Teaching during Consults: Effects of Multiple Educational Interventions on Satisfaction with Consultant Interactions among Internal Medicine Residents.

OBJECTIVE: To evaluate the effect of an educational intervention on Internal Medicine residents' satisfaction with the inpatient consultation process. METHODS: We hosted an optional workshop for Internal Medicine residents on placing and responding to consults using two memory aid tools. We then provided copies of these memory aids to residents on inpatient Medicine and Infectious Diseases teams, and later surveyed all of the residents who were finishing their inpatient Medicine rotation. Surveys assessed residents' participation in the workshop, receipt of the memory-aid tools, and satisfaction with Infectious Diseases consultation using a 5-point Likert scale. Residents were organized into the following groups: group 1 residents were exposed to the workshop and both memory aid tools; group 2 residents were exposed only to the "responding to consults" memory aid tool; group 3 residents were exposed to the workshop and the "placing consults" memory aid tool; and group 4 residents were not exposed to any interventions. We compared the percentage of satisfied residents among groups. RESULTS: A total of 36 out of 69 residents answered our survey (response rate of 52%). Among survey respondents, 7 (19.4%) were in group 1, 8 (22.2%) in group 2, 10 (27.8%) in group 3, and 11 (30.6%) in group 4. Group 4 residents had lower satisfaction with the overall consultation process (36.4% residents satisfied vs 90%-100% in the intervention groups, P < 0.001), the consultant's professionalism (54.5% vs 100%, P = 0.002), communication between the primary team and the consultant (54.5% vs 90%-100%, P = 0.01), and teaching received from the consultant (18.2% vs 57.1%-80.0%, P = 0.02). CONCLUSIONS: An educational workshop and use of structured memory aids can lead to improved resident satisfaction with the consultation process.

Impact of time off anticoagulation in patients with continuous-flow left ventricular assist devices.

Patients with left ventricular assist devices (LVADs) receive anticoagulation to decrease the risk of thrombosis. Various circumstances require discontinuing anticoagulation in LVAD patients, but the risks entailed are not well defined. In a retrospective review of LVAD implantation procedures, we examined the effect of time off anticoagulation on thrombosis and mortality rates after implantation. An international normalized ratio ≤ 1.5 was used to screen for patients taken off anticoagulation. Patients were divided into three groups by the cumulative number of days off anticoagulation: no discontinuation, short-term discontinuation (< 30 days), and long-term discontinuation (≥ 30 days). Rates of ischemic stroke, pump thrombosis, and mortality were compared among groups. Of 245 patients who underwent LVAD implantation during the study, 70 (28.6%) were off anticoagulation during follow-up: 37 (15.1%) had short-term discontinuation (median, 11 days), and 33 (13.5%) had long-term discontinuation (median, 124 days). Patients with long-term discontinuation had a higher rate of ischemic stroke (adjusted hazard ratio 8.5, p = 0.001) and death (adjusted hazard ratio 3.9, p = 0.001). The three groups did not differ in pump thrombosis rate. We conclude that after LVAD implantation, discontinuing anticoagulation for ≥ 30 days is independently associated with an increased risk of ischemic stroke and death.