Clinical decision support to improve management of diabetes and dysglycemia in the hospital: a path to optimizing practice and outcomes.

INTRODUCTION: Innovative approaches are needed to design robust clinical decision support (CDS) to optimize hospital glycemic management. We piloted an electronic medical record (EMR), evidence-based algorithmic CDS tool in an academic center to alert clinicians in real time about gaps in care related to inpatient glucose control and insulin utilization, and to provide management recommendations. RESEARCH DESIGN AND METHODS: The tool was designed to identify clinical situations in need for action: (1) severe or recurrent hyperglycemia in patients with diabetes: blood glucose (BG) ≥13.88 mmol/L (250 mg/dL) at least once or BG ≥10.0 mmol/L (180 mg/dL) at least twice, respectively; (2) recurrent hyperglycemia in patients with stress hyperglycemia: BG ≥10.0 mmol/L (180 mg/dL) at least twice; (3) impending or established hypoglycemia: BG 3.9-4.4 mmol/L (70-80 mg/dL) or ≤3.9 mmol/L (70 mg/dL); and (4) inappropriate sliding scale insulin (SSI) monotherapy in recurrent hyperglycemia, or anytime in patients with type 1 diabetes. The EMR CDS was active (ON) for 6 months for all adult hospital patients and inactive (OFF) for 6 months. We prospectively identified and compared gaps in care between ON and OFF periods. RESULTS: When active, the hospital CDS tool significantly reduced events of recurrent hyperglycemia in patients with type 1 and type 2 diabetes (3342 vs 3701, OR=0.88, p=0.050) and in patients with stress hyperglycemia (288 vs 506, OR=0.60, p<0.001). Hypoglycemia or impending hypoglycemia (1548 vs 1349, OR=1.15, p=0.050) were unrelated to the CDS tool on subsequent analysis. Inappropriate use of SSI monotherapy in type 1 diabetes (10 vs 22, OR=0.36, p=0.073), inappropriate use of SSI monotherapy in type 2 diabetes (2519 vs 2748, OR=0.97, p=0.632), and in stress hyperglycemia subjects (1617 vs 1488, OR=1.30, p<0.001) were recognized. CONCLUSION: EMR CDS was successful in reducing hyperglycemic events among hospitalized patients with dysglycemia and diabetes, and inappropriate insulin use in patients with type 1 diabetes.

Closing the Loop: Optimizing Diabetes Care in the Hospital by Addressing Dispersed Information in Electronic Health Records and Using Clinical Decision Support.

Multiple factors hinder the management of diabetes in hospitals. Amid the demands of practice, health care providers must collect, collate, and analyze multiple data points to optimally interpret glucose control and manage insulin dosing. Such data points are commonly dispersed in different sections of electronic health records (EHR), and the system for data display and physician interaction with the EHR are often poorly conducive to seamless clinical decision making. In this perspective article, we examine challenges in the process of EHR data retrieval, interpretation and decision making, using glucose management as an exemplar. We propose a conceptual, systems-based design for closing the loop between data gathering, analysis and decision making in the management of inpatient diabetes. This concept capitalizes on attributes of the EHR that can enable automated recognition of cases and provision of clinical recommendations.

The Educational Climate Inventory: Measuring Students' Perceptions of the Preclerkship and Clerkship Settings.

PURPOSE: To develop an instrument to assess educational climate, a critical aspect of the medical school learning environment that previous tools have not explored in depth. METHOD: Fifty items were written, capturing aspects of Dweck's performance-learning distinction, to distinguish students' perceptions of the educational climate as learning/mastery oriented (where the goal is growth and development) versus performance oriented (where the goal is appearance of competence). These items were included in a 2014 survey of first-, second-, and third-year students at six diverse medical schools. Students rated their preclerkship or clerkship experiences and provided demographic and other data. The final Educational Climate Inventory (ECI) was determined via exploratory and confirmatory factor analysis. Relationships between scale scores and other variables were calculated. RESULTS: Responses were received from 1,441/2,590 students (56%). The 20-item ECI resulted, with three factors: centrality of learning and mutual respect; competitiveness and stress; and passive learning and memorization. Clerkship students' ratings of their learning climate were more performance oriented than preclerkship students' ratings (P < .001). Among preclerkship students, ECI scores were more performance oriented in schools with grading versus pass-fail systems (P < .04). Students who viewed their climate as more performance oriented were less satisfied with their medical school (P < .001) and choice of medicine as a career (P < .001). CONCLUSIONS: The ECI allows educators to assess students' perceptions of the learning climate. It has potential as an evaluation instrument to determine the efficacy of attempts to move health professions education toward learning and mastery.

Practicing handoffs early: Applying a clinical framework in the anatomy laboratory.

The anatomy laboratory provides an ideal environment for the integration of clinical contexts as the willed-donor is often regarded as a student's "first patient." This study evaluated an innovative approach to peer teaching in the anatomy laboratory using a clinical handoff context. The authors introduced the "Situation, Background, Assessment, Recommendation" (SBAR) handoff framework within the anatomy laboratory. Study participants included 147 second-year medical students completing the head and neck portion of an anatomy course. The authors used mixed methods to evaluate the impact of the anatomic SBAR on the student anatomy laboratory experience. Qualitative analysis of student evaluations revealed three themes which emerged from students' summaries of their anatomic handoff experiences: Learning-by-teaching; Acquiescing to doing more with less; and Distrust of the peer handoff process. All the themes demonstrated that the anatomic handoff encouraged students' focus on the knowledge preparation and reflection. Closed question analysis suggested that that students' perceptions of handoff usefulness were tied to deeper learning strategies. The handoff provided a mechanism for promoting students' focus on anatomical relationships and facilitated students' learning of transferable clinical skills. Together, these results suggest that the introduction of a handoff process in anatomy education provided both a mechanism for learning anatomy and a unique opportunity for early exposure to an essential clinical skill. This clinical and basic science integration may serve as a vertical integration thread which can be woven throughout undergraduate medical education. Future study will focus on exploring the long-term impacts and learning outcomes of this integration. Anat Sci Educ 9: 476-487. © 2016 American Association of Anatomists.

Knowledge, attitudes, and decision making in hospital glycemic management: are faculty up to speed?

OBJECTIVE: Knowledge and confidence deficits in the management of hospital glucose abnormalities are prevalent among resident physicians. However, it is unclear whether such gaps prevail among faculty within different professional fields. In this study, we examined faculty knowledge and explored perceptions of challenges related to the management of inpatient hyperglycemia and diabetes. METHODS: We conducted a survey that examined management decisions about inpatient hyperglycemia and diabetes among Medicine, Medicine/Pediatrics, Family and Community Medicine, Surgery, and Neurology faculty clinicians. All participating faculty had teaching and patient care responsibilities. RESULTS: Responses from 69 faculty participants revealed gaps in several areas, including biomedical and contextual knowledge, familiarity with resources, clinical decision making, and self-efficacy. We identified important factors perceived as barriers to optimal glycemic management in the inpatient settings. CONCLUSION: The results of this study enhance our insight about the limitations existing among faculty related to the management of hyperglycemia and diabetes in hospitalized patients. We suggest that these barriers may impede optimization of patient care. Faculty play a crucial role in the clinical decision-making process and quality of care delivered by trainees. Therefore, attending physicians are likely to impact trainees' clinical performance and competency in the management of inpatient diabetes during training and beyond. Education in this subject should be a priority among trainees and faculty alike.

Team Emotional Intelligence, Team Interactions, and Gender in Medical Students During a Psychiatry Clerkship.

OBJECTIVE: This study examined the relationship between team emotional intelligence, quality of team interactions, and gender. METHODS: Psychiatry clerkship students participating in Team-Based Learning (TBL, n = 484) or no TBL (control, n = 265) completed the Workgroup Emotional Intelligence Profile (WEIP-S) and the Team Performance Scale (TPS). RESULTS: Significant correlations (p < 0.01) existed between quality of team interactions (i.e., TPS) and team emotional intelligence (i.e., WEIP-S) subscales, but not gender. Control and TBL groups experienced significant increases in WEIP-S subscales pre to post (p < 0.01, η (2) = .08), with the TBL group experiencing significantly higher gains in three of four subscales. Control group scored higher on TPS. CONCLUSIONS: A significant relationship exists between team emotional intelligence and quality of team interactions. Gender was unrelated to TPS or WEIP-S subscales. TBL group experienced higher gains in WEIP-S subscales while the control group experienced slightly higher TPS scores. Results suggest implications for medical educators who use TBL.

A Structured End-of-Life Curriculum for Neonatal-Perinatal Postdoctoral Fellows.

Death in tertiary care neonatal intensive care units is a common occurrence. Despite recent advances in pediatric palliative education, evidence indicates that physicians are poorly prepared to care for dying infants and their families. Numerous organizations recommend increased training in palliative and end-of-life care for pediatric physicians. The purpose of this study is to develop a structured end-of-life curriculum for neonatal-perinatal postdoctoral fellows based on previously established principles and curricular guidelines on end-of-life care in the pediatric setting. Results demonstrate statistically significant curriculum effectiveness in increasing fellow knowledge regarding patient qualification for comfort care and withdrawal of support (P = .03). Although not statistically significant, results suggest the curriculum may have improved fellows' knowledge of appropriate end-of-life medical management, comfort with addressing the family, and patient pain assessment and control.

A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care.

PURPOSE: To successfully design and implement longitudinal faculty development programs at five medical schools, and to determine whether faculty participants were perceived to be more effective humanistic teachers. METHOD: Promising teachers were chosen from volunteers to participate in groups at each of the medical schools. Between September 2004 and September 2006, the facilitators jointly designed and implemented a curriculum for enhancing humanistic teaching using previously defined learning goals that combined experiential learning of skills with reflective exploration of values. Twenty-nine participants who completed 18 months of faculty development at the five medical schools were compared with 47 controls drawn from the same schools in the final six months of the two-year project. For comparison, the authors developed a 10-item questionnaire, the Humanistic Teaching Practices Effectiveness Questionnaire (HTPE), to be filled out by medical students and residents taught by participants or control faculty. Items were designed to measure previously identified themes and domains of humanism. Control faculty were similar to participants by gender, specialty, and years of experience. RESULTS: Thirty-four (75%) of the original 45 enrollees completed the programs at the five schools. Faculty participants outperformed their peer controls on all 10 items of the HTPE questionnaire. Results were statistically significant (P < .05) and sufficiently robust (8%-13% differences) to suggest practical importance. CONCLUSIONS: A longitudinal faculty development process that combines experiential learning of skills and reflective exploration of values in the setting of a supportive group process was successfully accomplished and had a positive impact on participants' humanistic teaching.