Direct Patient Care Activities Research Articles

A multistep approach and executive summary assessing and addressing workforce satisfaction and retention of the oncology pharmacy workforce

AbstractIntroductionHematology/oncology pharmacists work in various roles in healthcare systems and represent a highly skilled and valuable resource. There remains a significant challenge in the recruitment and retention of these well‐trained pharmacists. We sought to identify key factors and propose solutions to impact the ability to recruit, promote, and retain pharmacists.MethodsAn initial survey in 2021 assessed the status of the oncology pharmacist workforce with regard to job satisfaction and attrition risk. Based on the top 5 factors identified in the Initial Survey, a Follow‐Up Survey was conducted in 2022 to further understand top dissatisfiers in the workplace. To address these factors, an in‐person collaborative workshop was conducted in 2023 with a focus on creating action plans around the practice model, professional development, well‐being, and metrics.ResultsA total of 392 individuals participated in the Follow‐Up Survey. Most were 31–40 years of age (56%), female (70%), Caucasian (78%), and from academic medical centers (68%). Of the 367 individuals who responded to factors contributing to dissatisfaction at work, 51 of the respondents selected all five factors. The most common factor was the practice model (77%), followed by burnout/well‐being (74%), leadership (62%), professional development (56%), and metrics (32%). At the workshop, teams worked collaboratively to review detailed data, evaluate root causes, define a goal future state, and build recommendations for incremental steps to pursue progress in each of these areas.DiscussionUtilizing key information learned from both the Initial and Follow‐Up Survey, the Oncology Pharmacy Workforce Collaborative demonstrated that the key themes are interconnected and institutional support is essential in modernizing practice models, revamping professional development, creating better measures of direct and indirect patient care activities, and ensuring effective support for well‐being.

Evaluation of a decentralized investigational drug service pharmacist in a cancer clinical trial infusion unit.

Investigational drug service (IDS) oversees and manages use of investigational products. There is limited data on utility of pharmacy services in clinical trial conduct and outcomes, specifically on the value of a decentralized IDS pharmacist. This is a quasi-experimental study conducted in an oncology clinical trial infusion unit. A retrospective chart review was done to reflect current practice from January through June 2022. A decentralized IDS pharmacist was piloted in December 2022. Data collected included number and types of consults, personnel requesting the consult, and intervention performed. A satisfaction questionnaire was conducted after the pilot program. A total of 16.3% (173 of 1062 patient visits) of pharmacy consults were completed in the centralized IDS pharmacy model, while 44.5% (81 of 182 patient visits) of pharmacy consults were completed during the decentralized IDS pharmacist pilot, p < .001. Decentralized IDS pharmacist completed 77% (62/81) of the consults during the pilot period. Most common types of consults were toxicity management (20%), electronic medical record issues (17%), and tubing and drug administration issues (16%). More than 80% of respondents to the satisfaction questionnaire responded that implementation of a decentralized IDS pharmacist is acceptable, appropriate, and feasible. This pilot study demonstrated that a decentralized IDS pharmacist in an oncology clinical trial infusion unit improved accessibility to an IDS pharmacist, increased pharmacy consults relevant to patient care and optimized centralized pharmacists medication distribution workflow. Further studies are needed to evaluate patient benefits from implementing decentralized IDS pharmacist in direct patient care activities.

Physicians’ and nurses’ perceptions of the factors influencing the implementation of paediatric clinical pharmacy services in Hong Kong: a qualitative study

ObjectivesTo identify barriers and facilitators that influence the implementation of paediatric clinical pharmacy services in Hong Kong public hospitals from physicians’ and nurses’ perspectives.MethodsA qualitative study was conducted based on...

Evaluation of the Role of a Clinical Pharmacist on Medication Management in an Adult Burn Clinic via a Collaborative Drug Therapy Management Protocol.

Historically, pharmacists have not been formally involved in managing burn clinic patients. Collaborative Drug Therapy Management (CDTM) protocols allow pharmacists working within a defined context to independently assume responsibility for direct patient care activities. The objective of this study was to evaluate the number and type of medication-related interventions made by a clinical pharmacist, in an adult burn clinic, via a CDTM protocol. The protocol allows pharmacists to independently manage the following disease states: pain, agitation, delirium, insomnia, venous thromboembolism, skin/soft tissue infections, and hypermetabolic complications. All pharmacist visits between 1/1/22 and 9/22/22 were included. A total of 16 patients were seen at 28 visits with a clinical pharmacist for a total of 148 interventions. Patients were mostly males (81%) with a mean ± SD age of 41 ± 15 years. The majority of patients were in-state (94%), with 9 (56%) being from an outlying county. Patients were seen for a median (IQR) of 2 (1,2) visits. Interventions were made at all visits (100%) with a median of 5 (4,6) per visit. Interventions (per visit) included medication reconciliation [28 (100%)], a median of 1 (0,2) medication ordered or adjusted, labs ordered at 7 (25%) visits, with adherence and patient education both reviewed at over 90% of visits. To the best of our knowledge, ours is the first burn center to implement a Clinical Pharmacist CDTM Protocol, with a pharmacist directly impacting transitions of care. This may serve as a framework for other sites. Future directions include continuing to track data for medication adherence and access, billing/reimbursement, and clinical outcomes.

Critical care pharmacy practice advancement recommendations on direct patient care activities: An opinion of the American College of Clinical Pharmacy Critical Care Practice and Research Network

AbstractAn updated position paper on critical care pharmacy services recommends the development of new clinical programs. However, proposed pragmatic strategies for critical care pharmacy practice advancement are lacking. The purpose of this position paper is to develop consensus recommendations aimed at direct patient care activities for the advancement of critical care pharmacy practice. A 24‐member task force of critical care pharmacists, physicians, and nurses participated in a Recommendation Development Phase and Consensus‐building Phase (using a Delphi method) to produce the final critical care practice advancement recommendations. Proposed recommendations of pragmatic medication management opportunities with an advanced scope of practice involving pharmacist prescriptive authority for initiating, modifying, or discontinuing drug therapy and medication monitoring were developed. Task force participants anonymously voted on each proposed recommendation using a five‐point Likert scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, and 5 = strongly disagree). Recommendations failing to achieve consensus (≥70% agreement on “strongly agree”/“agree” votes) were revised for subsequent voting. Task force response rates during the first and second voting rounds were 71% (n = 17) and 79% (n = 19), respectively. A total of 57 (93.4%) of the 61 proposed practice advancement recommendations achieved consensus of which 88.5% (n = 54) met consensus after the first round. Consensus recommendations involved the critical care pharmacist initiating (n = 15), modifying (n = 22), or discontinuing (n = 9) drug therapy, and ordering relevant laboratory values or tests to optimize drug therapy (n = 11). One recommendation failing consensus was not revised for additional voting given the impracticality of achieving agreement. Fifty‐seven of the proposed 61 recommendation statements (93%) achieved the consensus threshold after two rounds of voting by an interprofessional expert panel. These recommendations provide a conceptual framework for promoting novel critical care pharmacist prescriptive authority over specific aspects of direct patient care. Implementation challenges and barriers, further described in this paper, must be explored at the institutional level for acceptance.

532 The Impact of a Clinical Pharmacist on Medication Management in an Adult Burn Clinic

Abstract Introduction Pharmacists in our burn center have historically assisted with discharges and transitions of care for patients sent home or to a facility. Despite these efforts, pharmacists were not formally involved in managing burn clinic patients. Collaborative Drug Therapy Management (CDTM) protocols allow pharmacists working within a defined context to independently assume responsibility for direct patient care activities. The goal of implementing this model in our clinic was to improve access to care and streamline management of pharmacologic issues. The objective of our study was to assess the impact of a clinical pharmacist on medication management in an adult burn clinic via a CDTM protocol. Methods The CDTM protocol allows pharmacists to independently manage the following disease states via in-person or telephone visits: pain, agitation, delirium, insomnia, venous thromboembolism, skin/soft tissue infections, and hypermetabolic complications. All treatment decisions, interventions, and education are documented in the electronic record. “Incident-to” billing is completed at Level 99211. All pharmacist visits between 1/1/22-9/21/22 were included for review in the study. Demographics were reported for unique patients, and interventions were included from each visit for patients with multiple pharmacist visits. Results A total of 19 patients were seen at 39 visits with a clinical pharmacist during the study. Patients were mostly males (84%) with a mean (SD) age of 45 (18) years. Majority of patients were in-state (95%), with 11 (58%) being from an outside county. Patients were seen for a median (IQR) of 2 (1,2) visits each. Additional interventions were made in 12 patients (63%) at 19 visits (49%), including medication reconciliation [16 (41%)], medications ordered [14 (36%)], labs ordered [2 (5%)], referrals placed [1 (3%)], and allergies addressed [1 (3%)]. At applicable visits, patients had a median (IQR) of 2 (1,2) interventions made or 2 (1, 3) medications ordered. Conclusions Historically, pharmacists were only involved with clinic patients when issues arose, serving in an “as-needed” capacity. Pharmacists are now able to proactively help with medication reconciliation, medication prescribing, ordering labs, and placing referrals. Implementing a CDTM protocol has allowed our pharmacists to become more formally involved in post-discharge follow-up and managing ambulatory burn patients. Applicability of Research to Practice To our knowledge, ours is the first burn center to implement a Clinical Pharmacist CDTM Protocol, which may serve as a framework for others. Future directions include continuing to track data for adherence, medication access, billing/reimbursement, and clinical outcomes.

SG-APSIC1121: Family caregivers in the patient room: Exploring the family involvement in care provision across hospital settings from an infection prevention and control (IPC) perspective

Objectives: Across many Asian countries, family caregivers provide a wide range of patient care activities while staying in the patient’s room. This unique care arrangement has been reported as a factor contributing to the spread of outbreaks including Middle East respiratory syndrome and coronavirus disease 2019 (COVID-19) in many Asian countries. We sought to understand the context in which direct patient care activities are provided by family caregivers and/or private caregivers in hospitals across Bangladesh, Indonesia, and South Korea from the infection prevention and control (IPC) perspective. Methods: We used a multimethod design with both quantitative and qualitative approaches. In total, 432 patients were surveyed from 5 tertiary-care hospitals across 3 selected countries, and 64 participants from 2 groups were interviewed: group A comprised patients, family caregivers and private caregivers and group B comprised healthcare workers. Survey data were analyzed descriptively, and the interview data were analyzed using thematic analysis. Results: The study findings highlight the different landscapes of care provision in the selected countries. Both the interviews and surveys highlighted 2 aspects of family caregiving. (1) Family caregivers inhabit in the patient zone for long periods, resulting in overcrowding, and (2) they provide a wide ranges of physically associated care activities, including those associated with the risk of healthcare-associated infections (HAIs). Despite the high number of family caregivers and their in-depth involvement in direct patient care, education and support provided to family caregivers around IPC/HAI were insufficient and varied. Also, challenges related to maintaining adequate hygiene in the environment for minimum IPC were reported. Conclusions: This study has elucidated the current landscape of family involvement in inpatient care provision and acknowledges their contribution to high risks of HAI, as well as their current lack of IPC knowledge and practice. These findings reveal that future updates in IPC strategy should acknowledge this arrangement with family caregivers and should address this role with IPC measures.

Developing a Preclinical Nurse-Nurse Communication Framework for Clinical Trial Patient-Related Safety Information.

Clinical trial trials have become increasingly complex in their design and implementation. Investigational safety profiles are not easily accessed by clinical nurses and providers when trial participants present for clinical care, such as in emergency or urgent care. Wearable devices are now commonly used as bridging technologies to obtain participant data and house investigational product safety information. Clinical nurse identification and communication of safety information are critical to dissuade adverse events, patient injury, and trial withdrawal, which may occur when clinical care is misaligned to a research protocol. Based on a feasibility study and follow-up wearable device prototype study, this preclinical nurse-nurse communication framework guides clinical nurse verbal and nonverbal communication of safety-related trial information to direct patient care activities in the clinical setting. Communication and information theories are incorporated with Carrington's Nurse-to-Nurse Communication Framework to encompass key components of a clinical nurse's management of a trial participant safety event when a clinical trial wearable device is encountered during initial assessment. Use of the preclinical nurse-nurse communication framework may support clinical nurse awareness of trial-related wearable devices. The framework may further emphasize the importance of engaging with research nurses, patients, and caregivers to acquire trial safety details impacting clinical care decision-making.

Time and motion study quantifying the activities of the cardiology, respiratory, and geriatric clinical pharmacist

There are few studies evaluating the workforce and the time allocated to tasks performed by clinical specialty pharmacists in Australia. The aim of this study was to quantify the time that clinical specialty pharmacists spend on various activities. A Work Observation Method by Activity Timing (WOMBAT) time and motion study was conducted at a tertiary-referral metropolitan health service with comprehensive unit-based clinical pharmacy services. Direct observations of clinical pharmacists were conducted by researchers during weekdays. Tasks and times observed were categorised into domains of ‘What, Who, How, and Where’, accounting for interruptions and multitasking. Eighteen clinical cardiology, respiratory, and geriatric pharmacists were observed over 171.2 h. The majority of time involved direct patient care activities (76.1% [95% confidence interval 72.6-79.6%]), including admission-related (7.6%), discharge-related (16.2%), and inpatient clinical tasks (52.5%). Activities were undertaken independently (55.9%) with doctors (26.2%), with nurses (10.5%), or with patients (9.6)%; 19.1% of the pharmacist’s day involved multitasking. The tasks most frequently performed together were inpatient clinical activities, including rounding and daily medicine review. This study quantified the typical task allocation of clinical pharmacists in cardiology, respiratory, and geriatric units. It demonstrated that in a hospital setting supported by comprehensive operational pharmacy services, clinical pharmacists working in acute and subacute clinical specialities, predominately undertake direct patient care tasks that have been shown to improve patient safety.

Pediatric Perioperative Clinical Pharmacy Practice: Clinical Considerations and Management: An Opinion of the Pediatrics and Perioperative Care Practice and Research Networks of the American College of Clinical Pharmacy.

Pediatric perioperative clinical pharmacists are uniquely positioned to provide therapeutic and medication management expertise at a particularly vulnerable transition of care from the preoperative space, through surgery, and postoperative setting. There are many direct-patient care activities that are included in the role of the pediatric perioperative pharmacist, as well as many opportunities to develop effective, optimized, and safe medication use processes. This article outlines many of the areas in which a pediatric perioperative clinical pharmacist may intervene.

624 Implementation of a Collaborative Drug Therapy Management Protocol in an Adult Burn Clinic

IntroductionCollaborative Drug Therapy Management (CDTM) protocols allow qualified clinical pharmacists working within a defined context to independently assume responsibility for a variety of direct patient care activities. The goal of this model is to improve access to care, often in a more affordable and timely manner. Pharmacists in our burn center have historically assisted with discharge planning and transitions of care for patients being sent home or to a facility. Despite these efforts, pharmacists were not formally involved in managing Burn Clinic patients. The objective of implementing a CDTM Protocol in Burn Clinic was to streamline management of burn-related pharmacologic issues.MethodsThe CDTM protocol allows the pharmacist to assess patients’ therapeutic needs related to thermal injury, inhalation injury, or dermatologic disorder. Disease states managed include: pain, agitation, delirium, insomnia, venous thromboembolism, skin and soft tissue infections, and complications of hypermetabolic burn response.ResultsIn Burn Clinic, via in-person or telephone visits, pharmacists can independently evaluate and modify pharmacologic treatment regimens in accordance with state legislation, including initiation, renewal, and adjustment of drugs and vitamins. The pharmacist can also review, order, interpret, and conduct pertinent laboratory studies and wound culture results. In addition, the pharmacist completes medication reconciliation, performs patient education, and consults other healthcare providers, as needed. All visits, patient care, education, and treatment decisions are documented in the electronic record. “Incident-to” billing is completed at Level 99211, as this is a hospital-based clinic.ConclusionsHistorically, pharmacists were peripherally involved with Burn Clinic patients when issues arose, serving in an “as-needed” capacity. With more proactive involvement, pharmacists are uniquely positioned to help with de-prescribing, drug interactions, insurance issues, access to medications, adherence, and dose optimization. Implementing a CDTM protocol allows pharmacists to become more formally involved in post-discharge follow-up and to help manage ambulatory burn patients.

Occupational risk factors for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among healthcare personnel: A 6-month prospective analysis of the COVID-19 Prevention in Emory Healthcare Personnel (COPE) Study.

To determine the incidence of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among healthcare personnel (HCP) and to assess occupational risks for SARS-CoV-2 infection. Prospective cohort of healthcare personnel (HCP) followed for 6 months from May through December 2020. Large academic healthcare system including 4 hospitals and affiliated clinics in Atlanta, Georgia. HCP, including those with and without direct patient-care activities, working during the coronavirus disease 2019 (COVID-19) pandemic. Incident SARS-CoV-2 infections were determined through serologic testing for SARS-CoV-2 IgG at enrollment, at 3 months, and at 6 months. HCP completed monthly surveys regarding occupational activities. Multivariable logistic regression was used to identify occupational factors that increased the risk of SARS-CoV-2 infection. Of the 304 evaluable HCP that were seronegative at enrollment, 26 (9%) seroconverted for SARS-CoV-2 IgG by 6 months. Overall, 219 participants (73%) self-identified as White race, 119 (40%) were nurses, and 121 (40%) worked on inpatient medical-surgical floors. In a multivariable analysis, HCP who identified as Black race were more likely to seroconvert than HCP who identified as White (odds ratio, 4.5; 95% confidence interval, 1.3-14.2). Increased risk for SARS-CoV-2 infection was not identified for any occupational activity, including spending >50% of a typical shift at a patient's bedside, working in a COVID-19 unit, or performing or being present for aerosol-generating procedures (AGPs). In our study cohort of HCP working in an academic healthcare system, <10% had evidence of SARS-CoV-2 infection over 6 months. No specific occupational activities were identified as increasing risk for SARS-CoV-2 infection.

Survey of direct patient care and payment models among pharmacy practice faculty

AbstractIntroductionThe scope of pharmacy practice continues to expand into comprehensive medication management and direct patient care models, where practice‐based faculty play a central role. The extent to which schools/colleges of pharmacy have faculty embedded in health systems, physician practices, and other value‐based care settings involving practice plans is largely unknown.ObjectivesThe objectives of this project were to: (1) elucidate the perceptions, barriers, and implementation strategies related to direct patient care models, and (2) to further our understanding of how practice departments are employing practice plans, within schools/colleges of pharmacy.MethodsA 25‐item survey was distributed via email. Eligible respondents were pharmacy practice department chairs at United States‐based colleges/schools of pharmacy. Descriptive statistics were used to characterize workload allocations, direct patient care activities, and billing/reimbursement trends among practice faculty.Measurements and Main ResultsSurvey respondents included 43 institutions (32.6% institutional response rate) representing 1241 practice faculty and nearly 800 faculty involved in direct patient care activities. Faculty at private institutions tended to have a higher degree of effort in direct patient care (26.3% vs 4.3%) and were more involved in billing for services in the clinic setting, when compared with public institutions. Although Collaborative Practice Agreements were widely utilized, very few institutions employed practice revenue plans.ConclusionThe findings of our study indicate that pharmacy practice faculty provide significant effort in direct patient care that is critical to advancing the profession. These faculty practicing in primary and ambulatory care settings serve as role models to our student trainees, particularly in value‐based care settings. However, practice plan payment models appear to be rarely utilized. Failure to account for and recognize these valuable direct patient care activities may adversely impact the financial sustainability of schools and colleges of pharmacy in the future.

Evaluation of a remote hybrid staffing model for ambulatory clinical pharmacists in a pediatric health system during the COVID-19 pandemic.

PurposeTo describe and quantify patient care activities performed by ambulatory clinical pharmacists supporting medical specialty clinics in a pediatric health system utilizing a hybrid staffing model during the coronavirus disease 2019 (COVID-19) pandemic.MethodsFive ambulatory clinical pharmacists, integrated within a health-system specialty pharmacy (HSSP), utilized a web-based data collection tool to record time spent performing patient care activities over a 2-week period. Work location (onsite or offsite) of the pharmacist was reported for each activity. Activities were classified as direct or indirect patient care. Direct patient care activities were subcategorized as telemedicine appointments, in-person clinic appointments, HSSP call center work, medication access support, electronic medical record consults, and previsit planning/postvisit documentation. Administrative tasks and precepting were considered indirect patient care activities.ResultsA total of 1,190 activities were completed, with 77% of all activities performed offsite. Direct and indirect patient care activities accounted for 871 (73.2%) and 319 (26.8%) of total activities, respectively. No activity took longer for the pharmacists to complete offsite versus onsite.ConclusionUsing a hybrid staffing model employed by a pediatric health system, ambulatory clinical pharmacists were able to efficiently provide a high volume of direct patient care activities even when working offsite. Rapid adaptation and implementation of telemedicine services was critical for pharmacists to continue to provide essential services within pediatric medical specialty clinics.

109. Develop and Implement a Novel Pediatric Antimicrobial Stewardship Program in a Non-Freestanding Children’s Hospital Located in an Adult-Centered Community Hospital in San Joaquin Valley, California

BackgroundA pediatric-specific antimicrobial stewardship program (Ped ASP) has been shown to optimize antimicrobial use, improve patient outcomes, and reduce healthcare expenditures in this population. Opportunities and challenges exist when developing a Ped ASP for a children’s hospital within an adult-centered medical center primarily due to mixed infrastructure. The objective of this study is to provide process and outcome data of a new Ped ASP in a non-freestanding children’s hospital within an adult-centered tertiary hospital.MethodsA pediatric infectious disease physician and four pediatric pharmacists designed a Ped ASP utilizing direct and indirect patient care activities to optimize pediatric antimicrobial use in 21 bed-pediatric services within a 685-bed, adult-centered medical center. Implemented in 2020, Ped ASP activities include thrice weekly chart reviews followed by handshake rounds and quarterly reviews of documented interventions. The Ped ASP team also developed policies, education, and other resources to further guide appropriate antimicrobial use, in collaboration with the adult team.ResultsPed ASP was initiated on general pediatric (PED) and pediatric intensive care (PICU) units. In 2020, a total of 286 charts were reviewed with 199 antibiotic interventions provided, including optimization of antimicrobial selection (23%), IV-to-PO conversion (15%), and antimicrobial dosage adjustment (13%). Annual average antibiotic length and days of therapy per 1000 patient-days were 241 and 290 respectively in PED, and 388 and 432 in PICU. The overall trend from 2020 to 2021 decreased in PED but increased in PICU (Fig. 1). The ratio of narrow to broad spectrum antibiotic use increased for both PED and PICU (Fig. 2). Simultaneously, a pediatric-specific antibiogram, extended-infusion protocol of beta-lactams, and neonatal sepsis treatment algorithm were developed and implemented. Antibiotic Days of Therapy per 1000 Patient Days Ratio of Narrow: Broad Spectrum Antibiotic UsageConclusionA Ped ASP was successfully developed in a non-freestanding children’s hospital. Continual metrics served as an important tool to identify areas for improvement. Future goals include expansion of Ped ASP to other service lines, enhanced ASP education and development of additional pediatric antimicrobial treatment pathways.Disclosures All Authors: No reported disclosures

Nurse-to-Patient Ratios in Tele-Critical Care.

Nurse-to-Patient Ratios in Tele-Critical Care.

How Did Orthopaedic Surgeons Perform in the 2018 Centers for Medicaid & Medicare Services Merit-based Incentive Payment System?

The Merit-based Incentive Payment System (MIPS) is the latest value-based payment program implemented by the Centers for Medicare & Medicaid Services. As performance-based bonuses and penalties continue to rise in magnitude, it is essential to evaluate this program's ability to achieve its core objectives of quality improvement, cost reduction, and competition around clinically meaningful outcomes. We asked the following: (1) How do orthopaedic surgeons differ on the MIPS compared with surgeons in other specialties, both in terms of the MIPS scores and bonuses that derive from them? (2) What features of surgeons and practices are associated with receiving penalties based on the MIPS? (3) What features of surgeons and practices are associated with receiving a perfect score of 100 based on the MIPS? Scores from the 2018 MIPS reporting period were linked to physician demographic and practice-based information using the Medicare Part B Provider Utilization and Payment File, the National Plan and Provider Enumeration System Data (NPPES), and National Physician Compare Database. For all orthopaedic surgeons identified within the Physician Compare Database, there were 15,210 MIPS scores identified, representing a 72% (15,210 of 21,124) participation rate in the 2018 MIPS. Those participating in the MIPS receive a final score (0 to 100, with 100 being a perfect score) based on a weighted calculation of performance metrics across four domains: quality, promoting interoperability, improvement activities, and costs. In 2018, orthopaedic surgeons had an overall mean ± SD score of 87 ± 21. From these scores, payment adjustments are determined in the following manner: scores less than 15 received a maximum penalty adjustment of -5% ("penalty"), scores equal to 15 did not receive an adjustment ("neutral"), scores between 15 and 70 received a positive adjustment ("positive"), and scores above 70 (maximum 100) received both a positive adjustment and an additional exceptional performance adjustment with a maximum adjustment of +5% ("bonus"). Adjustments among orthopaedic surgeons were compared across various demographic and practice characteristics. Both the mean MIPS score and the resulting payment adjustments were compared with a group of surgeons in other subspecialties. Finally, multivariable logistic regression models were generated to identify which variables were associated with increased odds of receiving a penalty as well as a perfect score of 100. Compared with surgeons in other specialties, orthopaedic surgeons' mean MIPS score was 4.8 (95% CI 4.3 to 5.2; p < 0.001) points lower. From this difference, a lower proportion of orthopaedic surgeons received bonuses (-5.0% [95% CI -5.6 to -4.3]; p < 0.001), and a greater proportion received penalties (+0.5% [95% CI 0.2 to 0.8]; p < 0.001) and positive adjustments (+4.6% [95% CI 6.1 to 10.7]; p < 0.001) compared with surgeons in other specialties. After controlling for potentially confounding variables such as gender, years in practice, and practice setting, small (1 to 49 members) group size (adjusted odds ratio 22.2 [95% CI 8.17 to 60.3]; p < 0.001) and higher Hierarchical Condition Category (HCC) scores (aOR 2.32 [95% CI 1.35 to 4.01]; p = 0.002) were associated with increased odds of a penalty. Also, after controlling for potential confounding, we found that reporting through an alternative payment model (aOR 28.7 [95% CI 24.0 to 34.3]; p < 0.001) was associated with increased odds of a perfect score, whereas small practice size (1 to 49 members) (aOR 0.35 [95% CI 0.31 to 0.39]; p < 0.001), a high patient volume (greater than 500 Medicare patients) (aOR 0.82 [95% CI 0.70 to 0.95]; p = 0.01), and higher HCC score (aOR 0.79 [95% Cl 0.66 to 0.93]; p = 0.006) were associated with decreased odds of a perfect MIPS score. Collectively, orthopaedic surgeons performed well in the second year of the MIPS, with 87% earning bonus payments. Among participating orthopaedic surgeons, individual reporting affiliation, small practice size, and more medically complex patient populations were associated with higher odds of receiving penalties and lower odds of earning a perfect score. Based on these findings, we recommend that individuals and orthopaedic surgeons in small group practices strive to forge partnerships with larger hospital practices with adequate ancillary staff to support quality reporting initiatives. Such partnerships may help relieve surgeons of growing administrative obligations and allow for maintained focus on direct patient care activities. Policymakers should aim to produce a shortened panel of performance measures to ensure more standardized comparison and less time and energy diverted from established clinical workflows. The current MIPS scoring methodology should also be amended with a complexity modifier to ensure fair evaluation of surgeons practicing in the safety net setting, or those treating patients with a high comorbidity burden. Level III, therapeutic study.

Critical Care Clinical Nurse Specialist Role in Developmental Care for Infants With Heart Disease.

Critical Care Clinical Nurse Specialist Role in Developmental Care for Infants With Heart Disease.

Postgraduate year two ambulatory care residency program evaluation with a tool for assessing ambulatory care pharmacist practice

AbstractIntroductionA standardized set of required competency areas, goals, and objectives are used in accreditation to create consistency in learning experiences across programs. The individual postgraduate year two (PGY‐2) ambulatory care residency program is subsequently tasked with designing activities to achieve the defined goals and objectives, which may lead to variability in the constructed activities across residency programs.ObjectivesThe primary objective of this study was to describe (define, assess, and stratify) the current landscape of direct patient care activities provided within PGY‐2 ambulatory care residency program training environments.MethodsThis was a national, descriptive, cross‐sectional study using the Tool for Assessing Ambulatory Care Pharmacist Practice (TAAPP). The TAAPP questionnaire was disseminated via electronic mail to PGY‐2 ambulatory care Residency Program Directors (RPDs) meeting inclusion criteria. RPDs were requested to complete the questionnaire and disseminate it further to two preceptors of required rotations and all 2017‐2018 residents.ResultsIn total, 108 responses were received out of a possible 595 and 10 were excluded due to the respondents not meeting inclusion criteria or the questionnaire was incomplete. Ninety‐eight (16.5% response rate) underwent descriptive and statistical analysis. Fifty‐two participants (53%) indicated they provide a comprehensive or broad delivery of direct patient care, 44 respondents (45%) provide activities within a moderate scope of practice, and 2 respondents (2%) engage in a narrow scope of practice. Forty‐seven of the pharmacists (36%) stated they were functioning under a disease state specific collaborative practice agreement (CPA), 40 (31%) under a broad or comprehensive CPA, 24 (19%) under a protocol‐driven, and 13 (10%) under a medication‐specific agreement.ConclusionVariability in PGY‐2 ambulatory care residency programs was found with just half of participants functioning under a broad scope of pharmacist practice. Opportunities exist for programs to further standardize and advance program training environments.

Designing and Implementing a Novel Virtual Rounds Curriculum for Medical Students' Internal Medicine Clerkship During the COVID-19 Pandemic.

IntroductionDuring the COVID-19 pandemic, third-year medical students were temporarily unable to participate in onsite clinical activities. We identified the curricular components of an internal medicine (IM) clerkship that would be compromised if students learned solely from online didactics, case studies, and simulations (i.e., prerounding, oral presentations, diagnostic reasoning, and medical management discussions). Using these guiding principles, we created a virtual rounds (VR) curriculum to provide IM clerkship students with clinical exposure during a virtual learning period.MethodsHeld three times a week for 2 weeks, VR consisted of three curricular components. First, clerkship students prerounded on an assigned hospitalized patient by remotely accessing the electronic health record and calling into hospital rounds. Second, each student prepared an oral presentation on their assigned patient. Third, using videoconferencing, students delivered these oral presentations to telemedicine VR small groups consisting of three to four students and three tele-instructors. Tele-instructors then provided feedback on oral presentations and taught clinical concepts. We assessed the effectiveness of VR by anonymously surveying students and tele-instructors.ResultsTwenty-nine students and 34 volunteer tele-instructors participated in VR over four blocks. A majority of students felt VR improved their prerounding abilities (86%), oral presentation abilities (93%), and clinical reasoning skills (62%). All students found small group to be useful.DiscussionVR allowed students to practice rounding skills in a supportive team-based setting. The lessons learned from its implementation could facilitate education during future pandemics and could also supplement in-person clerkship education.