Case Review Sessions Research Articles

Interrater agreement of multi-professional case review as reference standard for specialist palliative care need: a mixed-methods study

BackgroundA wide variety of screening tools for the need for specialist palliative care (SPC) have been proposed for the use in oncology. However, as there is no established reference standard for SPC need to compare their results with, their sensitivity and specificity have not yet been determined. The aim of the study was to explore whether SPC need assessment by means of multi-professional case review has sufficient interrater agreement to be employed as a reference standard.MethodsComprehensive case descriptions were prepared for 20 inpatients with advanced oncologic disease at the University Hospital Freiburg (Germany). All cases were presented to the palliative care teams of three different hospitals in independent, multi-professional case review sessions. The teams assessed whether patients had support needs in nine categories and subsequently concluded SPC need (yes / no). Interrater agreement regarding SPC need was determined by calculating Fleiss’ Kappa.ResultsIn 17 out of 20 cases the three teams agreed regarding their appraisal of SPC need (substantial interrater agreement: Fleiss’ Kappa κ = 0.80 (95% CI: 0.55–1.0; p < 0.001)). The number of support needs was significantly lower for patients who all teams agreed had no SPC need than for those with agreed SPC need.ConclusionsThe proposed expert case review process shows sufficient reliability to be used as a reference standard. Key elements of the case review process (e.g. clear definition of SPC need, standardized review of the patients’ support needs) and possible modifications to simplify the process are discussed.Trial registrationGerman Clinical Trials Register, DRKS00021686, registered 17.12.2020.

NCCN Highlights Best Practices for Challenges in Oncology

NCCN Highlights Best Practices for Challenges in Oncology

783 Use of Multidisciplinary Collaboration to Establish a Standardized Endotracheal Tube Wiring Guideline

IntroductionPediatric patients with facial burns and advanced airway needs precipitate acute situations requiring multidisciplinary team member collaboration. Significant facial burns, particularly involving considerable edema or smoke inhalation, may warrant dental or circum-mandibular endotracheal tube (ETT) wiring for stabilization. Guidelines were created, trialed, and revised based on patient outcomes and clinician feedback at a pediatric verified burn center.MethodsThe guideline was created by the burn team in 2019. This standard work was utilized with pediatric burn cases presenting to the burn center. Guideline variances, such as prolonged time from door to ETT wiring, prompted a gap analysis need to improve the process. Through two case review sessions held in 2020, a multidisciplinary team consisting of the burn providers, emergency department providers, nursing, and respiratory therapists revealed process knowledge deficits, unclear role expectations, and supply issues. Literature was reviewed and a myAmeriburn listserv inquiry of current practice was made to seek additional guidance.ResultsBased on feedback from the multidisciplinary group and data gathered from the literature and collegial burn community, action plans and guideline modifications were developed in 2021. The respiratory therapy department developed education for their staff highlighting use of twill tape and taping. The use of ETT suturing was removed from the guidelines.ConclusionsMultidisciplinary contribution and engagement was necessary to produce, execute, and evaluate the pediatric endotracheal tube wiring guidelines. Through dialogue, patient trial, and constructive feedback, guidelines were amended to produce a smoother team process and better patient experience. The standard work is currently being evaluated in its modified version.

Responsive Web-based Breast Imaging Core Curriculum for International Radiology Residents with Self-Assessment: A Pilot Study

Lack of uniformity in radiology resident education is partially attributable to variable access to subspecialty education. Web-based courses improve standardization, but with growing emphasis on competency based education, more evaluation of their effectiveness is needed. We created a responsive web-based breast imaging curriculum for radiology residents including self-assessment and a satisfaction survey. Two global academic institutions collaboratively developed a breast imaging curriculum to address radiology residents' educational needs. This virtual course comprised 11 video lectures, nine didactic (with attached pre-test and post-test assessments) and two case review sessions. In April 2020, this optional curriculum was made available to all 56 radiology residents in one residency program cluster in Singapore, to be accessed alongside the breast imaging rotation as a supplement. A voluntary anonymous satisfaction survey was provided upon completion. A total of 39 of the 56 radiology residents (70%) completed the course. For the average score of nine lectures (maximum score 5), there was a significant increase in mean pre and post - test scores (mean=2.2, SD=0.7), p < 0.001. The proportion of residents with improvement between the pre-test score and the post-test score ranged from 74% to 100% (mean, 84%). Thirty three of the 39 participants (85%) completed the satisfaction survey, and all agreed or strongly agreed that the curriculum increased their knowledge of breast imaging. This web based breast imaging curriculum supplement was viewed positively by participating residents and improved their self-assessed knowledge. Curriculum access could be expanded to improve global radiology education.

4. University of Pittsburgh Plastic Surgery Virtual Sub-Internship: An Evolutionary Response to the Pandemic

Body: Background: Plastic surgery programs ceased to offer in-person sub-internships due to the COVID-19 pandemic. To overcome this hurdle, the University of Pittsburgh developed a virtual sub-internship (vSub-I) to provide an overview of plastic surgery and insight into the residency program. This study aims to present the vSub-I program and objectively assess its impact on student education and satisfaction. Methods: The vSub-I program consists of a virtual two-week experience, in which the student attends education and simulation sessions as well as one-on-one meetings with representative faculty/residents. Educational sessions include core conferences, grand rounds, journal clubs, indications conferences (head and neck, hand, breast, and pediatric plastic surgery), and case-review sessions discussing the breadth of plastic surgery including aesthetic surgery, breast surgery, pediatric plastic surgery, hand surgery, facial trauma, head and neck, and general reconstruction. Simulation sessions include cleft lip and palate, breast reduction, and flap markings. The student also participates in virtual social events with residents. Each student gives a 15-minutes talk during grand rounds about their journey and research/clinical interests. To assess this innovative program, student satisfaction was evaluated using an 8-question survey rated with a five-point Likert scale. Self-reported level of knowledge was assessed before and after the vSub-I using a 16-question survey rated with a five-point Likert scale. Results: The vSub-I program was attended by 20 students distributed into five consecutive two-week blocks (four students per block) between August-October. The program included 50% males and 50% females, 25% underrepresented minorities and 10% international medical graduates. The mean overall level of knowledge before and after completion of the vSub-I was 2.84 (SD±0.98) and 3.78 (SD±0.77), respectively, and mean level of improvement was +1.10 (SD±0.82, p<0.0001). Mean overall satisfaction was 4.83 (SD±0.44). Importantly, all students felt they gained plastic surgery knowledge, insight of the culture and clinical breadth/volume, and insight of the faculty and residents of the residency program. Conclusion: The vSub-I emerged as a response to the challenges of this new era. This study suggests that vSub-I offers a highly satisfactory experience by allowing direct involvement with our training program, and easy and effective incorporation of plastic surgery concepts.

Medical Student Education During the COVID-19 Pandemic: Initial Experiences Implementing a Virtual Interventional Radiology Elective Course

Rationale and objectivesIn response to the COVID-19 pandemic reducing medical student presence on clinical services and in classrooms, academic institutions are utilizing a virtual format to continue medical student education. We describe a successful initial experience implementing a virtual elective in interventional radiology (IR) and provide the course framework, student feedback, and potential improvements.Materials and methodsA 2-week virtual IR elective curriculum was created utilizing a combination of synchronous and asynchronous learning and the “flipped” classroom educational model. Students virtually participated in daily IR resident education conferences, resident-led case review sessions, and dedicated lectures. Asynchronous prelearning material consisted of text and video correlating to lecture topics. Anonymous precourse and postcourse surveys were sent to all participating students (n = 10).ResultsTen students (100%) completed precourse and seven (70%) completed postcourse surveys. Enrolled students were considering residencies in surgery (50%), internal medicine (40%), interventional radiology (30%), and/or diagnostic radiology (30%). Students’ understanding of what IRs do and the procedures they perform (p < 0.001), when to consult IR for assistance in patient management (p = 0.005), and the number of IR procedures students could recall (p = 0.015) improved after the course. Case-review sessions and virtual lectures ranked as having the highest education value. Students recommended additional small-group case workshops.ConclusionThis successful virtual IR elective provides a framework for others to continue IR medical student education during the pandemic and grow the specialty's presence within an increasingly virtual medical school curriculum. The described model may be modified to improve IR education beyond the COVID-19 era.

Improving interprofessional collaboration through data-driven process evaluation of interprofessional case reviews

Abstract Purpose To develop a transparent and reproducible method of evaluating communication within interprofessional educational (IPE) sessions that differentiates talk that is conversational, collaborative, and interprofessional from other types of dialogue, and to statistically model predictors of collaboration. The method and programmatic utility of this approach are detailed. Method Eight 2-h case review sessions (n = 125 participants: 7560 speech turns) were videoed and double coded for speaker, target, speech act, type of collaboration, professions of interlocutors, topic and sex. Length of speech acts were measured to 0.1 second. Data were statistically analyzed using multilevel models to identify predictors of time-in-collaboration. Instances of collaboration were then further analyzed using descriptive statistics. Results Four types of collaborative communication were identified. Subjective assessments overestimated the extent of collaboration. Direct, student-to-student collaboration comprised approximately 5.1% of the total time-in-talk. Using a reproducible, transparent method of assessing student collaboration provided the basis for evidence-directed program enhancements.

Transcatheter Aortic Valve Replacement in the Coronavirus Disease 2019 (COVID-19) Era.

Transcatheter Aortic Valve Replacement in the Coronavirus Disease 2019 (COVID-19) Era.

Sharing Coordination of Health Services on Flinders Island using an applied continuous quality improvement approach

Flinders Island is located in the north of Tasmania, with population of approximately 700 residents. Flinders Islanders are significantly older than Tasmanian and Australian averages, with high rates of avoidable mortality and living in one of Tasmania’s most socioeconomically disadvantaged regions. They have a large Aboriginal and Torres Strait Islander population, sparsely situated communities, a lack of public transport paired, costly fuel, fragmented service funding streams and intermittent fly-in outreach services. Stakeholders identified that coordinating available care was a critical factor to ensure a high risk population received care that was both appropriate to its needs and efficient in terms of local resourcing. The Flinders Island Aboriginal Association Inc. (FIAAI), government funded Multipurpose Centre (MPC) and Primary Health Tasmania (PHT) convened 10 multidisciplinary working group meetings to review 11 case studies of Flinders Islanders living with complex health needs between November 2015 and May 2016. The local general practice participated in working groups and an independent clinical facilitator interviewed consenting local residents for case study material. An applied continuous quality improvement (CQI) approach was used to identify barriers, enablers and opportunities. The aim was to improve the coordination of care for the people on Flinders Island living with complex health needs. The theory of change was that bringing stakeholders together to review common cases would enable them to identify common opportunities and the feasibility of testing these to improve the coordination of care for Flinders Islanders. Patient stories, combined with the facilitator’s clinical expertise, focussed case review sessions on problem solving for actual patients whom the providers around the table could identify with. Working group participants reporting increased motivation to involve patients and be stronger advocates for systems level processes that might contribute to improving their care. Noticeable cultural change was achieved within the provider group that participated in this project; improved inter-personal and inter-organisational provider relationships are a key requirement to ensure the sustainability of activity towards improved coordination of care for Flinders Islanders. The degree to which this cultural change is sustained is dependent upon multiple ongoing factors including staff availability and stability within the three organisations, the maintenance of cooperative interpersonal and inter-organisational relationships and sustained momentum. The CQI methodology is applicable and transferable to other scenarios where multiple providers service patient groups due to the use of patient centred case reviews which aid in focussing provider perspectives on common challenges and opportunities. This project brought together stakeholders to review current local practices and identify opportunities to overcome existing barriers to coordination of patient care on Flinders Island. It enhanced communication, coordination and planning between previously disparate providers. It enabled local identification of activities to sustain gains using a time delimited, locally sustainable and transferrable methodology. It has highlighted the importance of inter-provider relationships, the justification for change, change readiness and patient centred care in efforts to improve the coordination of health care delivery.

Feasibility of a multifaceted educational strategy for strengthening rural primary health care.

To evaluate the feasibility and acceptability of a comprehensive educational strategy designed to improve care quality in rural areas of Mexico. A demonstration study was performed in 18 public rural health centers in Mexico, including an educational intervention that consists of the following steps: Development of the strategy; Selection and training of instructors (specialist physicians from the referral hospital and multidisciplinary field teams); Implementation of the strategy among health care teams for six priority causes of visit, through workshops, individual tutorials, and round-table case-review sessions. Feasibility and acceptability were evaluated using checklists, direct observation, questionnaires and in-depth interviews with key players. Despite some organizational barriers, the strategy was perceived as worthy by the participants because of the personalized tutorials and the improved integration of health teams within their usual professional practice. The educational strategy proved to be acceptable; its feasibility for usual care conditions will depend on the improvement of organizational processes at rural facilities.

Anonymity and Electronics: Adapting Preparation for Radiology Resident Examination

Diagnostic radiology resident assessment has evolved from a traditional oral examination to computerized testing. Teaching faculty struggle to reconcile the differences between traditional teaching methods and residents' new preferences for computerized testing models generated by new examination styles. We aim to summarize the collective experiences of senior residents at three different teaching hospitals who participated in case review sessions using a computer-based, interactive, anonymous teaching tool, rather than the Socratic method. Feedback was collected from radiology residents following participation in a senior resident case review session using Nearpod, which allows residents to anonymously respond to the teaching material. Subjective resident feedback was uniformly enthusiastic. Ninety percent of residents favor a case-based board review incorporating multiple-choice questions, and 94% favor an anonymous response system. Nearpod allows for inclusion of multiple-choice questions while also providing direct feedback to the teaching faculty, helping to direct the instruction and clarify residents' gaps in knowledge before the Core Examination.

Pilot Study of Online Learning Modules for Hemoglobinopathy Education in Canadian Hematology Training Programs

Introduction: In North America, there are a growing number of patients with hemoglobinopathies, including sickle cell disease and thalassemia. As previously identified in needs assessment surveys of Canadian hematology training program directors and fellows (Verhovsek et. al. 2014 - https://ash.confex.com/ash/2014/webprogram/Paper71742.html), hemoglobinopathy learning constitutes an integral component of the hematology residency curriculum, however there are significant differences in volume and case-mix of hemoglobinopathy exposure among training programs. Fellows and program directors expressed strong interest in online e-learning modules to address gaps in clinical and laboratory learning. As such, we developed a set of e-learning modules for hemoglobinopathies that were implemented as a pilot study. We hypothesized that the e-learning-based curriculum would enhance education and standardize curricular exposure between Canadian hematology programs.Methods: Based on the National Hemoglobinopathy Learning Objectives, a curriculum of 12 case-based modules was developed. Modules were implemented as a pilot study in four Canadian hematology training programs using a distributed practice model - two modules every two months over the 12-month academic year. Training programs were selected based on baseline hemoglobinopathy exposure in their curriculum (two programs with high baseline exposure and two programs with low baseline exposure). Fellows completed the modules independently. Learning was supplemented with bimonthly module review sessions facilitated by expert faculty. In programs where the program directors did not identify a local faculty member with content expertise, review sessions were run by web conference. Data were collected regarding the efficacy of the intervention through three main formats: in-person fellow focus groups, online fellow questionnaires, and sets of designated hemoglobinopathy-related questions at the annual National Hematology Online Practice Exam for all Canadian Hematology fellows.Results: From online graded survey responses (1 to 5, "strongly disagree" to "strongly agree"), 97% of respondents indicated the modules were relevant to their particular learning needs (Mean 4.39, SD = 0.55). All survey respondents indicated the case scenarios were realistic, and 95% felt that the e-learning software was easy to use, engaging and offered flexibility of computer-based learning. Responses in focus group feedback sessions mirrored the survey findings: modules were described as "very useful", "realistic", and of high production quality, with participants indicating they felt the issue of variability in case mix could be addressed with online cases. With respect to the expert-led case review sessions, the majority of focus group responses indicated they were valuable and enhanced the learning obtained from online modules, with review sessions being increasingly useful with later modules that were more challenging. In addition, both online survey responses and focus group feedback identified that participants would strongly recommend the modules to their colleagues (97% of survey responses, Mean 4.43, SD = 0.56). Finally, comparing results of the annual National Hematology Online Practice exam, programs that participated in the online hemoglobinopathy modules saw their fellows achieve a higher incremental change in their score from 2015 to 2016, as compared to their counterparts who did not participate in the online modules (increase of 18.5% vs. 14.8%).Conclusion/Implications: In this pilot implementation study, online hemoglobinopathy modules were shown to have high usability and user satisfaction with content. Fellows agreed that the e-learning modules addressed current gaps in curricula and variability in case-mix exposure. Among fellows who have completed the annual National Hematology Online Practice Exam, comparison of the 2015 and 2016 exam scores in participating and non-participating programs indicated improved performance on hemoglobinopathy-related questions. Taken together, our study has shown that our proposed e-learning-based curriculum has been a successful intervention in promoting, standardizing and enhancing education in hemoglobinopathies among Canadian hematology programs. DisclosuresBates:Eli Lilly Canada: Other: Partial salary support through Eli Lilly Canada/May Cohen Chair in Women's Health.

Improvement in the Assessment of Diastolic Function in a Clinical Echocardiography Laboratory Following Implementation of a Quality Improvement Initiative

The aim of this study was to demonstrate improvement in the characterization of diastolic function in the routine practice of a clinical echocardiography laboratory after the implementation of a quality improvement initiative. The echocardiographic analysis of left ventricular (LV) diastolic dysfunction is an inherently complex process involving the integration of multiple indices for accurate assessment. A baseline survey of 50 randomly chosen echocardiographic studies was reviewed for the accuracy of diastolic function assessment. A four-step quality improvement protocol was then initiated: (1) sonographer and physician education; (2) the implementation of data acquisition protocol changes using LV inflow, tissue Doppler velocity of the mitral annulus in early diastole (e'), flow propagation velocity of LV inflow (Vp), and left atrial volume index (LAVI), along with the establishment of uniform criteria for diagnostic interpretation; (3) peer review of performance; and (4) focused interactive case review sessions. At baseline, measurements of LV inflow were most often correct (100% accurate), while measurements of e' (82% accurate), Vp (12% accurate), and LAVI (12% accurate) and the proper classification of diastolic function (44% accurate) were significantly limited. After the quality improvement initiative, there were significant increases in the accuracy of all recorded measurements, with e' 92% accurate (a 10% improvement; P < .10), Vp 67% accurate (a 55% improvement; P < .001), LAVI 80% accurate (a 68% improvement, P < .001), and proper characterization of diastolic function 76% accurate (a 32% improvement, P < .001). A multifaceted quality improvement protocol including staff education, systematic support with enhanced infrastructure, and peer review with feedback can be effective for improving the clinical performance of a nonacademic echocardiography laboratory in the characterization of diastolic function.

Development and implementation of a pharmacist-managed inpatient anticoagulation monitoring program

PURPOSE. A stepwise approach to development and implementation of a program to standardize and increase pharmacists' involvement in anticoagulation therapy at a large academic medical center is described. SUMMARY. In response to the Joint Commission's national goal of improved patient safety in anticoagulation therapy, a work group of pharmacy administrators, educators, clinical specialists, and decentralized pharmacists at the hospital developed the structure for a comprehensive inpatient anticoagulation program (IAP); the work group also developed a list of required competencies, educational materials, assessment methods, and mechanisms for eliciting feedback from IAP pharmacists and other patient care staff. After completion of training that included structured case-review sessions, a one-on-one shadowing experience, and competency assessment, IAP pharmacists began reviewing clinical and laboratory data on patients receiving warfarin and low-molecular-weight heparins and providing recommendations to physicians, nurse practitioners, and other health care team members. Feedback from other clinicians was generally positive, with a majority of those surveyed indicating that increased pharmacist involvement in anticoagulation monitoring and dosage adjustment resulted in improved patient care; about 80% indicated that they concurred with pharmacists' recommendations at least 75% of the time. Results of a survey of IAP pharmacists indicated increased satisfaction with their daily duties but also a need for improved pharmacist-to-pharmacist communication. CONCLUSION. Case-based advanced training and implementation of an IAP in a tertiary care hospital increased pharmacists' involvement in the management of inpatients receiving anticoagulants.

A randomized controlled trial of consensus-based child abuse case management

Objective This study evaluates the effects of expert-assisted child abuse and neglect case management in the German child welfare and healthcare system as perceived by the case workers themselves. Methods Case workers with different professions (social workers, counselors, clinic-based and office-based psychotherapists, and physicians) participated in the study. They were responsible for 80 child protection cases which were enrolled for the study and randomly assigned either to expert-assisted case management or to case management as usual. The sample represented a broad range of child protection problems with alleged or confirmed physical abuse, sexual abuse, emotional abuse and/or neglect. The victims were between 0 and 18 years of age. The intervention group received two to six case review sessions provided by child protection experts from outside of the case workers’ own institution within 6 months after referral of the case. The case workers’ satisfaction with the perceived degree of child protection, their level of certainty in the process of investigation, risk assessment and intervention planning, the quality of inter-institutional communication, and the involvement of children and families were evaluated. Results Overall, only few between-group differences indicated effects of the intervention program. There was a statistical tendency toward more satisfaction with the perceived degree of child protection in the intervention group. Certainty in the estimation of suspected child abuse decreased significantly in the intervention group, compared with the control group, whereas certainty with respect to intervention planning increased. There were no group differences in the estimation of inter-institutional communication. Case workers in the intervention reported significantly fewer legal prosecutions of the perpetrators than case workers without expert assistance. However, the involvement of children in planning the interventions was significantly lower in the intervention group. Conclusions Expert-assisted case management may change the case workers’ perception of the evidence for abuse and guide their interventions to provide child protection. Modifications of the method should consider improved participation of the child.