General Medicine Wards Research Articles

Study of a multisite prospective adverse event surveillance system

BackgroundWe have designed a prospective adverse event (AE) surveillance method. We performed this study to evaluate this method’s performance in several hospitals simultaneously.ObjectivesTo compare AE rates obtained by prospective AE...

Improving inpatient glycemic control by diabetes education program in internal medicine residents

AimsThe purpose of this study was to investigate the effectiveness of an inpatient diabetes care education during the first year of internal medicine residency training on inpatient glycemic control. MethodsThe program was comprised of 1-hr small group teaching per 4-week rotation and twice-a-week morning insulin round by an endocrinologist. Inpatient insulin management guideline leaflet was provided to all internal medicine residents. We retrospectively collected the point-of-care testing for glucose (POCT-glu) data in patients admitted to the general medicine wards and compared the mean of blood glucose (BG) before and after the education program. A total of 134438 POCT-glu values from 7055 patients were analyzed. ResultsAfter the initiation of the education program, mean BG levels significantly decreased during the first year and were lowest during the second year after education (Mean BG at baseline was 161.38 ± 64.10 mg/dL; 1st year, 159.48 ± 62.53 mg/dL and 2nd year, 155.60 ± 64.94 mg/dL, p-value < 0.0001). The reduction of BG levels was more pronounced in the patients with previously undiagnosed diabetes mellitus than patients with underlying diabetes mellitus. The rates of severe hypoglycemia (defined by BG < 40 mg/dL or 2.2 mmol/L) were not significantly different before and after education (baseline 0.12%, 1st year 0.14%, and 2nd year 0.14%, p-value = 0.632). ConclusionsLack of confidence and inadequate knowledge of insulin treatment in physicians were important barriers to glycemic management. Consistent education in internal medicine residents led to a significant improvement in inpatient glycemic control.

Qualitative experiential analysis of the BRASS scale.

Hospital discharge can potentially represent an issue. Therefore, it is important to early identify patients at higher risk. A valid tool in this field is the Blaylock Risk Assessment Screening Score (BRASS). The study aims to elaborate a simplified score system, throughout the contribution of healthcare professionals considering the single items of the original score. The study included a qualitative analysis, conducted in order to draft the synthetic tool. Alongside, a statistical analysis was carried out. The findings of these two works were compared and joined in the realization of the proposed evaluation tool. The synthetic tool, developed by the working team, is composed by 20 items. The qualitative analysis agrees with the statistical approach. Moreover, the qualitative analysis consented to redefine some items, especially considering social support, and to include some additional information e.g. clinical problems. The analysis considered only General Medicine wards, all located in the same Hospital. Therefore, generalisation to other settings or patients should be further tested. The synthetic tool, realized during the study, aims to improve the individuation of at-risk inpatients. The agreement between statistical and qualitative analysis can be considered a point of strength of our work. Our analysis consented to include some new items, improving overall organization. In conclusion, the working group aims to conduct further study in order to individuate the more appropriate cut-off of the new scoring method.

Evaluation of Hospital Discharge Prescriptions in the Elderly and Younger Adults Using the Medication Regimen Complexity Index.

Advances in the clinical management of diseases have been accompanied by increasing complexity of treatment regimens. The complexity of medication regimen is of concern for patients as well as doctors as it may adversely affect patient compliance and treatment outcomes. It may result in medication errors, increased utilization of health resources owing to a reduction in treatment effectiveness, and increased risk of therapeutic failure. This study aimed to assess the complexity of medication regimen prescribed to patients on hospital discharge using the medication regimen complexity index (MRCI). A cross-sectional, descriptive study was conducted. Hospital discharge prescriptions written for patients discharged from the General Medicine wards of a tertiary care teaching hospital in South India were scored for their complexity using MRCI. The correlation of age and gender with the MRCI scores was also assessed. Patients ≥60 years of age were considered elderly. The median MRCI score for 563 prescriptions studied was 14 (Interquartile range, 9-21). Elderly patients received a significantly more complex medication regimen compared with younger patients (p < 0.001) at the time of hospital discharge. Gender variation was seen with higher MRCI scores in females, but this was not statistically significant in the elderly group. MRCI scores are significantly high in elderly patients at the time of hospital discharge. Although a strong correlation is seen between the number of medications and the MRCI score, the latter helps to distinguish regimen complexity between prescriptions with the same number of medications.

Effective elimination of Staphylococcal contamination from hospital surfaces by a bacteriophage-probiotic sanitation strategy: a monocentric study.

SummaryPersistent contamination of hospital surfaces and antimicrobial resistance (AMR) is recognized as major causes of healthcare‐associated infections (HAI). We recently showed that probiotic‐based sanitation (PCHS) can stably decrease surface pathogens and reduce AMR and HAIs. However, PCHS action is slow and non‐specific. By contrast, bacteriophages have been proposed as a decontamination method as they can rapidly attack specific targets, but their routine application has never been tested. Here, we analysed the feasibility and effectiveness of phage addition to PCHS sanitation, aiming to obtain a rapid and stable abatement of specific pathogens in the hospital environment. Staphylococcal contamination in the bathrooms of General Medicine wards was analysed, being those areas the most contaminated and Staphylococci the most prevalent bacteria in such settings. Results showed that a daily phage application by nebulization induced a rapid and significant decrease in Staphylococcus spp. load on treated surfaces, up to 97% more than PCHS alone (P < 0.001), suggesting that such a system might be considered as a part of prevention and control strategies, to counteract outbreaks of specific pathogens and prevent associated infections.

Learning Together: Integration of Advanced Practice Providers into a General Medicine Ward Team.

The Accreditation Council for Graduate Medical Education (ACGME) demands that physicians should be trained to engage in clinical activities with other health profession providers. Incorporation of advanced practice providers (APPs) into medicine ward teams has not yet been described. To describe a pilot and feasibility evaluation of an interprofessional general medicine ward team with internal medicine residents and APPs to encourage resident leadership development, enhance service to education balance, and promote interprofessional collaboration. University of Colorado, Internal Medicine Residency Program. Sixteen internal medicine residents, 16 interns, 19 Department of Medicine faculty members, and 8 advanced practice provider fellows in hospital medicine. The authors describe an interprofessional general medicine ward team including team structure, and roles and responsibilities of each team member. Each team member completed an electronic survey following the rotation and the majority agreed that the pilot team allowed for an enhanced resident leadership role, and helped to restore the service to education balance and interprofessional collaboration. An interprofessional general medicine ward team is feasible, has the potential to optimize service to education balance, and exposes learners to a collaborative interprofessional clinical environment.

Reducing Unnecessary Treatment of Asymptomatic Elevated Blood Pressure with Intravenous Medications on the General Internal Medicine Wards: A Quality Improvement Initiative.

Asymptomatic elevated blood pressure (BP) is common in the hospital. There is no evidence supporting the use of intravenous (IV) antihypertensives in this setting. To determine the prevalence and effects of treating asymptomatic elevated BP with IV antihypertensives and to investigate the efficacy of a quality improvement (QI) initiative aimed at reducing utilization of these medications. Retrospective cohort study. Urban academic hospital. Patients admitted to the general medicine service, including the intensive care unit (ICU), with ≥1 episode of asymptomatic elevated BP (>160/90 mm Hg) during hospitalization. A two-tiered, QI initiative. The primary outcome was the monthly proportion of patients with asymptomatic elevated BP treated with IV labetalol or hydralazine. We also analyzed median BP and rates of balancing outcomes (ICU transfers, rapid responses, cardiopulmonary arrests). We identified 2,306 patients with ≥1 episode of asymptomatic elevated BP during the 10-month preintervention period, of which 251 (11%) received IV antihypertensives. In the four-month postintervention period, 70 of 934 (7%) were treated. The odds of being treated were 38% lower in the postintervention period after adjustment for baseline characteristics, including length of stay and illness severity (OR = 0.62; 95% CI 0.47-0.83; P = .001). Median SBP was similar between pre- and postintervention (167 vs 168 mm Hg; P = .78), as were the adjusted proportions of balancing outcomes. Hospitalized patients with asymptomatic elevated BP are commonly treated with IV antihypertensives, despite the lack of evidence. A QI initiative was successful at reducing utilization of these medications.

Higher rates of osteoporosis treatment initiation and persistence in patients with newly diagnosed vertebral fracture when introduced in inpatients than later in outpatients.

Fracture liaison services are standard care for secondary fracture prevention. A higher rate of osteoporosis treatment initiation may be considered when introduced in the hospital rather than an outpatient recommendation to a primary care physician (PCP). Whether this applies to patients with newly detected vertebral fractures in a general internal medicine ward remains unknown. We prospectively investigated whether in-hospital management of newly identified vertebral fractures led to a higher rate of osteoporosis medication initiation and persistence at 3 and 6months than delayed outpatient management by a PCP. We conducted a prospective study including hospitalized patients > 60years systematically searched for asymptomatic vertebral fractures on lateral chest and/or abdominal radiographs. Patients were included either in phase 1 (outpatient care recommendations on osteoporosis management to a PCP) or in phase 2 (inpatient care management initiated during hospitalization). The percentage of patients under osteoporosis treatment was evaluated by telephone interview at 3 and 6months. Outpatients' (84 with fracture/407 assessed (21%); 75.7 ± 7.7years) and inpatients' (100/524 (19%); 77.8 ± 9.4years) characteristics were similar. Osteoporosis medication was more often prescribed in inpatients at 3 (67% vs. 19%, respectively; p < 0.001) and 6months (69 vs. 27%, respectively; p < 0.001). The percentage under treatment was also higher in inpatients than in outpatients at 3 (52 vs. 19%, p < 0.001) and 6months (54 vs. 22%, p < 0.001). Length of stay and destination post-discharge were not different between groups. Early patient management after a newly detected vertebral fracture during hospitalization was a more efficacious strategy of secondary fracture prevention than delayed outpatient management following discharge.

Clinical measurements obtained from point-of-care ultrasound images to assess acquisition skills

BackgroundCurrent methods of assessing competence in acquiring point-of-care ultrasound images are inadequate. They rely upon cumbersome rating systems that do not depend on the actual outcome measured and lack evidence of validity. We describe a new method that uses a rigorous statistical model to assess performance of individual trainees based on the actual task, image acquisition. Measurements obtained from the images acquired (the actual desired outcome) are themselves used to validate effective training and competence acquiring ultrasound images. We enrolled a convenience sample of 21 spontaneously breathing adults from a general medicine ward. In random order, two trainees (A and B) and an instructor contemporaneously acquired point-of-care ultrasound images of the inferior vena cava and the right internal jugular vein from the same patients. Blinded diameter measurements from each ultrasound were analyzed quantitatively using a multilevel model. Consistent mean differences between each trainee’s and the instructor’s images were ascribed to systematic acquisition errors, indicative of poor measurement technique and a need for further training. Wider variances were attributed to sporadic errors, indicative of inconsistent application of measurement technique across patients. In addition, the instructor recorded qualitative observations of each trainee’s performance during image acquisition.ResultsFor all four diameters, the means and variances of measurements from trainee A’s images differed significantly from the instructor’s, whereas those from trainee B’s images were comparable. Techniques directly observed by the instructor supported these model-derived findings. For example, mean anteroposterior diameters of the internal jugular vein obtained from trainee A’s images were 3.8 mm (90% CI 2.3–5.4) smaller than from the instructor’s; this model-derived finding matched the instructor’s observation that trainee A compressed the vein during acquisition. Instructor summative assessments agreed with model-derived findings, providing internal validation of the descriptive and quantitative assessments of competence acquiring ultrasound images.ConclusionsClinical measurements obtained from point-of-care ultrasound images acquired contemporaneously by trainees and an instructor can be used to quantitatively assess the image acquisition competence of specific trainees. This method may obviate resource-intensive qualitative rating systems that are based on ultrasound image quality and direct observation, while also helping instructors guide remediation.

Intensive Care Units of a Tertiary Care Hospital: A Detailed Study of Patient Symptomatology.

IntroductionNosocomial infection (NI) is a factor of considerable significance in determining the morbidity and mortality of patients admitted to the intensive care units (ICUs). Our aim was to study the frequencies of various symptoms that might emerge due to nosocomial infection (NI) among ICU patients.Materials and methodsThis was a cross-sectional study conducted in intensive care units of General Medicine, General Surgery and Paediatric wards in Ruth M. Pfau Civil Hospital Karachi, Pakistan, using well-structured questionnaire created after a thorough literature study. Patients who had an ICU admission for more than five days but less than two weeks were set as the inclusion criteria. The remaining patients were excluded from the study. ResultsAmong the patients who developed gastrointestinal disturbances while in the intensive units, loss of appetite had the highest ratio in the paediatric ICU, whereas vomiting was most prevalent in the surgical ICU and weight loss was the most recurring symptom in the medical ICU. With regard to the respiratory and cardiovascular symptoms, dyspnea stood out in medicine ICU while fatigue was the most evident symptom amidst the paediatrics and surgical ICU patients. Insomnia was the most common neuropsychiatric symptom in the surgical and paediatric ICUs. Insomnia also paralleled tremors frequently in the medical ICU.ConclusionInfections in patients under intensive care in a tertiary care setup are not restricted to a specific type but present variously, as indicated by the type of symptoms the patients develop during their stay.

Handheld ECG Tracking of in-hOspital Atrial Fibrillation The HECTO-AF trial Clinical Study Protocol

Background/rationaleAtrial fibrillation (AF) is frequent and causes great morbidity in the aging population. While initial events may be symptomatic, many patients have silent AF and are at risk of ischemic embolic complications. Timely detection of asymptomatic patients is paramount. The HECTO-AF trial aims to investigate the efficacy of an electrocardiogram (ECG) handheld device for the detection of AF in patients in hospital without a prior diagnosis of AF.Methods/designThe “Handheld ECG tracking of in-hospital atrial fibrillation” (HECTO-AF) study is a single-center, open-label, randomized controlled trial. The study population consists of all adult patients admitted to a general medicine ward of the University and Hospital of Fribourg throughout the study period. The study will enroll 1600 patients with 1:1 ratio allocation to either the detection group with one-lead handheld ECG recordings twice daily and extra recordings in the case of palpitations, versus a control group undergoing detection of AF as per routine clinical practice. Recordings will be self-performed after dedicated training, and will be independently adjudicated through a specific web-based interface. All enrolled patients will be followed clinically at 1, 2 and 5 years to assess the occurrence of AF, death, non-fatal stroke, systemic embolism, myocardial infarction and bleeding. The primary outcome is incidence of newly detected AF during the hospital stay. Secondary outcomes are incidence of AF, cardiovascular death, stroke, myocardial infarction and bleeding complications at 1, 2 and 5 years.DiscussionHECTO-AF is an independent randomized study aiming to detect the incidence of silent AF in all-comers hospitalized in general medicine wards.Trial registrationClinicalTrials.gov, NCT03197090. Registered on 23 June 2017. Local ethical Committee (CER-VD) registration number: 2017–01594. There are no conflicts of interest to declare.

A prospective observational study on psychotropic drug use in non psychiatric wards.

Background:Psychotropic medications are the first line for the management of psychiatric illnesses; in addition, they are also being used in an off-labeled manner. Inappropriate prescribing of psychotropic medications either can cause serious harm or may be of no benefit to the patients. However, there is a dearth of information on the pattern of psychotropic drug use in the nonpsychiatry wards.Aim:The aim of this study is to assess the use of psychotropic drugs in general medicine and surgical wards of a teaching hospital.Materials and Methods:An observational study was conducted in the general medicine and surgical wards of a university teaching hospital over 6 months. Patients admitted to the medicine and surgical ward were observed for a prescription of psychotropic medications. Once they were prescribed with a psychotropic medication, the patients were included in the study and were followed until discharge. All the necessary information such as dose, route, class of psychotropic and prescriber's status were documented and analyzed.Results:A total of 322 patients were prescribed with 452 psychotropic medications. The average number of psychotropic per patient was 1.40 ± 0.76 (range: 1–4). The rate of psychotropic medications prescription in the nonpsychiatric ward is 10.73%. Alcohol dependence syndrome (n = 90 [26.71%]) and pain (n = 43 [43.87%]) were the observed psychiatric and nonpsychiatric indications. The frequently prescribed psychotropic classes were benzodiazepines (n = 165 [36.50%]) and antidepressants (n = 144 [31.86%]). Nonpsychiatrists (n = 250 [55.3%]) were the common prescribers and benzodiazepines (n = 124 [27.43%]) were the preferred class for nonpsychiatrist, whereas psychiatrist prescribed different class of psychotropic drugs.Conclusion:This study emphasizes that nonpsychiatrist irrespective of their specialty prescribed psychotropic medication for psychiatric and nonpsychiatric indications.

Characteristics of short general internal medicine hospital stays: a multicentre cross-sectional study.

Short hospital stays may represent opportunities to avert unnecessary admissions or expedite inpatient care. To inform the design of interventions that target patients with potentially avoidable hospital admissions or brief stays, we examined the patient, physician and situational characteristics associated with short stays among patients admitted to general internal medicine wards and describe the use of hospital resources by these patients. This was a multicentre cross-sectional study conducted between Apr. 1, 2012, and Mar. 31, 2015, at 5 teaching hospitals in Toronto. We included all general internal medicine admissions through the emergency department. We examined patient, physician and situational predictors of a short hospital stay, which was defined as the patient's being discharged home alive in 2 possible time windows: less than 24 hours, or 72 hours or less. The final study sample included 56 055 admissions and 37 700 unique patients. Patients discharged in less than 24 hours and in 72 hours or less accounted for 4245 (7.6%) and 13 442 (31.6%) admissions, respectively. After we controlled for patient factors, patients of female physicians were less likely than those of male physicians to have stays lasting less than 24 hours (adjusted odds ratio [OR] 0.80, 95% confidence interval [CI] 0.74-0.86) or 72 hours or less (adjusted OR 0.82, 95% CI 0.79-0.86). Patients admitted at night or on a weekday were significantly more likely than those admitted at other times to have stays lasting less than 24 hours (night: adjusted OR 2.73, 95% CI 2.44-3.06; weekday: adjusted OR 1.26, 95% CI 1.17-1.36) or 72 hours or less (night: adjusted OR 1.29, 95% CI 1.22-1.37, weekday: adjusted OR 1.05, 95% CI 1.01-1.10). Among stays lasting less than 24 hours and 24-72 hours, intravenously administered medications were ordered for 2788 (65.7%) and 10 722 (79.8%) patients, respectively, and computed tomography scans were performed for 1561 (36.8%) and 5354 (39.1%) patients, respectively. Short general internal medicine hospital stays were common and were associated with patient, physician and situational factors. Interventions to avert hospital admission or reduce length of stay may be more effective if they are accessible outside typical working hours and provide access to intravenous therapy and radiological investigations.

Utilisation and Price Variability of Cephalosporins in General Medicine Department of a Tertiary Care Hospital

Objective: The aim of the study is to assess the drug utilisation pattern of cephalosporins in general medicine ward of a tertiary care hospital. Methods: A prospective observational study was conducted among 100 patients admitted in general medicine ward of the tertiary care hospital. The patients who received cephalosporins during the time were included in the study. Data of enrolled patients was collected from inpatient records and assessed by statistical analysis. Results: 100 patients were enrolled into the present study (61% male and 39% female). The majority of patients (25%) belonged to age group 50-59 years. 17% patients had to urinary tract infections followed by 15% for acute febrile illness and 13 % for lower respiratory tract diseases. The duration of treatment was found to be 4-6 days in 48% patients. The route of administration of cephalosporins was intravenous in 91% patients. Only brand drugs (100%) were prescribed in this study. Ceftriaxone (89%) was the most commonly prescribed drug followed by Cefixime (7%). 4 different brands of ceftriaxone (1gm) were prescribed with a price variability of 4.66% and 3 different brands of cefixime were prescribed with a price variability of 29.67%. Conclusion It was observed that physicians prescribed cephalosporins rationally with no newer drugs or banned drugs but showed evident price variation. The study provides an insight to the pharmacists and other health care professionals on the need to work together for promoting the rational use of antibiotics and to minimize the cost of therapy.

I-CATCH: A Novel Bundle to Improve Postcall Morning Handoffs.

Conducting postcall morning handoffs using a resident handoff bundle such as I-PASS can prove challenging. This may delay recognizing and acting on clinically important patient issues that arose overnight. We developed and implemented the I-CATCH morning handoff bundle and evaluated its impact on the proportion of overnight patient issues handed off from the on-call resident to the daytime team. We evaluated the I-CATCH (Identify patient; Characterize situation; Action-what was done overnight?; To do for the team in the morning; Confirm the Handoff) handoff bundle from November 2015 to May 2016 on general internal medicine wards at 1 academic teaching hospital. The bundle entailed staff/resident training, structured communication, and dedicated handoff space and time. We compared handoffs of overnight on-call issues by evening resident to daytime medical team before and after implementation, and used statistical process control to analyze adherence to the mnemonic. We observed 435 handoffs (242 pre- and 193 postimplementation) over 63 days. There was no significant association between I-CATCH implementation and proportion of on-call overnight issues handed off (OR = 0.96; 95% confidence interval [CI] 0.52-1.47; P = .85). Running the list by going through patients one-by-one (OR = 1.74; 95% CI 1.1-2.77; P = .019), progress note documentation (OR = 3.80; 95% CI 2.19-6.60; P < .001), and direct handoff (OR = 4.84; 95% CI 1.43-16.42; P = .011) correlated with an increased likelihood of morning handoff. Implementing the I-CATCH bundle did not improve handoff of overnight issues to the daytime team.

Advance care planning after hospital discharge: qualitative analysis of facilitators and barriers from patient interviews

BackgroundPatients who engage in Advance Care Planning (ACP) are more likely to get care consistent with their values. We sought to determine the barriers and facilitators to ACP engagement after discharge from hospital.MethodsPrior to discharge from hospital eligible patients received a standardized conversation about prognosis and ACP. Each patient was given an ACP workbook and asked to complete it over the following four weeks. We included frail elderly patients with a high risk of death admitted to general internal medicine wards at a tertiary care academic teaching hospital. Four weeks after discharge we conducted semi-structured interviews with patients. Interviews were transcribed, coded and analysed with thematic analysis. Themes were categorized according to the theoretical domains framework.ResultsWe performed 17 interviews. All Theoretical Domain Framework components except for Social/Professional Identity and Behavioral Regulation were identified in our data. Poor knowledge about ACP and physician communication skills were barriers partially addressed by our intervention. Some patients found it difficult to discuss ACP during an acute illness. For others acute illness made ACP discussions more relevant. Uncertainty about future health motivated some participants to engage in ACP while others found that ACP discussions prevented them from living in the moment and stripped them of hope that better days were ahead.ConclusionsFor some patients acute illness resulting in admission to hospital can be an opportunity to engage in ACP conversations but for others ACP discussions are antithetical to the goals of hospital care.

Acute Management of Diabetic Ketoacidosis in Adults at 3 Teaching Hospitals in Canada: A Multicentre, Retrospective Cohort Study.

Diabetic ketoacidosis (DKA) is a common acute complication of diabetes mellitus and is associated with significant morbidity and mortality. There is currently a paucity of data concerning the Canadian experience with DKA. We aimed to characterize the acute management and course of DKA at several Canadian hospitals. We performed a retrospective cohort study of patients admitted to 3 teaching hospitals in Edmonton, Canada. We extracted clinical and laboratory data from the medical charts of patients admitted to general internal medicine wards or intensive care units with moderate or severe DKA. We included 103 admissions (84 patients) in our study. The majority (68.9%) had type 1 diabetes and presented with severe DKA (60.2%). In the first 24h, the median (interquartile range) intravenous fluid received was 7.0 (5.5 to 8.8) litres; 23.3% received a priming insulin bolus, 24.3% received bicarbonate and 91.3% received potassium. Hypoglycemia was relatively rare (5.8%), but hypokalemia was common (41.7%). The median time to anion gap ≤12mmol/L was 8.8 (6.0 to 12.3) h. In 27.1% of cases, intravenous insulin was stopped prior to subcutaneous insulin administration, with a median of 95 (30 to 310) min elapsing before subcutaneous insulin was given. DKA-related mortality was 2.9%. The acute management of DKA was generally aligned with clinical guidelines. Areas for improvement include preventing hypokalemia by proactively increasing potassium repletion, reducing initial insulin boluses, administering subcutaneous insulin before stopping intravenous insulin and administering sodium bicarbonate judiciously. Protocols and preprinted order sets may be helpful, especially in smaller centres.

Pain assessment: a duty in daily practice

An analysis of pain management was carried out on a general medicine ward. A task force was thereby created in order to identify the issues surrounding this management and suggest improvements. Collaboration between the different participants resulted in actions involving all of the professionals working on the ward. The evaluation of the effectiveness of these actions is envisaged, as a conclusion to two years of fruitful learning.

Generalist versus specialist nurses' knowledge, attitudes, and behavioral intentions toward promoting pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: A cross-sectional correlational study.

Pulmonary rehabilitation (PR) is an effective strategy to manage chronic obstructive pulmonary disease (COPD), though its utilization rate is low. One reason for this low utilization rate is that nurses do not provide COPD patients with enough health education to increase the patient's motivation for PR participation. This study examined knowledge, attitudes, and behavioral intention toward PR promotion. The study also investigated the correlates of behavioral intentions to promote PR among pulmonary nurses.A cross-sectional correlational design was used. Overall, 284 nurses (all women) from chest medicine and general internal medicine wards in 3 hospitals within Midwest Taiwan were recruited. Data were collected by anonymous, self-administered questionnaires. We aimed to understand if there would be differences in the Chest Medicine and Generalist nurses on these outcomes, given the specialty versus generalist nature of their practice. Results were analyzed using multiple linear regressions.Although the 2 groups of nurses (ie, Chest Medicine, General Medicine) showed no differences in PR knowledge, attitudes, or behavioral intentions, they lacked sufficient PR knowledge and skills. The accuracy rate of PR knowledge was approximately 12% and self-evaluated PR skills were less than 50%. Self-efficacy in promoting PR was above average (ie, 57%–60%), and the strength of attitudes and behavioral intentions was over 70%. A multiple linear regression revealed that behavioral intentions of nurses working in the chest medicine ward were influenced by behavioral attitudes, and also PR skills and self-efficacy (explanatory power 33.3%).Attitudes, skills, and self-efficacy heavily affected pulmonary nurses’ ability to promote PR; however, PR knowledge and skills remain low. Therefore, future implementation of practical PR training courses is needed to strengthen nurses’ behavioral intentions toward PR promotion.Improved pulmonary rehabilitation-related skill, attitudes, clinical experience of PR programs, and/or practical PR training are needed among both generalist and specialist nurses. Education courses and clinical practice training should be increased in the future to promote pulmonary rehabilitation of COPD patients.

Managing Inpatient Constipation: A Docusate Initiative

Introduction: Constipation is a common occurrence in the inpatient setting that mandates initiation of medications as appropriate. Docusate is a commonly used stool softener that decreases surface tension in the intestine and allows increased water entry into stool. Several studies conducted in different patient settings, including geriatric, pain, and general hospital medicine wards, have found inpatient use of docusate to be ineffective. In addition to little therapeutic benefit, docusate requires significant nursing time (45 sec/pill administered) and adds to patient pill burden. The aim of this study was to determine physician understanding of the management of constipation in the inpatient setting and to implement system-wide education initiatives and tools on appropriate therapies in order to reduce unnecessary docusate prescribing. Methods: Baseline data from a large academic inner-city hospital was obtained to determine prescribing habits of docusate. Utilizing the Plan-Do-Study-Act (PDSA) (Figure 1) quality improvement workflow, high-volume prescribers were determined. Interventions including education sessions on alternative therapies, including polyethylene glycol as a preferred laxative, as well as bowel-regimen prescribing guidance in the electronic medical record (EMR) prescribing dashboard were put in place.1108_A Figure 1. PDSA Cycle - Docusate prescribing initiativeResults: Orthopedic, Ob-Gyn, Neurosurgical, Medicine, and Urology services made the majority of docusate prescriptions. Baseline physician survey results from 70 medicine residents, found that 43% of residents reflexively ordered a bowel regimen if patient was elderly (age >65), while 34% of residents reflexively ordered a bowel regimen for all patients. Only 37% would wait to order bowel regimen if the patient had reported constipation. The majority (61%) of bowel regimens ordered included docusate, with 89% of prescriber's belief that docusate was at least some what effective in treatment of inpatient constipation. Following the intervention period, the overall docusate prescribing was reduced from an average of 22.6 orders/day to 17.5 orders/day (22% reduction) (Figure 2), along with a 60% increase (8.4 orders/day to 13.4 orders/day) in polyethylene glycol prescribing over this study period.1108_B Figure 2. Docusate prescribing; Trend throughout intervention periodConclusion: Our data demonstrate that implementation of system-wide educational and EMR prescribing tools can reduce inappropriate docusate prescriptions in the inpatient setting. Further steps will include continued education initiatives and resources for all high volume prescribers.