% (n=27) were White. Eligible participants resided in 21 states, with Georgia and Ohio having the highest number of eligible individuals.To date, 9 people have completed a lung CT and 3 are in progress of scheduling. On average, appointments were scheduled within 25 days from the initial referral submission (range: 8-55 days) and all appointments were within 17 miles from the individual’s preferred location (average: 6.8 miles, range: 0.5-17 miles).3 participants had a change in their lung screening plan based on their result, with 2 participants having Lung-RADS 3 category nodules (follow-up in 6 months) and 1 having Lung-RADS 4A nodules (follow-up in 6 months). Other findings included an ascending aortic aneurysm (4.2 cm), a hiatal hernia, an indeterminate adrenal nodule, and mild coronary artery calcification, some of which required additional follow-up care with a PCP or cardiologist within 3-12 months. No participants were recommended to have immediate diagnostic testing for lung cancer based on their results. The Color/ACS Lung Screening Access Program demonstrates the impact that a virtual lung cancer screening program has on closing screening gaps. It underscores the critical role of supporting patients not only in undergoing cancer screening, but also in navigating the complexities of follow-up care, thereby enhancing the overall efficacy of lung cancer prevention and early detection strategies. Citation Format: Deanna Brockman, Jennifer Fung, Ashly Emig, Gabrielle Hands, Wendy McKennon, Jennifer Cho, Robert Smith, William Dahut, Alicia Zhou, Keegan Duchicela. A nationwide initiative to expand access to lung cancer screening: Results and impact of the Color/American Cancer Society Lung Screening Access Program [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A125.

Impact of Computerized Physician Order Entry (CPOE) Coupled With Clinical Decision Support (CDS) on Radiologic Services.

Medical imaging is an essential component of healthcare, enabling accurate diagnoses and facilitating effective treatment plans. However, the field is not without its challenges, including medical imaging errors, overutilization of procedures, and adverse reactions to contrast agents. This review explores the impact of computerized physician order entry (CPOE) systems coupled with clinical decision support (CDS) on radiologic services. By analyzing the findings from various studies, this paper highlights how CPOE coupled with CDS can significantly reduce inappropriate imaging, enhance adherence to clinical guidelines, and improve overall patient safety. The implementation of CPOE with CDS optimizes the utilization of radiologic procedures, thereby reducing healthcare costs and minimizing patients' exposure to unnecessary radiation. Despite its benefits, the adoption of CPOE with CDS encounters challenges such as high implementation costs, changes in workflow, and alert fatigue among healthcare providers. Addressing these challenges requires careful system design, including the customization of alerts to reduce override rates and improve the specificity of CDS recommendations. This review underscores the potential of CPOE with CDS to transform radiologic services, enhancing both the quality and safety of patient care. Further research is needed to explore the system's effectiveness in preventing adverse reactions to contrast media and to identify best practices for overcoming the barriers to its broader adoption.

The electronic health record: does it enhance or distract from patient safety?

The electronic health record (EHR) is an invaluable tool that may be used to improve patient safety. With a variety of different features, such as clinical decision support and computerized physician order entry, it has enabled improvement of patient care throughout medicine. EHR allows for built-in reminders for such items as antibiotic dosing and venous thromboembolism prophylaxis. In anesthesiology, EHR often improves patient safety by eliminating the need for reliance on manual documentation, by facilitating information transfer and incorporating predictive models for such items as postoperative nausea and vomiting. The use of EHR has been shown to improve patient safety in specific metrics such as using checklists or information transfer amongst clinicians; however, limited data supports that it reduces morbidity and mortality. There are numerous potential pitfalls associated with EHR use to improve patient safety, as well as great potential for future improvement.

Clinical decision-making process and distributive justice: The mediating role of economic analysis. Empirical evidence from Italy.

The COVID-19 pandemic has not only tested the resilience of public health systems but also underscored the criticality of allocative choices on health resources. These choices, however, are not confined to health emergencies but are integral to public health decisions, which inherently grapple with limited resources. In this context, physicians play a pivotal role as the architects of clinical actions in various scenarios. Therefore, doctors are called upon to make their decisions by considering not only the criteria of clinical appropriateness but also the ethical aspects linked, in particular, to the principle of justice. Indeed, the assessment of the effectiveness of a treatment for a particular patient must be balanced against criteria of equity and justice for the whole. To be fully applied, the principle of justice presupposes the use of economic evaluation techniques designed to drive the organisation decisions by effectiveness and efficiency. The present paper aims to empirically analyse whether and to what extent economic evaluation is known and used by doctors in healthcare decision-making and, therefore, what the most widespread approaches are used in such processes. In particular, this paper intends to present the results of an empirical study on a sample of doctors registered with the Order of Physicians in Lombardy (Italy), one of the areas most affected by the COVID-19 pandemic. The research reveals a particular awareness of the criticality of allocation issues accompanied by a lack of knowledge of the economic evaluation techniques or, more broadly, by an almost total disuse of financial criteria. The main reasons are doctors' need for more knowledge of these tools and insufficient availability of economic information at the country system level. In the conclusion, we propose some suggestions to facilitate the transition to more current decision-making models consistent with the characteristics of more advanced national healthcare contexts.

Applying Machine Learning for Prescriptive Support: A Use Case with Unfractionated Heparin in Intensive Care Units.

Continuous unfractionated heparin is widely used in intensive care, yet its complex pharmacokinetic properties complicate the determination of appropriate doses. To address this challenge, we developed machine learning models to predict over- and under-dosing, based on anti-Xa results, using a monocentric retrospective dataset. The random forest model achieved a mean AUROC of 0.80 [0.77-0.83], while the XGB model reached a mean AUROC of 0.80 [0.76-0.83]. Feature importance was employed to enhance the interpretability of the model, a critical factor for clinician acceptance. After prospective validation, machine learning models such as those developed in this study could be implemented within a computerized physician order entry (CPOE) as a clinical decision support system (CDSS).

A Retrospective Observational Study of Continuous Wireless Vital Sign Monitoring via a Medical Grade Wearable Device on Hospitalized Floor Patients.

Background: Continuous vital sign monitoring via wearable technology, combined with algorithm-based notifications, has been utilized for early detection of patient deterioration. In this retrospective observational study, we summarize a large-scale implementation of a continuous monitoring system in medical-surgical units of two hospitals over the course of fifteen (15) months. Methods: An FDA-cleared wireless monitoring device (BioButton®, BioIntelliSense Inc., Golden, CO, USA), was placed on each patient upon admission. The wearable device measures heart rate and respiratory rate at rest, skin temperature, and patient activity levels. High-frequency data (up to 1440 measurements per day) are transmitted to display in exception management software (BioDashboard™, version 2.9, BioIntelliSense Inc.). Algorithmic and rules-based notifications are triggered based on clinical and statistical trending criteria. We present (i) agreement of device readings with bedside charted measurements, (ii) the frequency of notifications, (iii) the occurrence of notifications prior to clinical deterioration events, and (iv) impact on clinical management, including early data on length of stay (LOS). Results: In total, 11,977 patient encounters were monitored at two sites. Bias ±95% limits of agreement were 1.8 ± 12.5 for HR and 0.4 ± 8.0 for RR. The rates of notifications were 0.97 and 0.65 per patient-day at Sites 1 and 2, respectively. Among clinical deteriorations, 73% (66%) had at least one notification within 24 h prior at Site 1 (Site 2). At Site 1, there were 114 cases for which a notification led to a new or changed physician's order. LOS in the first unit monitored by the system exhibited a decreasing trend from 3.07 days to 2.75 days over 12 months. Conclusions: Wearable continuous vital sign monitoring with the BioIntelliSense BioButton® system enables early detection of clinical deterioration.

The Progression of End-of-Life Wishes and Concordance with End-of-Life Care: An Update.

Importance: Concordance between physician orders for life-sustaining treatment (POLST) preferences and treatment at end-of-life is an important outcome measure of providing patient-centered care. Objectives: We determine whether the COVID pandemic affected clinician ability to provide goal concordant care and replicate our previous report on care concordance and change in patient preferences over time with a larger sample size. We also investigate the quality of POLST completion to determine the number of documents completed with an advance care planning (ACP) conversation or a decision maker present. Methods: Chart abstraction via structured questionnaire of 796 randomly selected patients who died in 2020 with a POLST on file. Results: We found 99% concordance in the last setting of death between a patient's POLST preferences and the care they received. We confirm our previous finding that patients' wishes shift towards a preference for lower treatment intensity at end-of-life. We found that 82% of POLSTs were created in the context of an ACP conversation, 77% with a decision maker present. Conclusion: High levels of goal concordant care were maintained during the pandemic. Because patient wishes evolve over time, clinicians should be trained and supported to revisit care preferences across the illness trajectory.

Nurses' engagement in advance care planning practices: A descriptive cross-sectional study.

To describe and compare nurses' awareness of, attitudes toward, and participation in advance care planning, as well as related facilitators and challenges, in four types of healthcare settings. A cross-sectional descriptive study. Four hundred and ninety-eight registered nurses from tertiary, secondary and primary healthcare institutions, along with long-term care centres in South Korea, participated in an investigator-developed online survey. The collected data were analysed using descriptive statistics, chi-squared test, one-way ANOVA, and binary logistic regression. Participants were on average 30.6 ± 7.3 years old, mostly female (95.4%), employed as staff nurses (95.4%), held bachelor's degrees or higher (84.1%), and had worked for less than 5 years at their current institutions (69.7%). Overall, 49% of the participants were familiar with advance care planning. While most participants supported nurse involvement in advance care planning with patients and surrogates, fewer were willing to engage or recommend it. Less than half were actively engaged in advance care planning practices. A notable challenge was the lack of time due to excessive workload. Compared to those from tertiary healthcare institutions, participants from secondary and primary healthcare institutions and long-term care centres were less likely to be aware of advance care planning. Participants from secondary and primary healthcare institutions had lower odds of checking for the presence of advance directives and the physician orders for life-sustaining treatment. Nurses demonstrated low awareness and participation in advance care planning. Nurses' insufficient time and competency to conduct advance care planning in their practice should be addressed. Educational programs, initiatives (e.g. guidelines, position statements) and legal and policy-level efforts (e.g. nurse staffing, role clarification, reimbursement) are crucial to incorporate advance care planning into routine nursing practice. What problem did the study address? Nurses play an important role in advance care planning; however, limited is understood about their readiness and involvement in such practices. What were the main findings? Nurses' awareness of advance care planning practices and their participation in such practices is low across care settings. Although nurses have a positive attitude toward advance care planning, there are challenges (e.g. insufficient time to conduct advance care planning discussions and lack of relevant knowledge and skills) that impede their participation in practice. Where and on whom will the research have an impact? This study may serve as a foundation for nursing societies in countries, where advance care planning is emerging, to discuss strategies to increase nurses' competency in advance care planning and promote their participation in the practice. The STROBE checklist was followed. No patient or public contribution.

Assessing knowledge gaps and educational needs in urine drug test interpretation among health care professionals.

Urine drug testing (UDT) is a critical tool used in medical, forensic, and occupational settings, but interpreting results can be challenging. We performed a study to assess the ability of health care professionals to interpret UDT results accurately. In total, 911 clinical and laboratory professionals in the United States and Canada responded to a survey with questions gauging expertise in UDT interpretation. Responses were analyzed to identify knowledge gaps. Toxicologists and laboratory PhD scientists performed well, with means of 4.82 and 4.63 questions answered correctly (out of 6 possible), respectively. Physicians specializing in pathology, emergency medicine, primary care, and internal medicine, however, displayed concerning knowledge gaps, as did laboratorians with nondoctoral degrees. Experience and training correlated with interpretation accuracy. Identification of simulated compliance as well as understanding opioid exposure, metabolism, and immunoassay cross-reactivity were among the most clinicallysignificant knowledge gaps. More than 30% of survey respondents indicated that they would seek UDT information from the internet or peers rather than clinical or laboratory experts. The study highlighted the need for targeted education and better collaboration between clinical and laboratory experts and other health care professionals to ensure that when physicians order UDT, they can accurately interpret results and reduce harm.

Life-sustaining treatment decisions and family evaluations of end-of-life care for Veteran decedents in Department of Veterans Affairs nursing homes.

Modeled after the Physician Orders for Life Sustaining Treatment program, the Veterans Health Administration (VA) implemented the Life-Sustaining Treatment (LST) Decisions Initiative to improve end-of-life outcomes by standardizing LST preference documentation for seriously ill Veterans. This study examined the associations between LST documentation and family evaluation of care in the final month of life for Veterans in VA nursing homes. Retrospective, cross-sectional analysis of data for decedents in VA nursing homes between July 1, 2018 and January 31, 2020 (N = 14,575). Regression modeling generated odds for key end-of-life outcomes and family ratings of care quality. LST preferences were documented for 12,928 (89%) of VA nursing home decedents. Contrary to our hypothesis, neither receipt of wanted medications and medical treatment (adjusted odds ratio [OR]: 0.85, 95% confidence interval [CI] 0.63, 1.16) nor ratings of overall care in the last month of life (adjusted OR: 0.96, 95% CI 0.76, 1.22) differed significantly between those with and without completed LST templates in adjusted analyses. Among Community Living Center (CLC) decedents, 89% had documented LST preferences. No significant differences were observed in family ratings of care between Veterans with and without documentation of LST preferences. Interventions aimed at improving family ratings of end-of-life care quality in CLCs should not target LST documentation in isolation of other factors associated with higher family ratings of end-of-life care quality.

Literature Review: Development of Electronic Medical Records In Hospital Management Information Systems

Introduction: Health technology today is developing very quickly from the initially conventional using paper to being computerized. This literature review aims to map and critically summarize the scientific evidence on the cost-effectiveness and acceptability of Computerized Physician Order Entry (CPOE) and Electronic Health Reports. This Journal have Question that need to be answered how does the development of CPOE in medical records affect cost-effectiveness improvement so that it can be accepted by many parties? Method used in this journal is literature review is conducted on journal articles related to costs and receipts in CPOE. The systematic search was conducted from 5 databases namely PubMed, Science Direct, ProQuest, DOAJ and Ebscohost. Journal articles are selected and selected following PRISMA guidelines. Twenty-five journal articles qualified based on predetermined criteria. At the end as result, Cost-effectiveness with CPOE is more likely to be found that it is easier to reach compared to conventional methods. In addition, the acceptance of patients and health workers is also high. These factors can have a positive or negative influence on the hospital management system because developing countries still need adequate resources so that they can run these methods. Discussion and conclusion CPOE systems can improve patient safety by detecting drug interactions and actions. It is necessary to develop medical records in order to provide effective financing and acceptance.