Attending Rounds Research Articles

ChatGPT as a Tool for Medical Education and Clinical Decision-Making on the Wards: Case Study.

Large language models (LLMs) are computational artificial intelligence systems with advanced natural language processing capabilities that have recently been popularized among health care students and educators due to their ability to provide real-time access to a vast amount of medical knowledge. The adoption of LLM technology into medical education and training has varied, and little empirical evidence exists to support its use in clinical teaching environments. The aim of the study is to identify and qualitatively evaluate potential use cases and limitations of LLM technology for real-time ward-based educational contexts. A brief, single-site exploratory evaluation of the publicly available ChatGPT-3.5 (OpenAI) was conducted by implementing the tool into the daily attending rounds of a general internal medicine inpatient service at a large urban academic medical center. ChatGPT was integrated into rounds via both structured and organic use, using the web-based "chatbot" style interface to interact with the LLM through conversational free-text and discrete queries. A qualitative approach using phenomenological inquiry was used to identify key insights related to the use of ChatGPT through analysis of ChatGPT conversation logs and associated shorthand notes from the clinical sessions. Identified use cases for ChatGPT integration included addressing medical knowledge gaps through discrete medical knowledge inquiries, building differential diagnoses and engaging dual-process thinking, challenging medical axioms, using cognitive aids to support acute care decision-making, and improving complex care management by facilitating conversations with subspecialties. Potential additional uses included engaging in difficult conversations with patients, exploring ethical challenges and general medical ethics teaching, personal continuing medical education resources, developing ward-based teaching tools, supporting and automating clinical documentation, and supporting productivity and task management. LLM biases, misinformation, ethics, and health equity were identified as areas of concern and potential limitations to clinical and training use. A code of conduct on ethical and appropriate use was also developed to guide team usage on the wards. Overall, ChatGPT offers a novel tool to enhance ward-based learning through rapid information querying, second-order content exploration, and engaged team discussion regarding generated responses. More research is needed to fully understand contexts for educational use, particularly regarding the risks and limitations of the tool in clinical settings and its impacts on trainee development.

Speaking up on attending ward rounds: a qualitative study of internal medicine residents

Attending rounds are a core educational component of learning in teaching hospitals. Speaking up in this context has not been explored among medical residents. We aimed to understand residents’ perspectives on speaking up about their own clinical reasoning during attending rounds. This was a qualitative study performed at a single teaching hospital. We selected a random sample of 45 internal medicine residents among 141 in the training program, among whom 21 accepted the invitation to participate. Semi-structured interviews were conducted over Zoom. We performed thematic analysis within a social constructionist epistemology to develop codes, categories, and themes. Analysis continued until thematic saturation was achieved. We interviewed 21 residents, including 9 interns, 7 junior residents, and 5 senior residents. Residents described factors related to team culture, team dynamics, knowledge and experience, domain of patient care, and structure of rounds that influence speaking up during rounds. We identified four themes that were critical for speaking up: (1) promoting a culture of learning; (2) creating psychological safety; (3) developing self-efficacy; and (4) fostering resident autonomy. Feedback from the attending, particularly nonverbal cues perceived as negative, played a prominent role in preventing residents from speaking up. We identified factors for speaking up among residents during attending rounds. Feedback conveyed during attending rounds influenced the culture of learning, psychological safety, and residents’ self-efficacy, which impacted residents’ motivation to speak up. Ward attendings should be mindful of verbal and nonverbal forms of feedback on rounds.

The Indispensable Student.

The Indispensable Student.

Enseigner et apprendre lors des grandes visites en médecine interne hospitalière. Une étude anthropologique

This anthropological research aims to highlight the educational approaches in action during attending rounds. The goal is to understand how specific learning domains, professional socialization and learning environments are influenced by the different ways of conducting attending rounds. Two formats of rounds were noted: the IN format, when the patient case is presented in the patient room, and the OUT format. Six educational approaches were identified. The attending round format has an impact on the approaches used. The latter contribute to the development, to varying degrees, of knowledge, skills and attitudes. Attending rounds remain a space for "top-down" transmission and supervision, even though some approaches involve learner initiatives and peer group logic.

Impact of Hospitalist-Led Interdisciplinary Antimicrobial Stewardship Interventions at an Academic Medical Center

Approximately 20%-50% of antimicrobial use in hospitals is inappropriate. Limited data exist on the effect of frontline provider engagement on antimicrobial stewardship outcomes. A three-arm pre-post quality improvement study was conducted on three adult internal medicine teaching services at an urban academic hospital. Data from September through December 2016 were compared to historic data from corresponding months in 2015. Intervention arms were (1) Educational bundle (Ed-only); (2) Educational bundle plus antimicrobial stewardship rounds twice weekly with an infectious disease-trained clinical pharmacist (Ed+IDPharmDx2); and (3) Educational bundle plus internal medicine-trained clinical pharmacist embedded into daily attending rounds (Ed+IMPharmDx5). Total antibiotic use decreased by 16.8% (p < 0.001), 6.8% (p = 0.08), and 33.0% (p < 0.001) on Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Broad-spectrum antibiotic use decreased by 26.2% (p < 0.001), 7.8% (p = 0.09), and 32.4% (p < 0.001) on the Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Duration of inpatient antibiotic therapy decreased from 4 to 3 days on the Ed+IMPharmDx5 team (p = 0.01). Length of stay for patients who received any antibiotic decreased from 9 to 7 days on the Ed-only team (p < 0.001) and from 9 to 6 days on the Ed+IMPharmDx5 team (p < 0.001). There was no significant change in 30-day readmission to the same facility, transfer to ICU, or in-hospital mortality for any team. Multidisciplinary, frontline provider-driven approaches to antimicrobial stewardship may contribute to reduced antibiotic use and length of hospital stay.

Service and Education: The Association Between Workload, Patient Complexity, and Teaching on Internal Medicine Inpatient Services.

Attending rounds remain the primary venue for formal teaching and learning at academic medical centers. Little is known about the effect of increasing clinical demands on teaching during attending rounds. To explore the relationships among teaching time, teaching topics, clinical workload, and patient complexity variables. Observational study of medicine teaching teams from September 2008 through August 2014. Teams at two large teaching hospitals associated with a single medical school were observed for periods of 2 to 4weeks. Twelve medicine teaching teams consisting of one attending, one second- or third-year resident, two to three interns, and two to three medical students. The study examined relationships between patient complexity (comorbidities, complications) and clinical workload variables (census, turnover) with educational measures. Teams were clustered based on clinical workload and patient complexity. Educational measures of interest were time spent teaching and number of teaching topics. Data were analyzed both at the daily observation level and across a given patient's admission. We observed 12 teams, 1994 discussions (approximately 373h of rounds) of 563 patients over 244 observation days. Teams clustered into three groups: low patient complexity/high clinical workload, average patient complexity/low clinical workload, and high patient complexity/high clinical workload. Modest associations for team, patient complexity, and clinical workload variables were noted with total time spent teaching (9.1% of the variance in time spent teaching during a patient's admission; F[8,549] = 6.90, p< 0.001) and number of teaching topics (16% of the variance in the total number of teaching topics during a patient's admission; F[8,548] = 14.18, p< 0.001). Clinical workload and patient complexity characteristics among teams were only modestly associated with total teaching time and teaching topics.

Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital

Background and aimsHospitalization as a result of acute exacerbation of complex chronic pain is a largely hidden problem, as patients are often admitted to hospital under a variety of specialities, and there is frequently no overarching inpatient chronic pain service dedicated to their management. Our institution had established an inpatient acute pain service overseen by pain physicians and staffed by specialist nurses that was intended to focus on the management of perioperative pain. We soon observed an increasing number of nurse-to-nurse referrals of non-surgical inpatients admitted with chronic pain. Some of these patients had seemingly intractable and highly complex pain problems, and consequently we initiated twice-weekly attending physician-led inpatient pain rounds to coordinate their management. From these referrals, we identified a cohort of 20 patients who were frequently hospitalized for long periods with exacerbations of chronic pain. We sought to establish whether the introduction of the physician-led inpatient pain ward round reduced the number and duration of hospitalizations, and costs of treatment. MethodsWe undertook a retrospective, observational, intervention cohort study. We recorded acute Emergency Department (ED) attendances, hospital admissions, and duration and costs of hospitalization of the cohort of 20 patients in the year before and year after introduction of the inpatient pain service. ResultsThe patients’ mean age was 38.2 years (±standard deviation 13.8 years, range 18–68 years); 13 were women (65.0%). The mode number of ED attendances was 4 (range 2–15) pre-intervention, and 3 (range 0–9) afterwards (p=0.116). The mode bed occupancy was 32 days (range 9–170 days) pre-intervention and 19 days (range 0–115 days) afterwards (p=0.215). The total cost of treating the cohort over the 2-year study period was £733,010 (US$1.12m), comprising £429,479 (US$656,291) of bed costs and £303,531 (US$463,828) of investigation costs. The intervention did not achieve significant improvements in the total costs, bed costs or investigation costs. ConclusionsDespite our attending physician-led intervention, the frequency, duration and very substantial costs of hospitalization of the cohort were not significantly reduced, suggesting that other strategies need to be identified to help these complex and vulnerable patients. ImplicationsFrequent hospitalization with acute exacerbation of chronic pain is a largely hidden problem that has very substantial implications for patients, their carers and healthcare providers. Chronic pain services tend to focus on outpatient management. Breaking the cycle of frequent and recurrent hospitalization using multidisciplinary chronic pain management techniques has the potential to improve patients’ quality of life and reduce hospital costs. Nonetheless, the complexity of these patients’ chronic pain problems should not be underestimated and in some cases are very challenging to treat.

Standardized Attending Rounds to Improve the Patient Experience: A Pragmatic Cluster Randomized Controlled Trial.

At academic medical centers, attending rounds (AR) serve to coordinate patient care and educate trainees, yet variably involve patients. To determine the impact of standardized bedside AR on patient satisfaction with rounds. Cluster randomized controlled trial. 500-bed urban, quaternary care hospital. 1200 patients admitted to the medicine service. Teams in the intervention arm received training to adhere to 5 AR practices: 1) pre-rounds huddle; 2) bedside rounds; 3) nurse integration; 4) real-time order entry; 5) whiteboard updates. Control arm teams continued usual rounding practices. Trained observers audited rounds to assess adherence to recommended AR practices and surveyed patients following AR. The primary outcome was patient satisfaction with AR. Secondary outcomes were perceived and actual AR duration, and attending and trainee satisfaction. We observed 241 (70.1%) and 264 (76.7%) AR in the intervention and control arms, respectively, which included 1855 and 1903 patient rounding encounters. Using a 5-point Likert scale, patients in the intervention arm reported increased satisfaction with AR (4.49 vs 4.25; P = 0.01) and felt more cared for by their medicine team (4.54 vs 4.36; P = 0.03). Although the intervention shortened the duration of AR by 8 minutes on average (143 vs 151 minutes; P = 0.052), trainees perceived intervention AR as lasting longer and reported lower satisfaction with intervention AR. Medicine teams can adopt a standardized, patient-centered, time-saving rounding model that leads to increased patient satisfaction with AR and the perception that patients are more cared for by their medicine team. Journal of Hospital Medicine 2017;12:143-149.

All Together Now: Impact of a Regionalization and Bedside Rounding Initiative on the Efficiency and Inclusiveness of Clinical Rounds.

Attending rounds at academic medical centers are often disconnected from patients and team members who are not physicians. Regionalization of care teams may facilitate bedside rounding and more frequent interactions among doctors, nurses, and patients. We used time-motion analysis to investigate how regionalization of medical teams and encouragement of bedside rounds affect participants on rounds and rounding time. We used pre-post analysis to study the effects of care redesign on teams' daily rounds on a general medicine service at an academic medical center. Four general medical teams were evaluated before the intervention and 5 teams afterward. General medical teams were regionalized to specific units, the admitting structure was changed to facilitate regionalization, and teams were encouraged to round bedside. Primary outcomes included proportion of time each team member was present on rounds and proportion of bedside rounding time. Secondary outcomes included round duration and non-patient time during rounds. Proportion of time the nurse was present on rounds increased from 24.1% to 67.8% (P ⟨ 0.001), and proportion of total bedside rounding time increased from 39.9% to 55.8% (P ⟨ 0.001). Mean total rounding time decreased from 3.0 hours to 2.4 hours (P = 0.01), despite a higher patient census. Creating regionalized care teams and encouraging interdisciplinary bedside rounds increased the proportion of bedside rounding time and the presence of nurses on rounds while decreasing total rounding time. Journal of Hospital Medicine 2017;12:150-156.

Improving Trainee Education During Family-Centered Rounds: A Resident's Perspective.

* Abbreviation: FCR — : family-centered rounds At 8:00 am on a busy morning, the pediatrics team begins rounds. The team of 12 providers dons gowns and gloves before entering the room of the first patient, a 9-month-old girl with bronchiolitis. They enter slowly, introducing themselves one-by-one to the patient’s mother. The intern relays the patient’s history, examination, and plan for the day, speaking quietly to avoid waking the patient while the attending carefully examines her. “She seems improved. We will keep monitoring her, but we hope to get you home soon.” The next few minutes are spent answering the mother’s questions. After 10 minutes, the team files out of the room quietly. “Alright, let’s keep moving,” says the senior resident once they re-enter the hallway. “We have 24 patients left and mandatory conference at noon.” In 2003, the American Academy of Pediatrics deemed family-centered rounds (FCR) to be the standard of care.1 Defined as conducting attending rounds, including patient presentations and discussions, in the patient’s room with nursing and family present, FCR has improved multiple aspects of patient care.1 However, both trainees and attending physicians have debated the impact FCR may have on medical education. Although studies have demonstrated residents’ belief in FCR as a forum to hone skills such as communication and professionalism, they have frequently acknowledged a weakness in didactic teaching.2,3 Before proposing remedies to this … Address correspondence to Natalja Stanski, MD, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 5018, Cincinnati, OH 45229. E-mail: natalja.stanski{at}cchmc.org

Impact of the surgeon of the week system in an academic pediatric surgery practice

BackgroundA pilot rounding surgeon of the week (SOW) program was implemented in our institution on July 2013 to improve patient care through focused attending rounds. The purpose of this study was to assess the impact of the SOW. MethodsWe performed a descriptive retrospective study from a single, large-volume academic center. Data were collected from July to December 2013 (post-SOW) and compared to July to December 2012 (pre-SOW). Outcomes included patient safety (safety reports) and team productivity (billing data). We also evaluated nursing satisfaction through a 10-point Likert scale survey. ResultsThe total number of patient safety complaints decreased after the SOW (37 pre-SOW versus 27 post-SOW). Work relative value units (wRVUs) increased by 8% while nonoperative billing increased by 15%. Twenty of the daytime nursing staff completed the survey and overall satisfaction with the SOW was 8.3. Twelve were employed prior to the SOW and, when analyzed independently, the proportion of employees satisfied with nursing to physician communication was higher after the SOW (55% pre-SOW vs. 83% post-SOW, p=0.13) as was perception of parental satisfaction (33% vs. 75%, p=0.04). ConclusionsThe SOW program appears to improve patient safety as evidenced by a decrease in patient safety events. Additionally, the SOW program led to higher ancillary staffing satisfaction and perceived parental satisfaction without decreasing revenue. This study suggests that the SOW may be a beneficial program that could be considered at other large-volume institutions.

Improving attending rounds: Qualitative reflections from multidisciplinary providers

Background. Attending rounds, the time for the attending physician and the team to discuss the team’s patients, take place at teaching hospitals every day, often with little standardization. Objective. This hypothesis-generating qualitative study sought to solicit improvement recommendations for standardizing attending rounds from the perspective of a multi-disciplinary group of providers. Methods. Attending physicians, housestaff (residents and interns), medical students, nurses and pharmacists at an academic medical center participated in a quality improvement initiative between January and April 2013. Participants completed an individual or focus group interview or an e-mail survey with three open-ended questions: (1) What are poor or ineffective practices for attending rounds? (2) How would you change attending rounds structure and function? (3) What do you consider best practices for attending rounds? We undertook content analysis to summarize each clinical stakeholder group’s improvement recommendations. Results. Sixty stakeholders participated in our study including 23 attending hospitalists, 24 housestaff, 7 medical students, 2 pharmacists and 4 nurses. Key improvement recommendations included (1) performing a pre-rounds huddle, (2) planning of the visit schedule based on illness or pending discharge, (3) real-time order writing, (4) patient involvement in rounds with shared decision-making, (5) bedside nurse inclusion and (6) minimizing interruption of intern or student presentations. Conclusions. The practice improvement recommendations identified in this study will require deliberate systems changes and training to implement, and they warrant rigorous evaluation to determine their impact on the clinical and educational goals of rounds.

Navigating a Successful Course Through GI Fellowship: A Year-by-Year Perspective

The sense of accomplishment you felt as a resident newly-matched into your chosen field of gastroenterology gradually morphs into a combination of excitement, anticipation, and indeed a healthy amount of trepidation, as you inch closer to the start of your fellowship. But fear not. While fellowship is no doubt a character-building experience, presenting unique challenges, it can be effectively navigated with a deliberate approach. This article is intended to serve as a roadmap to guide you in successfully completing your gastroenterology fellowship.

Residents' attitudes toward a smartphone policy for inpatient attending rounds

Residents' attitudes toward a smartphone policy for inpatient attending rounds

Are Family Characteristics Associated With Attendance at Family Centered Rounds in the PICU?*

The objective of this study was to identify if family characteristics or opinions affected participation in family centered rounds. Observational study of 431 patient encounters on daily work rounds, followed by 100 questionnaires completed by family members of patients in the unit during observation. PICU at a tertiary care, academic, free-standing children's hospital. Patients and families admitted to the PICU during the observation period. None. The most frequent family members present for rounds were mothers (40%). Race, educational level, age of the family member, age of the child, whether the admission was expected, and whether the family member was a medical professional had no association with whether the family member attended rounds. Both family members who were present and those who were not present felt being at rounds would improve the care of their child (87% vs. 100%, p = 0.57). A family's response that they preferred to attend rounds was the only factor associated with a higher likelihood of attending rounds (odds ratio 3.4, 95% confidence interval 1.1-10.8, p = 0.03). Families feel that participating in family centered rounds improves the care of their children. Those that like attending rounds are more likely to participate in family centered rounds, but family demographic characteristics were not associated with rounds attendance. Future studies are needed to identify barriers to family participation in family centered rounds.

Smartphone use during inpatient attending rounds: Prevalence, patterns and potential for distraction

While there are numerous benefits of smartphone use for physicians, little is known about the negative effects of using these devices in the context of patient care. To assess resident and faculty smartphone use during inpatient attending rounds and its potential as a source of distraction during transfer of clinical information. Cross-sectional survey. University-affiliated public teaching hospital. All housestaff and inpatient faculty in the departments of Medicine and Pediatrics. Participants were asked about smartphone ownership, usage patterns during attending rounds, and whether team members had ever missed important data during rounds due to distraction from smartphones. Attendings were asked whether policies should be established for smartphone use during rounds. The overall response rate was 73%. Device ownership was prevalent (89% residents, 98% faculty), as was use of smartphones during inpatient rounds (57% residents, 28% attendings). According to self-reports, smartphones were used during rounds for patient care (85% residents, 48% faculty), reading/responding to personal texts/e-mails (37% residents, 12% faculty), and other non-patient care uses (15% residents, 0% faculty). Nineteen percent of residents and 12% of attendings believed they had missed important information because of distraction from smartphones. Residents and faculty agreed that smartphones "can be a serious distraction during attending rounds," and nearly 80% of faculty believed that smartphone policies should be established. Smartphone use during attending rounds is prevalent and can distract users during important information transfer. Attendings strongly favored the institution of formal policies governing appropriate smartphone use during inpatient rounds.

Using Cognitive Mapping to Define Key Domains for Successful Attending Rounds

Ward attending rounds are an integral part of internal medicine education. Being a good teacher is necessary, but not sufficient for successful rounds. Understanding perceptions of successful attending rounds (AR) may help define key areas of focus for enhancing learning, teaching and patient care. We sought to expand the conceptual framework of 30 previously identified attributes contributing to successful AR by: 1) identifying the most important attributes, 2) grouping similar attributes, and 3) creating a cognitive map to define dimensions and domains contributing to successful rounds. Multi-institutional, cross-sectional study design. We recruited residents and medical students from a university-based internal medicine residency program and a community-based family medicine residency program. Faculty attending a regional general medicine conference, affiliated with multiple institutions, also participated. Participants performed an unforced card-sorting exercise, grouping attributes based on perceived similarity, then rated the importance of attributes on a 5-point Likert scale. We translated our data into a cognitive map through multi-dimensional scaling and hierarchical cluster analysis. Thirty-six faculty, 49 residents and 40 students participated. The highest rated attributes (mean rating) were "Teach by example (bedside manner)" (4.50), "Sharing of attending's thought processes" (4.46), "Be approachable-not intimidating" (4.45), "Insist on respect for all team members" (4.43), "Conduct rounds in an organized, efficient & timely fashion" (4.39), and "State expectations for residents/students" (4.37). Attributes were plotted on a two-dimensional cognitive map, and adequate convergence was achieved. We identified five distinct domains of related attributes: 1) Learning Atmosphere, 2) Clinical Teaching, 3) Teaching Style, 4) Communicating Expectations, and 5) Team Management. We identified five domains of related attributes essential to the success of ward attending rounds.

The surgical clerkship: a contemporary paradigm

BackgroundTraditional surgical clerkships have been composed of hospitalized patients, usually in academic centers, daily resident interaction, periodic attending rounds, assigned texts, and a lecture format. However, traditional clerkships do not reflect the current changes in learning theory nor the economic realities of today’s surgical practice. Initiated in 2001, the allopathic Florida State University College of Medicine provided an opportunity to create a contemporary surgical clerkship. MethodsAt each of 6 regional campuses, clerkship students served as apprentices to a board-certified community surgeon. In addition, during weekly meetings with the student, a campus-specific Clerkship Director administered a centralized curriculum with defined objectives and competencies. Contact with residents was minimal, and lectures were not used. Students were free to choose from suggested texts or to use alternative learning sources. An electronic data system monitored patient contacts. Evaluations of the students’ clinical performance are 360 degrees. ResultsTo date, 450 students have graduated. No significant differences were found between campuses for the following: types of patients encountered, U.S. Medical Liscensure Examination Step 2 Clinical Knowledge and Clinical Skills scores, internal Objective Structured Clinical Examination results, or National Board of Medical Examiners scores (P > 0.05). The national examination metrics have been met or exceeded. On the recent anonymous Association of American Medical Colleges Graduation Questionnaire survey, the students rated the surgery clerkship as the best course in the school. Overall, 23.3% of graduates have chosen some aspect of surgery as a career. ConclusionsA quality clerkship in surgery can be provided using a nontraditional community-based system, with as many as 6 distributed campuses. Also, the distributed campus model does not lead to inequality in learning opportunities, surgical experiences, or basic surgical knowledge. Third, documentation of campus comparability is markedly assisted by electronic monitoring. Fourth, the tutorial model offers, at the very least, a comparable learning experience and is strongly supported by both students and the community surgical faculty. Finally, student learning and acquisition of a fund of surgical knowledge in this system has been confirmed by national metrics.

The Surgical Clerkship: A Contemporary Paradigm

Introduction: Traditional Surgical clerkships have been composed of a mixture of hospitalized patients, daily resident interaction, periodic attending rounds, and assigned texts, often augmented by lectures. Recently, academic research has challenged the underpinnings of this traditional curriculum. Moreover, traditional clerkships do not necessarily mirror today's surgical practice given its increasing short-stay and out-patient emphasis. Initiated in 2001, the allopathic Florida State University College of Medicine provided an opportunity to create a contemporary surgical curriculum, emphasizing learning rather than teaching. Methods: The eight week FSU surgical clerkship is a tutorial model. at each of our six regional campuses, students are assigned one-on-one to a carefully selected, board-certified community surgeon, responsible for daily in-patient and out-patient teaching. the academic spine for the rotation is provided by a central curriculum, containing defined objectives and competencies, administered during weekly meetings with the student by campus-specific surgical clerkship directors. Residents do not participate in student teaching, nor are lectures used. Students are free to choose from among suggested print materials or alternative learning sources. Patient contacts are entered into an electronic data collection system, capable of comparing both student and individual campus experiences. Evaluations of student performance are 360 degrees: by patients, staff, clerkship faculty, and clerkship directors. Results: to date, 456 students have graduated. No significant differences exist between campuses with respect to either the numbers or types of patients encountered. USMLE Step II CK and CS scores, or NBME Surgery Subject Examination scores (p>.05). Student satisfaction with the course is evidenced by exceptionally positive responses to the end-of-clerkship evaluations of both faculty and clerkship at each of the campuses, and by anonymous laudatory responses by graduating seniors to the AAMC GQ Survey. Overall, 23.3% of graduates have chosen some aspect of Surgery as a career. the community faculty retention rate exceeds 97%. Conclusions: 1) A quality clerkship experience in Surgery can be provided by a non-traditional community-based system, 2) the distributed campus model does not lead to inequality of learning opportunities or surgical experiences, 3) Both students and community faculty strongly support the tutorial model, 4) Student learning has been confirmed by national metrics.

Daily Multidisciplinary Rounds To Implement the Ventilator Bundle Decreases Ventilator-Associated Pneumonia in Trauma Patients: But Does It Affect Outcome?

The incidence of ventilator-associated pneumonia (VAP) in trauma patients can be decreased with use of the ventilator bundle (VAPB). Our VAP rate remained high despite the adoption of the VAPB. To better implement the VAPB, a multidisciplinary team composed of the surgical intensive care unit (SICU) nursing staff, physician, and respiratory therapist reviewed briefly a checklist of VAPB goals for each patient before morning attending rounds. We hypothesized that such daily goal rounds (GR) focused on the VAPB would decrease the VAP rate. A pre-GR ten-month period (November 2006 to August 2007) was compared with the ten-month period (September 2007 to June 2008) with daily GRs. The occurrence of VAPs was tallied prospectively in all intubated trauma patients using the National Nosocomial Infection Surveillance criteria. Patient characteristics and outcome data were obtained from our trauma registry and medical records. Patient characteristics were similar in the 85 pre-GR patients and the 89 GR patients. The number of VAPs decreased 67% in the GR patients (15 pre-GR vs. 5 GR; p=0.02); however, the all-cause mortality rate remained similar (16.5% vs. 21.3%; p=0.41). When patients were divided into those with and without VAP, there was a significant increase in mean ventilator, SICU, and hospital days in patients with VAP (p=0.01 for all). There were only two deaths among trauma patients with VAP. Daily multidisciplinary GRs focused on the VAPB can decrease the incidence of VAP significantly in trauma patients. Ventilator-associated pneumonia correlated with extended mean ventilator, SICU, and hospital days. Interestingly, despite a significant decrease in VAP, a decrease in the mortality rate was not observed. Given the small number of deaths in the VAP cohort, this study has insufficient statistical power to elucidate the true impact of GR intervention or VAP on the mortality rate in trauma patients.