Clinical Focus

  • Internal Medicine

Academic Appointments

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 Medical Center (1999) CA
  • Medical Education:Harvard Medical School (1996) MA
  • Board Certification: Internal Medicine, American Board of Internal Medicine (1999)
  • Internship:Stanford University Medical Center (1997) CA
  • Residency, Stanford Univ Medical Center, Internal Medicine (1999)
  • MD, Harvard University, Medicine (1996)
  • PhD, MIT, Medical Engineering (1995)
  • BS, Purdue University, Chemical Engineering (1989)


2016-17 Courses


All Publications

  • 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


    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


    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

  • 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

    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


    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?

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

    View details for Web of Science ID 000350886500011

    View details for PubMedID 25416599

  • Septris: A Novel, Mobile, Online, Simulation Game That Improves Sepsis Recognition and Management ACADEMIC MEDICINE Evans, K. H., Dais, W., Tsui, J., Strehlow, M., Maggio, P., Shieh, L. 2015; 90 (2): 180-184


    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 ( 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 Web of Science ID 000348808000022

  • 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


    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 Web of Science ID 000349068600005

    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

    View details for DOI 10.1002/jhm.2236

    View details for Web of Science ID 000347516300001

  • 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


    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
  • 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

    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


    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?

    View details for DOI 10.1002/jhm.2228

    View details for Web of Science ID 000342679100004

    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


    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 Web of Science ID 000335634700024

    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


    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


    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



    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

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