The Impact of Asking Medical Students What They Want to Learn on Student Participation in Lectures.

BACKGROUND: The General Internal Medicine Acting Internship (GIM AI) at our school is a compulsory, one-month-long experience. Morning report-style case-based discussions were conducted on a weekly basis as part of the acting internship and were poorly attended. We sought to redesign our academic half day didactic curriculum and increase voluntary student attendance by allowing students to actively participate in determining the content of the acting internship academic half day. INTERVENTION: Prior to the beginning of the acting internship, students were sent an email survey listing seven inpatient topics to rank on a scale of 1-5 (1=not at all interested, 5=very interested). Based on student feedback, one additional topic was added: antibiotic use for common inpatient diagnoses. Topics that received the highest score were selected for topic-based sessions. A total of 32 teaching sessions were conducted over eight months. Twenty-four of these sessions were topic-based and the remainder were case-based. Student attendance at these sessions was voluntary. KEY RESULTS: Case-based discussions had the lowest preference ranking (n=94, mean=2.9), while cross-cover-based discussions (n=94, mean=4.3, p=0.001) and antibiotic use (n=52, mean=4.3, p=0.001) received the highest scores. Thirty-four percent (41/120) of possible learners attended case-based discussions, while 78% (281/360) of possible learners attended topic-based sessions (p<0.001). Learners reported a statistically significant improvement in comfort level in recognizing and managing 73% of sub-topics (29 out of 41) covered in topic-based sessions. CONCLUSIONS: A learner-centered approach to curriculum design led to robust student engagement in our acting internship academic half day. Fourth-year students prefer specific topic-based teaching sessions over case-based, morning report-style sessions.

Discharge When Medically Ready.

QUALITY PROBLEM: The timing and pace of patient discharges are not level-loaded throughout the day at many institutions including ours, an academic medical center and adult Level I trauma center located in Milwaukee, Wisconsin. INITIAL ASSESSMENT: Only 4% of patients were being discharged with rooms marked dirty by 11 AM at our institution. CHOISE OF SOLUTION: We put together a multidisciplinary team of approximately 30 stakeholders to develop a revised process that focused on coordination of discharge activities, plan of care awareness among team members, and communication with patients and families. IMPLEMENTATION: The discharge process was piloted and iteratively adjusted on a single medicine floor. EVALUATION: Our interventions made a noticeable impact on median room "ready to be cleaned" (RTBC) time without having an adverse impact on length of stay. RTBC improved by a median of 39 minutes (P = 0.019), and the proportion of rooms ready to be cleaned by 11 AM increased from 4.19% to 8.13%. LESSONS LEARNED: Having a multidisciplinary team participate in the evaluation and development of a new process was critical. Additionally, implementing solutions on a single unit allowed for rapid iteration of changes.

The Impact of Hospitalist Switch Day on Length of Stay.

BACKGROUND AND OBJECTIVE: Hospitalist practices around the country switch service on different days of the week. It is unclear whether switching clinical service later in the week is associated with an increase in length of stay (LOS). The aim of this study was to examine the association between service switch day for hospitalists at an academic medical center and LOS. METHODS: A single-center, cross-sectional study examined 4284 discharges from hospitalist staffed general internal medicine ward teams over a 1-year period between July 2018 and June 2019. Hospitalist service switch day changed from Tuesday to Thursday on January 1, 2019. The period between July 1, 2018, and December 31, 2018, was defined as the pre-switch time, while January 1, 2019, to June 30, 2019, was defined as the post-switch period. We calculated the LOS in days for patients discharged from hospitalist general internal medicine teams in the 2 periods. Generalized linear models were used to examine the association between attending switch day and LOS while adjusting for demographic factors, payer status, markers of severity of illness, and hospital or discharge-level confounders. RESULTS: There was no difference in mean LOS for patients discharged in the pre-switch time (6 days) period versus patients discharged in the post-switch time (6.03 days) (difference of means 0.03 days, 95% confidence interval -0.04 to 0.09, P value .37). CONCLUSIONS: Change in attending switch day from earlier in the week to later in the week is not associated with an increase in LOS. Other factors such as group preference and institutional needs should drive service switch day selection for hospitalist groups.

Creating a culture of quality: our experience with providing feedback to frontline hospitalists.

BACKGROUND: One way to provide performance feedback to hospitalists is through the use of dashboards, which deliver data based on agreed-upon standards. Despite the growing trend on feedback performance on quality metrics, there remain limited data on the means, frequency and content of feedback that should be provided to frontline hospitalists. OBJECTIVE: The objective of our research is to report our experience with a comprehensive feedback system for frontline hospitalists, as well as report the change in our quality metrics after implementation. DESIGN, SETTING AND PARTICIPANTS: This quality improvement project was conducted at a tertiary academic medical centre among our hospitalist group consisting of 46 full-time faculty members. INTERVENTION OR EXPOSURE: A monthly performance feedback report was distributed to provide ongoing feedback to our hospitalist faculty, including an individual dashboard and a peer comparison report, complemented by coaching to incorporate process improvement tactics into providers' daily workflow. MAIN OUTCOMES AND MEASURES: The main outcome of our study is the change in quality metrics after implementation of the monthly performance feedback report RESULTS: The dashboard and rank order list were sent to all faculty members every month. An improvement was seen in the following quality metrics: length of stay index, 30-day readmission rate, catheter-associated urinary tract infections, central line-associated bloodstream infections, provider component of Healthcare Consumer Assessment of Healthcare Providers and Systems scores, attendance at care coordination rounds and percentage of discharge orders placed by 10:00. CONCLUSIONS: Implementation of a monthly performance feedback report for hospitalists, complemented by peer comparison and guidance on tactics to achieve these metrics, created a culture of quality and improvement in the quality of care delivered.

Perioperative anemia: clinical practice update.

Perioperative medicine is an evolving area of medicine in which collaboration between internists, hospitalists, surgeons and anesthesiologists is the key to delivering high-quality care. Research in all areas of perioperative medicine, including perioperative anemia, is constantly evolving. Perioperative anemia is a major contributor to mortality and morbidity in the perioperative period. It is associated with an increased likelihood of postoperative wound complications, infections, delirium, increased length of stay and increased risk of readmissions. However, there is a lack of comprehensive guidelines for management of perioperative anemia. We performed an exhaustive review of contemporary literature on perioperative anemia and present evaluation and management recommendations that have the potential to impact clinical practice in the perioperative period.

Surgical venous thromboembolism prophylaxis: clinical practice update.

BACKGROUND: Perioperative medicine continues to evolve as new literature emerges. This article provides an update on prevention of venous thromboembolism (VTE) in surgical patients. METHODS: We reviewed articles on VTE prevention in surgical patients published in peer-reviewed journals since the publication of 2012 ACCP guidelines on VTE prevention in surgical patients. RESULTS: Methods of VTE prophylaxis include aggressive ambulation, mechanical prophylaxis, and pharmacological prophylaxis. In non-orthopedic surgery, the overall approach remains assessment of thrombosis risk with the recommendation to use a risk assessment tool such as the modified Caprini score. Low molecular weight heparin (LMWH) appears to be more effective than unfractionated heparin (UFH) for VTE prophylaxis in non-orthopedic surgery. For orthopedic surgery, recent studies now recognize aspirin as an option for VTE prophylaxis after total hip arthroplasty, total knee arthroplasty, and hip fracture surgery. Extended prophylaxis with LMWH reduces the risk of symptomatic VTE in high risk abdominal and pelvic cancer surgery without an appreciable increase in risk of bleeding and decreased symptomatic VTE in major orthopedic surgery but with more minor but not major bleeding. Prophylactic Inferior vena cava (IVC) filter placement or surveillance compression ultrasonography is not recommended in management or detection of VTE in surgical patients. CONCLUSIONS: This article aims to provide insight into data from last several years which has potential to change clinical practices in perioperative setting.

A Qualitative Exploration to Understand Hospitalists' Attitude Toward the Patient Experience Scoring System.

Patient's perception of their inpatient experience is measured by the Center for Medical Services' (CMS) administered Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) survey. There is scant existing literature on physicians' perceptions toward the HCAHPS scoring system. Understanding hospitalist knowledge and attitude toward the HCAHPS survey can help guide efforts to impact HCAHPS survey scores by improving the patient's perception of their hospital experience. The goal of this study is to explore hospitalists' knowledge and perspective of the physician communication domain of the HCAHPS survey at an academic medical center. Seven hospitalists at an academic medical center were interviewed for this report using a semistructured interview. Thematic analysis approach was used to analyze data. Open, line-by-line coding was performed on all 7 transcripts. Categories were derived in an inductive fashion. Categories were refined using the techniques of constant comparison and axial coding. We generated themes reflecting hospitalists' knowledge of the HCAHPS scoring system, their perception of the HCAHPS scoring system and the impact of the HCAHPS scoring system on their practice. While hospitalists acknowledged physician-patient communication is a challenging area to study, they are unlikely to embrace the feedback provided by HCAHPS surveys. There is a need to deploy tactics that provide timely and actionable feedback to providers on their bedside communication skills.

Effect of a rapid response team on patient outcomes in a community-based teaching hospital.

BACKGROUND: Rapid response teams have been adopted across hospitals to reduce the rate of inpatient cardiopulmonary arrest. Yet, data are not uniform on their effectiveness across university and community settings. OBJECTIVE: The objective of our study was to determine the impact of rapid response teams on patient outcomes in a community teaching hospital with 24/7 resident coverage. METHODS: Our retrospective chart review of preintervention-postintervention data included all patients admitted between January 2004 and April 2006. Rapid response teams were initiated in March 2005. The outcomes of interest were inpatient mortality, unexpected transfer to the intensive care unit, code blue (cardiac or pulmonary arrest) per 1000 discharges, and length of stay in the intensive care unit. RESULTS: Rapid response teams were activated 213 times during the intervention period. There was no statistically significant difference in inpatient mortality (3.13% preintervention versus 2.91% postintervention), code blue calls (3.09 versus 2.89 per 1000 discharges), or unexpected transfers of patients to the intensive care unit (15.8% versus 15.5%). CONCLUSIONS: The implementation of a rapid response team did not appear to affect overall mortality and code blue calls in a community-based hospital with 24/7 resident coverage.

Targeted nonviral gene-based inhibition of Gα(i/o)-mediated vagal signaling in the posterior left atrium decreases vagal-induced atrial fibrillation.

BACKGROUND: Pharmacologic and ablative therapies for atrial fibrillation (AF) have suboptimal efficacy. Newer gene-based approaches that target specific mechanisms underlying AF are likely to be more efficacious in treating AF. Parasympathetic signaling appears to be an important contributor to AF substrate. OBJECTIVE: The purpose of this study was to develop a nonviral gene-based strategy to selectively inhibit vagal signaling in the left atrium and thereby suppress vagal-induced AF. METHODS: In eight dogs, plasmid DNA vectors (minigenes) expressing Gα(i) C-terminal peptide (Gα(i)ctp) was injected in the posterior left atrium either alone or in combination with minigene expressing Gα(o)ctp, followed by electroporation. In five control dogs, minigene expressing scrambled peptide (Gα(R)ctp) was injected. Vagal- and carbachol-induced left atrial effective refractory periods (ERPs), AF inducibility, and Gα(i/o)ctp expression were assessed 3 days following minigene delivery. RESULTS: Vagal stimulation- and carbachol-induced effective refractory period shortening and AF inducibility were significantly attenuated in atria receiving a Gα(i2)ctp-expressing minigene and were nearly eliminated in atria receiving both Gα(i2)ctp- and Gα(o1)ctp-expressing minigenes. CONCLUSION: Inhibition of both G(i) and G(o) proteins is necessary to abrogate vagal-induced AF in the left atrium and can be achieved via constitutive expression of Gα(i/o)ctps expressed by nonviral plasmid vectors delivered to the posterior left atrium.