Effect of Increased Interprofessional Familiarity on Team Performance, Communication, and Psychological Safety on Inpatient Medical Teams: A Randomized Clinical Trial.

Importance: In large academic centers, medical residents work on multiple clinical floors with transient interactions with nursing colleagues. Although teamwork is critical in delivering high-quality medical care, little research has evaluated the effect of interprofessional familiarity on inpatient team performance. Objective: To determine the effectiveness of increased familiarity between medical residents and nurses on team performance, psychological safety, and communication. Design, Setting, and Participants: A 12-month randomized clinical trial in an inpatient general medical service at a large academic medical center was completed from June 25, 2019, to June 24, 2020. Participants included 33 postgraduate year (PGY)-1 residents in an internal medicine residency program and 91 general medicine nurses. Interventions: Fifteen PGY-1 residents were randomized to complete all 16 weeks of their general medicine inpatient time on 1 medical nursing floor (intervention group with 43 nurses). Eighteen PGY-1 residents completed 16 weeks on 4 different general medical floors as per usual care (control group with 48 nurses). Main Outcomes and Measures: The primary outcome was an assessment of team performance in physician-nurse simulation scenarios completed at 6 and 12 months. Interprofessional communication was assessed via a time-motion study of both work rounds and individual resident clinical work. Psychological safety and teamwork culture were assessed via surveys of both residents and nurses at multiple time points. Results: Of the intervention and control PGY-1 residents, 8 of 15 (54%) and 8 of 18 (44%) were women, respectively. Of the nurses in the intervention and control groups with information available, 37 of 40 (93%) and 34 of 38 (90%) were women, respectively, and more than 70% had less than 10 years of clinical experience. There was no difference in overall team performance during the first simulation. At the 12-month simulation, the intervention teams received a higher mean overall score in leadership and management (mean [SD], 2.47 [0.53] vs 2.17 [0.39]; P = .045, Cohen d = 0.65) and on individually rated items were more likely to work as 1 unit (100% vs 62%; P = .003), negotiate with the patient (61% vs 10%; P = .001), support other team members (61% vs 24%; P = .02), and communicate as a team (56% vs 19%; P = .02). The intervention teams were more successful in achieving the correct simulation case outcome of negotiating a specific insulin dose with the patient (67% vs 14%; P = .001). Time-motion analysis noted intervention teams were more likely to have a nurse present on work rounds (47% vs 28%; P = .03). At 6 months, nurses in the intervention group were more likely to report their relationship with PGY-1 residents to be excellent to outstanding (74% vs 40%; P = .003), feel that the input of all clinical practitioners was valued (95% vs 53%; P < .001), and say that feedback between practitioners was delivered in a way to promote positive interactions (90% vs 60%; P = .003). These differences diminished at the 12-month survey. Conclusions and Relevance: In this randomized clinical trial, increased familiarity between nurses and residents promoted more rapid improvement of nursing perception of team relationships and, over time, led to higher team performance on complex cognitive tasks in medical simulations. Medical centers should consider team familiarity as a potential metric to improve physician-nursing teamwork and patient care. Trial Registration: ClinicalTrials.gov Identifier: NCT05213117.

Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education: A Randomized Clinical Trial.

Importance: While the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient safety. Objective: To determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes. Design, Setting, and Participants: This 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program. Interventions: Twenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order. Main Outcomes and Measures: The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings. Results: Of the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04). Conclusions and Relevance: Increased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy. Trial Registration: ClinicalTrials.gov Identifier: NCT03318198.

Brief Report: Meeting the Needs of Medically Hospitalized Adults with Autism: A Provider and Patient Toolkit.

In an effort to meet the needs of adults with autism spectrum disorder (ASD) while hospitalized, a team of experts and providers from Massachusetts General Hospital (MGH), MGH for Children as well as parents of individuals with ASD was sparked in 2013. This became a multidisciplinary collaborative, the MGH Autism Care Collaborative, to improve adult care for inpatients with ASD. The collaborative was created with three goals in mind: (1) to educate internal medicine adult inpatient providers and staff on the unique needs of adults with ASD when hospitalized; (2) to create ASD specific resources for internal medicine adult inpatient providers; (3) to optimize patient care from admission to discharge among adults with ASD admitted to internal medicine services.

Beyond Continuing Medical Education: Clinical Coaching as a Tool for Ongoing Professional Development.

PROBLEM: For most physicians, the period of official apprenticeship ends with the completion of residency or fellowship, yet the acquisition of expertise requires ongoing opportunities to practice a given skill and obtain structured feedback on one's performance. APPROACH: In July 2013, the authors developed a clinical coaching pilot program to provide early-career hospitalists with feedback from a senior clinical advisor (SCA) at Massachusetts General Hospital. A Hospital Medicine Unit-wide retreat was held to help design the SCA role and obtain faculty buy-in. Twelve SCAs were recruited from hospitalists with more than five years of experience; each served as a clinical coach to 28 early-career hospitalists during the pilot. Clinical narratives and programmatic surveys were collected from SCAs and early-career hospitalists. OUTCOMES: Of 25 responding early-career hospitalists, 23 (92%) rated the SCA role as useful to very useful, 20 (80%) reported interactions with the SCA led to at least one change in their diagnostic approach, and 13 (52%) reported calling fewer subspecialty consults as a result of guidance from the SCA. In response to questions about professional development, 18 (72%) felt more comfortable as an independent physician following their interactions with the SCA, and 19 (76%) thought the interactions improved the quality of care they delivered. NEXT STEPS: To better understand the impact and generalizability of clinical coaching, a larger, longitudinal study is required to look at patient and provider outcomes in detail. Further refinement of the SCA role to meet faculty needs is needed and could include faculty development.

Assessment of leadership training needs of internal medicine residents at the Massachusetts General Hospital.

Internal medicine (IM) physicians, including residents, assume both formal and informal leadership roles that significantly impact clinical and organizational outcomes. However, most internists lack formal leadership training. In 2013 and 2014, we surveyed all rising second-year IM residents at a large northeastern academic medical center about their need for, and preferences regarding, leadership training. Fifty-five of 113 residents (49%) completed the survey. Forty-four residents (80% of respondents) reported a need for additional formal leadership training. A self-reported need for leadership training was not associated with respondents' gender or previous leadership training and experience. Commonly cited leadership skill needs included "leading a team" (98% of residents), "confronting problem employees" (93%), "coaching and developing others" (93%), and "resolving interpersonal conflict" (84%). Respondents preferred to learn about leadership using multiple teaching modalities. Fifty residents (91%) preferred to have a physician teach them about leadership, while 19 (35%) wanted instruction from a hospital manager. IM residents may not receive adequate leadership development education during pregraduate and postgraduate training. IM residents may be more likely to benefit from leadership training interventions that are physician-led, multimodal, and occur during the second year of residency. These findings can help inform the design of effective leadership development programs for physician trainees.

Improving the discharge process by embedding a discharge facilitator in a resident team.

BACKGROUND: Hospital discharges are vulnerable periods for patient safety, especially in teaching hospitals where discharges are done by residents with competing demands. We sought to assess whether embedding a nurse practitioner on a medical team to help physicians with the discharge process would improve communication, patient follow-up, and hospital reutilization. METHODS: A 5-month randomized controlled trial was conducted on the medical service at an academic tertiary-care hospital. A nurse practitioner was randomly assigned to 1 resident team to complete discharge paperwork, arrange follow-up appointments and prescriptions, communicate discharge plans with nursing and primary care physicians, and answer questions from discharged patients. RESULTS: Intervention patients had more discharge summaries completed within 24 hours (67% vs. 47%, P < 0.001). Similarly, they had more follow-up appointments scheduled by the time of discharge (62% vs. 36%, P < 0.0001) and attended those appointments more often within 2 weeks (36% vs. 23%, P < 0.0002). Intervention patients knew whom to call with questions (95% vs. 85%, P = 0.003) and were more satisfied with the discharge process (97% vs. 76%, P < 0.0001). Attending rounds on the intervention team finished on time (45% vs. 31%, P = 0.058), and residents signed out on average 46 minutes earlier each day. There was no significant difference between the groups in 30-day emergency department visits or readmissions. CONCLUSIONS: Helping resident physicians with the discharge process improves many aspects of discharge communication and patient follow-up, and saves residents' time, but had no effect on hospital reutilization for a general medicine population.

Diminished production of monocyte proinflammatory cytokines during human immunodeficiency virus viremia is mediated by type I interferons.

The effect of human immunodeficiency virus (HIV) infection and high-level HIV replication on the function of monocytes was investigated. HIV-positive patients had elevated levels of spontaneous production of some or all of the monocyte proinflammatory cytokines measured (interleukin-1beta [IL-1beta], IL-6, and tumor necrosis factor alpha [TNF-alpha]) compared to uninfected controls. In patients on therapy with high frequencies of monocytes producing proinflammatory cytokines, this frequency was diminished in the context of viremia during an interruption of therapy. Diminished production of proinflammatory cytokines during viremia was restored by culture with autologous CD4(+) T cells or monocytes from an on-therapy time point or lipopolysaccharide (LPS). Microarray analysis demonstrated that diminished monocyte production of proinflammatory cytokines was correlated with elevated type I interferon-stimulated gene transcripts. The addition of exogenous alpha 2A interferon diminished the spontaneous production of IL-1beta, IL-6, and TNF-alpha but did not affect responses to LPS, recapitulating the changes observed for HIV-viremic patients. These results suggest that monocyte function is diminished during high-level HIV viremia and that this effect is mediated by chronic stimulation by type I interferons. This effect on monocytes during viremia may play a role in diminished innate or adaptive immune system functions in HIV-infected patients. In addition, the restoration of these functions may also play a role in some immune reconstitution syndromes observed during initiation of therapy.

Diminished proliferation of human immunodeficiency virus-specific CD4+ T cells is associated with diminished interleukin-2 (IL-2) production and is recovered by exogenous IL-2.

Virus-specific CD4(+) T-cell function is thought to play a central role in induction and maintenance of effective CD8(+) T-cell responses in experimental animals or humans. However, the reasons that diminished proliferation of human immunodeficiency virus (HIV)-specific CD4(+) T cells is observed in the majority of infected patients and the role of these diminished responses in the loss of control of replication during the chronic phase of HIV infection remain incompletely understood. In a cohort of 15 patients that were selected for particularly strong HIV-specific CD4(+) T-cell responses, the effects of viremia on these responses were explored. Restriction of HIV replication was not observed during one to eight interruptions of antiretroviral therapy in the majority of patients (12 of 15). In each case, proliferative responses to HIV antigens were rapidly inhibited during viremia. The frequencies of cells that produce IFN-gamma in response to Gag, Pol, and Nef peptide pools were maintained during an interruption of therapy. In a subset of patients with elevated frequencies of interleukin-2 (IL-2)-producing cells, IL-2 production in response to HIV antigens was diminished during viremia. Addition of exogenous IL-2 was sufficient to rescue in vitro proliferation of DR0101 class II Gag or Pol tetramer(+) or total-Gag-specific CD4(+) T cells. These observations suggest that, during viremia, diminished in vitro proliferation of HIV-specific CD4(+) T cells is likely related to diminished IL-2 production. These results also suggest that relatively high frequencies of HIV-specific CD4(+) T cells persist in the peripheral blood during viremia, are not replicatively senescent, and proliferate when IL-2 is provided exogenously.