Clinical Pharmacist Led Medication Reconciliation Program in an Emergency Department Observation Unit.

Objectives: Medication reconciliation is the process of comparing a patient's hospital medication orders to all of the medications that the patient has been taking prior to admission. The primary aim of this study was to evaluate the effectiveness of pharmacist-led medication reconciliation in reducing ED visit rates. The secondary aim of this study was to evaluate if a clinical pharmacist reduces medication errors in an ED observation unit (OBS). Methods: This was a retrospective, IRB approved, chart review conducted at New York University Langone Health-Tisch Hospital. The study defines the year before a clinical pharmacist was present on the unit (July 5, 2016 through July 4, 2017) as the control group and the first year a clinical pharmacist was present on the unit (July 5, 2017 through July 4, 2018) as the intervention group. The primary endpoint was 30-day ED re-visits. The secondary endpoints were 60-and 90-day ED re-visits, number, type and severity of medication history and reconciliation discrepancies. Results: The primary endpoint of 30-day ED visits occurred in 153 patients in the no pharmacist group and 88 patients in the OBS clinical pharmacist group (19.1% vs 9.9%, P < .00001). The secondary endpoint of 60- day ED visits occurred in 53 patients in the no pharmacist group and 39 patients in the OBS clinical pharmacist group (8.2% vs 4.9%, P = .01). The secondary endpoint of 90- day ED visits occurred in 31 patients in the no pharmacist group and 26 patients in the OBS clinical pharmacist group (5.2% vs 3.4%, P = .01). Conclusion: The benefits of having a clinical pharmacist perform medication reconciliation are highlighted by the reduction in ED visits, cost savings, and the prolific amount of errors corrected.

An Observation Medicine Curriculum for Emergency Medicine Education.

Audience and type of curriculum: This curriculum, designed and implemented at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, primarily targets third- and fourth-year emergency medicine (EM) residents, and is an immersive observation medicine rotation that can be integrated into existing emergency medicine residency training. Length of curriculum: The curriculum is designed for a dedicated rotation of two weeks for senior residents and can be expanded to 4 weeks. Introduction: Observation medicine is an extension of emergency medicine and is increasingly playing a role in the delivery of acute healthcare, with over half of all observation units (OUs) in the nation being led by emergency medicine.1 Despite this, many emergency medicine residencies have yet to establish a formal observation medicine curriculum. In a 2002 study by Mace and Shah, only 10% of emergency medicine residencies had a dedicated observation medicine rotation, despite 85% of emergency medicine residency directors believing this was an important part of emergency medicine training.2 The first description of a model longitudinal observation medicine curriculum did not appear until 2016.3 In order to prepare our graduates for the evolving demands of the EM workplace, we must provide diverse educational experiences that train and showcase the expanding skill set of future emergency physicians. Educational Goals: The primary goal of this observation medicine curriculum is to train current EM residents in short-term acute care beyond the initial ED visit. This entails caring for patients from the time of their arrival to the OU to the point when a final disposition from the OU is determined, be it inpatient admission or discharge to home. Educational Methods: The educational strategies used in this curriculum include experiential learning through supervised direct patient care, independent learning based on prescribed literature, and didactic teaching. Research Methods: Education content was evaluated by the learners through pre- and post-rotation surveys, as well as written attending evaluations describing the progress of the learners during the rotation. Results: All residents reported increases in the confidence of their abilities to perform observation care. Discussion: Observation medicine is an increasingly vital aspect of emergency medicine, but education in observation medicine has not developed in tandem with its implementation. A lack of observation medicine training represents a missed opportunity for each trainee to gain a robust understanding of the interface between inpatient and outpatient care, and how to arrive at the most appropriate disposition for ED patients. Considering the wide breadth of clinical conditions managed in OUs and the variability of OU management at various learning sites, the curriculum must be tailored to the specific unit to maximize effectiveness of the learning experience. Topics: Observation medicine, curriculum, education, clinical rotation.

Implementation of the Surviving Sepsis Campaign one-hour bundle in a short stay unit: A quality improvement project.

OBJECTIVE: To improve timely sepsis care by implementing the 2018 Surviving Sepsis Campaign one-hour interventions. DESIGN: Ten-month prospective quality improvement project. SETTING: A 38-bed short stay unit within an 800-bed hospital in New York City. PARTICIPANTS: Patients admitted to the short stay unit who screened positive for sepsis. INTERVENTION: A sepsis implementation tool was created from the 2018 Surviving Sepsis Campaign guidelines. Sepsis champions delivered education on sepsis recognition, treatment, and management, and the sepsis implementation tool to the healthcare staff. PROCESS AND OUTCOME MEASURES: Time to first lactate, blood cultures × 2, antibiotic administration, length of stay and mortality were tracked weekly for five months. RESULTS: From May 6, 2019 to October 1, 2019, 32 patients were diagnosed with sepsis. Initial lactate and blood cultures were completed on every patient within 1one-hour of sepsis diagnosis. Administration of antibiotics within one-hour reached 100% after week four and was sustained. CONCLUSION: Use of a registered nurse-initiated sepsis implementation tool in a short stay unit led to the completion of blood cultures, initial lactate, and antibiotic administration within one-hour. Key factors to support this practice improvement were increasing registered nurse, physician and physician assistant sepsis knowledge, registered nurse and physician/physician assistant early collaboration, increased staffing and intravenous access equipment.

Recruiting and Training a Health Professions Workforce to Meet the Needs of Tomorrow's Health Care System.

The quality of any health care system depends on the caliber, enthusiasm, and diversity of the workforce. Yet, workforce research often focuses on the number and type of health professionals needed and anticipated shortages compared with anticipated needs. These projections do not address whether the workforce will have the requisite social, intellectual, cultural, and emotional capital needed to deliver care in an increasingly complex health care system.Building a workforce that can deliver care in such a system begins by recruiting individuals with the requisite knowledge, skills, and attributes. To address this and other workforce needs, the authors argue that health professions education programs must make purposeful changes to their admissions criteria, such as focusing on emotional intelligence and diversity and recruiting students from the communities where they will return to work; partner with communities; ensure that accreditation systems support these goals of fostering diversity; recruit students who can bridge the gap between public health and health care; and invest in health professions education research.In this article, they contemplate how health professions education programs can recruit and educate talented health professionals to create a high-performing workforce that is capable of serving in the complex health care system of tomorrow. They provide examples of successful programs to highlight the potential effects of their recommendations.

Increased Public Accountability for Hospital Nonprofit Status: Potential Impacts on Residency Positions.

BACKGROUND: The Institute of Medicine recently called for greater graduate medical education (GME) accountability for meeting the workforce needs of the nation. The Affordable Care Act expanded community health needs assessment (CHNA) requirements for nonprofit and tax-exempt hospitals to include community assessment, intervention, and evaluation every 3 years but did not specify details about workforce. Texas receives relatively little federal GME funding but has used Medicaid waivers to support GME expansion. The objective of this article was to examine Texas CHNAs and regional health partnership (RHP) plans to determine to what extent they identify community workforce need or include targeted GME changes or expansion since the enactment of the Affordable Care Act and the revised Internal Revenue Service requirements for CHNAs. METHODS: Texas hospitals (n = 61) received federal GME dollars during the study period. Most of these hospitals completed a CHNA; nearly all hospitals receiving federal GME dollars but not mandated to complete a CHNA participated in similar state-based RHP plans. The 20 RHPs included assessments and intervention proposals under a 1115 Medicaid waiver. Every CHNA and RHP was reviewed for any mention of GME-related needs or interventions. The latest available CHNAs and RHPs were reviewed in 2015. All CHNA and RHP plans were dated 2011 to 2015. RESULTS: Of the 38 hospital CHNAs, 26 identified a workforce need in primary care, 34 in mental health, and 17 in subspecialty care. A total of 36 CHNAs included implementation plans, of which 3 planned to address the primary care workforce need through an increase in GME funding, 1 planned to do so for psychiatry training, and 1 for subspecialty training. Of the 20 RHPs, 18 identified workforce needs in primary care, 20 in mental health, and 15 in subspecialty training. Five RHPs proposed to increase GME funding for primary care, 3 for psychiatry, and 1 for subspecialty care. CONCLUSIONS: Hospital CHNAs and other regional health assessments could be potentially strategic mechanisms to assess community needs as well as GME accountability in light of community needs and to guide GME expansion more strategically. Internal Revenue Service guidance regarding CHNAs could include workforce needs assessment and intervention requirements. Preference for future Medicaid or Medicare GME funding expansion could potentially favor states that use CHNAs or RHPs to identify workforce needs and track outcomes of related interventions.

Office Visits for Women Aged 45-64 Years According to Physician Specialties.

BACKGROUND: The increase in access to healthcare through the Affordable Care Act highlights the need to track where women seek their office-based care. The objectives of this study were to examine the types of physicians sought by women beyond their customary reproductive years and before being elderly. METHODS: This retrospective cohort study involved an analysis of national data from the Medical Expenditure Panel Survey (MEPS) between 2002 and 2012. Women between 45 and 64 years old (n = 44,830) were interviewed, and reviews of corresponding office visits (n = 330,114) were undertaken. RESULTS: In 2002, women aged 45-64 years (62%) went to a family or internal medicine physician only and this reached 72% in 2012. The percentage of women who went to an obstetrician-gynecologist (ob-gyn) only decreased from 20% in 2002 to 12% in 2012. Most went to a family physician or general internist for a general checkup or for diagnosis or treatment. By contrast, visits to ob-gyn physicians were predominantly for general checkups. Those who went to an ob-gyn office were more likely to have a higher family income, live in the Northeast, and describe their overall health as being excellent. CONCLUSIONS: Women aged 45-64 years were substantially more likely to obtain care exclusively at offices of family physicians or general internists than of ob-gyn physicians. Overlap in care provided at more than one physician's office requires continued surveillance in minimizing redundant cost and optimizing resource utilization.

A Primary Care Panel Size of 2500 Is neither Accurate nor Reasonable.

Primary care panel sizes are an important component of primary care practices. Determining the appropriate panel size has implications for patient access, physician workload, and care comprehensiveness and will have an impact on quality of care. An often quoted standard panel size is 2500. However, this number seems to arise in the literature anecdotally, without a basis in research. Subsequently, multiple studies observed that a panel size of 2500 is not feasible because of time constraints and results in incomplete preventive care and health care screening services. In this article we review the origins of a panel size of 2500, review the subsequent work examining this number and effectively debunking it as a feasible panel size, and discuss the importance of primary care physicians setting an appropriate panel size.

Improving your care of patients with spinal cord injury/disease.

Ninety percent of patients with spinal cord injury/disease identify FPs as their "regular doctors." So what can you do to keep them healthy and out of the hospital?

Saving Women, Saving Families: An Ecological Approach to Optimizing the Health of Women Refugees with S.M.A.R.T Primary Care.

More than 43 million people worldwide have been forcibly displaced from their homes as a result of conflict and persecution, over 50% of whom are women and 41% are children. The United Nations estimates that two-thirds of the world's refugees have been in exile for over 5 years, and more than half are in urban environments, as opposed to camps. Therefore, long-term strategies for healthcare in receiving countries are needed. The unique challenges facing refugee women as they seek safe and stable living situations are compelling. A system that optimizes the health of women refugees has significant implications for the rest of the family.