House Staff Physicians Research Articles

Mental health consequences of COVID-19 in house staff physicians

Background: A new coronavirus, SARS-CoV-2, was associated with a newly identified respiratory syndrome, COVID-19 in Wuhan, China, in early December 2019. SARS-CoV-2 rapidly spread across the globe, imposing increased working hours and workloads for healthcare workers. We have evaluated the prevalence of mental health outcomes and associated factors in house staff physicians in Panama. Methods: A cross-sectional study was undertaken from July 23, 2020, to August 13, 2020. Snowball sampling was used to recruit participants. Then, an electronic questionnaire with scales to evaluate anxiety disorders (GAD-7), depression (PHQ-9) and post-traumatic stress (IES-R) was administered. In addition, socio-demographic variables, clinical history of mental disorders and COVID-19 exposure were evaluated. Independent analyses for each mental health outcome were undertaken using a logistic regression analysis. Results: A total of 517/1,205 (42.9%) interns and residents were recruited nationwide. The overall prevalence of depression symptoms was 25.3%, 13.7% for anxiety and 12.2% for post-traumatic stress. At least 9.3% participants reported having suicidal ideation. The most parsimonious model showed females had a higher prevalence of mental health disorders across results, and married participants were more likely to present depression (OR, 1.73; 95% CI, 1.03-2.91; P = 0.039) or at least one mental health disorder (OR, 1.66; 95% CI, 1.03-2.68; P = 0.039). Conclusions: A high prevalence of mental health disorders was found, showing the need to mitigate this emotional burden among healthcare workers in the current context of the COVID-19 pandemic.

Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors

Sleep-related impairment in physicians is an occupational hazard associated with long and sometimes unpredictable work hours and may contribute to burnout and self-reported clinically significant medical error. To assess the associations between sleep-related impairment and occupational wellness indicators in physicians practicing at academic-affiliated medical centers and the association of sleep-related impairment with self-reported clinically significant medical errors, before and after adjusting for burnout. This cross-sectional study used physician wellness survey data collected from 11 academic-affiliated medical centers between November 2016 and October 2018. Analysis was completed in January 2020. A total of 19 384 attending physicians and 7257 house staff physicians at participating institutions were invited to complete a wellness survey. The sample of responders was used for this study. Sleep-related impairment. Association between sleep-related impairment and occupational wellness indicators (ie, work exhaustion, interpersonal disengagement, overall burnout, and professional fulfillment) was hypothesized before data collection. Assessment of the associations of sleep-related impairment and burnout with self-reported clinically significant medical errors (ie, error within the last year resulting in patient harm) was planned after data collection. Of all physicians invited to participate in the survey, 7700 of 19 384 attending physicians (40%) and 3695 of 7257 house staff physicians (51%) completed sleep-related impairment items, including 5279 women (46%), 5187 men (46%), and 929 (8%) who self-identified as other gender or elected not to answer. Because of institutional variation in survey domain inclusion, self-reported medical error responses from 7538 physicians were available for analyses. Spearman correlations of sleep-related impairment with interpersonal disengagement (r = 0.51; P < .001), work exhaustion (r = 0.58; P < .001), and overall burnout (r = 0.59; P < .001) were large. Sleep-related impairment correlation with professional fulfillment (r = -0.40; P < .001) was moderate. In a multivariate model adjusted for gender, training status, medical specialty, and burnout level, compared with low sleep-related impairment levels, moderate, high, and very high levels were associated with increased odds of self-reported clinically significant medical error, by 53% (odds ratio, 1.53; 95% CI, 1.12-2.09), 96% (odds ratio, 1.96; 95% CI, 1.46-2.63), and 97% (odds ratio, 1.97; 95% CI, 1.45-2.69), respectively. In this study, sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Interventions to mitigate sleep-related impairment in physicians are warranted.

Preparation and redeployment of house staff during a pandemic

The COVID-19 pandemic created unique issues for house staff physicians. Gaps in surgical experience due to canceled cases, a focus on obstetrics over gynecology during the spring months when many senior residents and fellows are completing their case requirements and the stress of working with patients infected with a highly communicable disease all contributed to an unprecedented challenge facing residency and fellowship programs. Our objective is to describe how the Obstetrics and Gynecology residency and fellowship programs at Columbia University Irving Medical Center adapted to their changing landscape, redeployed their residents and fellows while assuring ongoing trainee education, wellness and scholarship during the peak of the pandemic.

515 Compliance with a Restrictive Blood Transfusion Strategy: Do We Actually Follow Scientific Evidence?

Abstract Introduction Many burn centers use a restrictive blood transfusion strategy based on randomized controlled trials in burn patients (e.g. Transfusion Requirements in Burn Care Evaluation -TRIBE) and non-burn populations (e.g. Transfusion Requirements in Critical Care – TRICC), which have demonstrated no increased morbidity or mortality between restrictive and liberal transfusion approaches. The purpose of this study was to evaluate the adherence to a restrictive hemoglobin transfusion trigger strategy of 7 g/dL. Methods Retrospective study of all patients admitted to an adult regional ABA-verified burn centre between 15/11/ 2015 and 15/6/2018 who received at least one unit of blood (RBC). We use a restrictive transfusion strategy that administers RBC for a hemoglobin (HGb) &amp;lt; 7 gm/dL, one unit at a time, with a pre and post HGb level for each RBC transfusion, unless the patient is actively bleeding and/or hemodynamically unstable. RBC transfusions in the operating room do not follow this policy and were not studied. Values are presented as mean ± SD or median (IQR) as appropriate. Results We studied 66 patients (30% female) with age 53.2 ± 18.3 years, % TBSA burn 22 (11–41), % TBSA full thickness burn 6.5 (0.5 -21.8), and with 41% having inhalation injury. Overall, there were 691 RBC transfusions (TXns). A pre-TXn HGb was obtained 95% of the time and was 6.8 (6.5–7) gm/dL. TXn for a HGb &amp;gt; 7 gm/dL occurred in 35%. A post TXn HGb was obtained for 92% of these TXns with a HGb of 7.6 (7.2–8) gm/dL. RBC TXns during nighttime (1700 to 0800, n=449) were given for a HGb trigger of 6.8 (6.4–6.9) and were not compliant with our restrictive strategy 22% of the time. Daytime transfusions (0800 to 1700, n=207) were given for a significantly higher HGb [7 (6.7–7.1), p&amp;lt; 0.001] with significantly more non-compliance with the restrictive strategy (50%, p&amp;lt; 0.001). We also compared TXns before and after the TRIBE publication. Pre-TRIBE TXns (n=484) were given for significantly lower HGb than 172 post TRIBE TXns [6.8 (6.4–7) vs 6.9 (6.6–7.1) gm/dL respectively, p=0.001] and at significantly lower rate of non-compliance with the 7 gm/dL threshold than post TRIBE transfusions (28.1% vs 37.8%, respectively, p=0.02). Conclusions While a pre-TXn HGb level was available for 95% of blood transfusions, approximately one-third were given for a HGb &amp;gt; 7 gm/dL. Transfusion during nighttime (being predominantly ordered by housestaff physicians) were administered at a significantly lower HGb trigger and with significantly better compliance with the restrictive strategy than daytime transfusions. Paradoxically, compliance with the restrictive strategy was worse following the TRIBE publication. Applicability of Research to Practice These results identify important areas for improvement in adherence to our restrictive transfusion strategy.

Gender differences among medical students, house staff, and faculty physicians at high risk for suicide: A HEAR report.

In comparison with the general population, physicians, and physicians-in-training are at greater risk for suicide. Although key gender differences in suicide risk factors and behaviors have been identified in the general population, the extent to which these differences apply to physicians and physicians-in-training is unclear. Here, we aimed to identify gender differences in risk factors, clinical presentation, and help-seeking behaviors of medical students, house staff, and physician faculty at high risk for suicide. We explored gender differences among 450 physicians and trainees meeting criteria for high suicide risk on anonymous online questionnaires completed between 2009 and 2017. High-risk female trainees and physicians had higher mean Patient Health Questionnaire-9 (PHQ-9) scores compared with the males (11.1, standard deviation [SD] 5.1 vs. 9.8, SD 4.7) and were more likely to endorse feeling worried (73.8% vs. 61.2%), irritable (60.4% vs. 49.4%), and stressed (79.6% vs. 70%). High-risk male trainees and physicians were more likely than females to endorse suicidal thoughts (31.2% vs. 22.1%), intense anger (24.3% vs. 16.1%), drinking too much (31.2% vs. 22.3%), and recreational drug or prescription medication use without clinically appropriate follow-up (9.4% vs. 4.3%). There were no gender differences in help-seeking behaviors. This is the first study to report gender differences among risk factors, presentation, and help-seeking behaviors of physicians, and trainees at high risk for suicide. Our findings are mostly consistent with those of the general population and show that only a minority of at-risk men and women in healthcare sought treatment, highlighting the importance of intervention and suicide prevention in this population.

Effect of Clinical Decision Support on Appropriateness of Advanced Imaging Use Among Physicians-in-Training

Clinical decision support (CDS) tools have been shown to reduce inappropriate imaging orders. We hypothesized that CDS may be especially effective for house staff physicians who are prone to overuse of resources. Our hospital implemented CDS for CT and MRI orders in the emergency department with scores based on the American College of Radiology's Appropriateness Criteria (range, 1-9; higher scores represent more-appropriate orders). Data on CT and MRI orders from April 2013 through June 2016 were categorized as pre-CDS or baseline, post-CDS period 1 (i.e., intervention with active feedback for scores of ≤ 4), and post-CDS period 2 (i.e., intervention with active feedback for scores of ≤ 6). Segmented regression analysis with interrupted time series data estimated changes in scores stratified by house staff and non-house staff. Generalized linear models further estimated the modifying effect of the house staff variable. Mean scores were 6.2, 6.2, and 6.7 in the pre-CDS, post-CDS 1, and post-CDS 2 periods, respectively (p < 0.05). In the segmented regression analysis, mean scores significantly (p < 0.05) increased when comparing pre-CDS versus post-CDS 2 periods for both house staff (baseline increase, 0.41; 95% CI, 0.17-0.64) and non-house staff (baseline increase, 0.58; 95% CI, 0.34-0.81), showing no differences in effect between the cohorts. The generalized linear model showed significantly higher scores, particularly in the post-CDS 2 period compared with the pre-CDS period (0.44 increase in scores; p < 0.05). The house staff variable did not significantly change estimates in the post-CDS 2 period. Implementation of active CDS increased overall scores of CT and MRI orders. However, there was no significant difference in effect on scores between house staff and non-house staff.

Barriers to Early Hospital Discharge: A Cross-Sectional Study at Five Academic Hospitals.

Understanding the issues delaying hospital discharges may inform efforts to improve hospital throughput. This study was conducted to identify and determine the frequency of barriers contributing to delays in placing discharge orders. This was a prospective, cross-sectional study. Physicians were surveyed at approximately 8:00 AM, 12:00 PM, and 3:00 PM and were asked to identify patients that were "definite" or "possible" discharges and to describe the specific barriers to writing discharge orders. This study was conducted at five hospitals in the United States. The study participants were attending and housestaff physicians on general medicine services. Specific barriers to writing discharge orders were the primary outcomes; the secondary outcomes included discharge order time for high versus low team census, teaching versus nonteaching services, and rounding style. Among 1,584 patient evaluations, the most common delays for patients identified as "definite" discharges (n = 949) were related to caring for other patients on the team or waiting to staff patients with attendings. The most common barriers for patients identified as "possible" discharges (n = 1,237) were awaiting patient improvement and for ancillary services to complete care. Discharge orders were written a median of 43-58 minutes earlier for patients on teams with a smaller versus larger census, on nonteaching versus teaching services, and when rounding on patients likely to be discharged first (all P < .003). Discharge orders for patients ready for discharge are most commonly delayed because physicians are caring for other patients. Discharges of patients awaiting care completion are most commonly delayed because of imbalances between availability and demand for ancillary services. Team census, rounding style, and teaching teams affect discharge times.

An Informatics Approach to Implement Support for Shared Decision Making for Primary Prevention Statin Therapy.

Background. Shared decision making (SDM) is recommended prior to initiation of statin therapy for primary prevention but is underutilized. We designed an informatics decision-support tool to facilitate use of the Mayo Clinic Statin Choice decision aid at the point-of-care and evaluated its impact. Methods. Using an iterative approach, we designed and implemented a single-click decision-support tool embedded within the electronic health records (EHRs) to automate the calculation of 10-year atherosclerotic cardiovascular disease (ASCVD) risk and populate the Statin Choice decision aid. We surveyed primary care providers at two clinics regarding their attitudes about SDM before and after deployment of intervention, as well as their usage of and perceived competence regarding SDM for primary prevention statin therapy. Three-month web traffic to the Statin Choice website was calculated before and after deployment of the intervention. Results. Pre–post surveys were completed by 60 primary care providers (24 [40%] attending physicians and 36 [60%] housestaff physicians). After deployment of the EHR tool, respondents were more aware of the Statin Choice decision aid (P < 0.001), reported being more competent regarding SDM (P = 0.047), and reported using decision aids more often when considering statin initiation (P = 0.043). There was no significant change in attitudes about SDM as measured through the Patient Provider Orientation Scale (pre 4.23 ± 0.40 v. post 4.16 ± 0.38, P = 0.11) and the SDM belief scale (pre 21.4 ± 2.1 v. post 21.1 ± 2.0, P = 0.35). Web-based usage rates for the Statin Choice decision aid increased from 3.4 to 5.2 per 1,000 outpatient clinic visits (P = 0.002). Conclusions. Implementation of a point-of-care decision-support tool increased the usage of decision aids for primary prevention statin therapy. This effect does not appear to be mediated by any concomitant changes in physician attitude toward SDM.

Decreasing Unnecessary Daily Labs by Choosing Wisely

Introduction: The utilization of laboratory services has increased across various healthcare settings. We assessed the impact of the implementation of a Quality Improvement project aimed at reducing Complete Blood Count (CBC) and Basic Electrolyte Panel (BEP) ordered by house staff physicians. Materials and Methods: This study with a pre-post design was conducted in a community hospital in Connecticut, USA. The study was performed between January 2014 and December 2016. At initiation of the project, a taskforce consisting of attending doctors and house staff physicians was created. The taskforce reviewed and determined the current practices of ordering CBC and BEP. The taskforce members analyzed every step of the process and unveiled circumstances where unnecessary CBC and BEPs were ordered. Based on the results of the analysis, a multi-level intervention of one-year duration was then developed to address the ordering of unnecessary CBC and BEPs. The intervention consisted of daily decision making about labs during rounds, incorporating lab documentations planned for the next day into daily progress notes, including the rationale for these labs, audit and reporting of ordering practices to each medical team, and providing direct feedback to each house staff not providing appropriate documentation of lab rationale. The average numbers of CBC and BEP orders per patient days were used to assess the impact of our intervention. Results:After implementing this Quality Improvement program, the average number of CBC and BEPs per patient days ordered by the house staff physicians decreased (i.e., from 1.20 to 1.09; P<0.01, and from 0.88 to 0.80; P<0.01, respectively). This corresponds to a reduction of 9% in both CBC and BEP orderings per patient days. There were no unintended adverse consequences from the interventions. Conclusion: Our Quality Improvement initiative resulted in a reduction in CBC and BEP orderings per patient days by the house staff without adversely affecting our patients’ length of stay or mortality.

Abstract 109: A Multidisciplinary Checklist for Management of Acute Decompensated Heart Failure: A Quality Improvement Initiative

Objectives: To determine the effect of a comprehensive checklist on readmission rate and providers adherence to 2013 AHA/ACC guidelines in the management of heart failure (HF) at Buffalo General Medical Center (BGMC). Background: HF is among the most common admitting diagnoses at BGMC. From prior studies, HF readmission can be prevented substantially by effective education, discharge instructions and appropriate medications. Intervention and Methods: A multidisciplinary checklist was developed as a tool to guide house staff physicians in the care of patients with acute decompensated HF. It includes optimal pharmacological therapy as recommended by guidelines, relevant HF education and counseling by dedicated nurse practitioner, nutrition consultation, physical therapy evaluation and treatment and scheduled out-patient follow up. The laminated checklist cards and brief presentation of current HF guideline were provided to house staff physicians on teaching cardiology service weekly from April to June 2015. The control group was randomly selected from the patients who were admitted with acute decompensated HF prior to intervention period. Results: Thirty-day readmission decreased from 47% (16 of 34) to 24% (8 of 34) following the implementation (adjusted OR = 0.32 95% CI = 0.11-0.97). A higher percentage of patients were discharged on angiotensin-converting enzyme inhibitors or angiotensin receptor blockers or had documentation of a reason for not prescribing the medication in the checklist group compared with the control group (31 of 34 vs 21 of 34, P&lt;0.05). Similarly, a higher percentage of patients were discharged on β-blockers or had documentation of a reason for not prescribing the medication in the checklist group compared with the control group (34 of 34 vs 32 of 34, P 0.15). Conclusion: Our initiative, which consists of HF checklist use and reminders, was associated with decreased thirty-day readmission rate and increased providers adherence to current HF guidelines.

Administration of a survey to evaluate the attitudes of house staff physicians towards antimicrobial resistance and the antimicrobial stewardship programme at a community teaching hospital.

Antimicrobial stewardship programmes (ASPs) are used in numerous institutions in an effort to promote safe and effective antimicrobial use. The objectives of this study were to (i) assess physicians' perceptions, attitudes and knowledge about antimicrobial use, resistance and the ASP at The Brooklyn Hospital Center (TBHC) and (ii) measure physicians' beliefs and attitudes to the current system of prior authorisation of antimicrobials. A 75-item, anonymous, voluntary, traditional paper and pencil survey was distributed to resident physicians at TBHC. Multiple-choice, 5-point Likert scale and knowledge-based questions were utilised. Of the 261 residents, 129 (49%) completed the survey. The respondents significantly believed that antibiotics are overused more frequently nationally vs. locally [117/129 (91%) vs. 91/129 (71%); P=0.0001]. Although 49% (63/129) felt that other providers overprescribe antibiotics, only 26% (34/129) agreed that they themselves were contributing to the current problem (P=0.0003). Fifty-seven percent of respondents agreed that individual patient care is improved by having an antibiotic approval programme; however, 45% of respondents reported that the antibiotic approval programme limits their autonomy in choosing antibiotics. Compared with surgical residents, medical residents were more likely (33% vs. 13%; P=0.02) to feel that the antibiotic approval programme forced them to choose an inappropriate antibiotic. On the antibiotic knowledge assessment segment of the survey, there was no difference in score when stratified by specialty or years of postgraduate training. Based on the survey results, house staff are supportive of antimicrobial stewardship and feel that the ASP is valuable for patient care.

Patient Perceptions of Whom is Most Involved in Their Care with Successive Duty Hour Limits.

Although direct patient care is necessary for experiential learning during residency, inpatient perceptions of the roles of resident and attending physicians in their care may have changed with residency duty hours. We aimed to assess if patients' perceptions of who is most involved in their care changed with residency duty hours. This was a prospective observational study over 12 years at a single institution. Participants were 22,408 inpatients admitted to the general medicine teaching service from 2001 to 2013, who completed a 1-month follow-up phone interview. Percentage of inpatients who reported an attending, resident, or intern as most involved in their care by duty hour period (pre-2003, post-2003-pre-2011, post-2011). With successive duty hour limits, the percentage of patients who reported the attending as most involved in their care increased (pre-2003 20 %, post-2003-pre-2011 29 %, post-2011 37 %, p < 0.001). Simultaneously, fewer patients reported a housestaff physician (resident or intern) as most involved in their care (pre-2003 20 %, post-2003-pre-2011 17 %, post-2011 12 %, p < 0.001). In multinomial regression models controlling for patient age, race, gender and hospitalist as teaching attending, the relative risk ratio of naming the resident versus the attending was higher in the pre-2003 period (1.44, 95 % CI 1.28-1.62, p < 0.001) than the post-2003-pre-2011 (reference group). In contrast, the relative risk ratio for naming the resident versus the attending was lower in the post-2011 period (0.79, 95 % CI 0.68-0.93, p = 0.004) compared to the reference group. After successive residency duty hours limits, hospitalized patients were more likely to report the attending physician and less likely to report the resident or intern as most involved in their hospital care. Given the importance of experiential learning to the formation of clinical judgment for independent practice, further study on the implications of these trends for resident education and patient safety is warranted.

Standardizing postoperative PICU handovers improves handover metrics and patient outcomes.

To improve handover communication and patient outcomes for postoperative admissions to a multidisciplinary PICU. Prospective cohort study. Multidisciplinary PICU in a university hospital. The multidisciplinary team responsible for postoperative PICU admissions and patient care, including attending, fellow, house staff physicians, and nurses from pediatric critical care medicine, surgery, and anesthesia. An online survey distributed to PICU, surgery, and anesthesia providers identified existing barriers and challenges to effective postoperative PICU handovers and guided the formation of a standard protocol. Handovers for postoperative PICU admissions were then directly observed for 3 months pre- and postimplementation of the protocol, with data collected on communication, metrics, and patient outcomes. Observations and data collection, as well as the online provider survey, were repeated approximately 1 year after handover protocol implementation. Survey data demonstrated increases in provider ratings of handover attendance, communication, and quality after implementation of the handover protocol (p < 0.001). Surgical report errors were eliminated (p = 0.03), and the prevalence of provider attendance for the handover duration increased from 39.3% to 68.2% (p = 0.01). Following protocol implementation, fewer patients experienced antibiotic delays (34.5% to 13.9%; p = 0.03) or required hemodynamic or respiratory interventions within the first 6 hours of PICU admission (24.6% to 9.1%; p = 0.04). Patients received their first dose of analgesia (62.3 to 17.4 min; p = 0.01) and had their admission laboratory studies sent (42.3 to 32.9 min; p = 0.04) more quickly. Data collected at 12 months postimplementation demonstrated sustained reductions in analgesia timing, antibiotic delays, and handover barriers. Postoperative communication and patient outcomes can be improved and sustained over time with implementation of a standardized handover protocol.

A survey to evaluate our physician-trainees' comfort and knowledge in communicating their final good-bye to their terminally ill patient.

114 Background: Although dealing with end of life (EOL) issues is common and can be stressful in cancer care, very little is taught and written in regards to how healthcare professionals should communicate their final good-bye with their terminally ill patients. There is a wealth of literature available about communicating “bad news”, but a literature review elicited scant data about this topic. Methods: We conducted a pilot survey on 88 house staff physicians to evaluate the frequency, their level of comfort, whether they had prior training and their knowledge about communicating their final good-bye at the EOL and their interest to learn more about this communication skill. Results: 42% were first year trainees across all specialties. 61% encountered at least 1 patient monthly at the EOL. 45% felt comfortable saying good-bye to a patient they were unlikely to see alive again. 54% have expressed interest in learning how to communicate their final good-bye to their patient at the EOL. However, only 5.7% have reported receiving a thorough training and 2.2% endorsed being very knowledgeable in this communication skill. 81% were interested to learn these skills from experienced mentors. Conclusions: Communicating the final good-bye with the terminally ill patient is an important skill that is not routinely taught to our physician-trainees. The majority of them expressed their interest to learn this skill from experienced mentors. Palliative care healthcare professionals can play a pivotal role in our physician training programs by mentoring our trainees on communicating their final good-bye to their terminally ill patient effectively and compassionately. Once implemented, further studies will be needed to assess the impact of experienced mentors on the comfort and knowledge of our physician-trainees in this communication skill.

Quality and safety during the off hours in medicine units: a mixed methods study of front-line provider perspectives.

Hospital off-hours care is associated with poor outcomes. Mutual conceptualization among provider groups may facilitate improvement efforts. Provider-perceived threats to quality are unreported. The objectives of this study were to identify perceived off-hours quality and safety issues, assess the most significant, and evaluate differences between nurses, and attending and housestaff physicians, and providers with day and night experience. Prospective, sequential, exploratory mixed-methods study. Open-ended descriptions of adverse events/near misses occurring overnight (n = 190) were analyzed using thematic analysis. From these results, a survey was developed to assess perceptions of quality/frequency of each issue (7-point scale, 7 = the highest rating) and highest-quality overnight period (7-10 pm, 10 pm-1 am, 1-4 am, 4-7 am). Primary issues related to mismanagement, delivery processes, and communication/coordination. Of 214 surveys, 160 responses (75%) were received. Least-optimal issues related to "communication" (2.93) and "timeliness/safety" (3.89) of emergency department transfers; most-optimal issues related to timely lab reporting (4.70). On the 7-point scale, comparisons among nurses, and attending and housestaff physicians revealed differences in quality of "communication between physicians" (4.29 vs 6.00 vs 5.14) and "communication between consultants-primary providers" (3.46 vs 5.75 vs 4.35, P < 0.001). Comparisons between day-night providers revealed lower ratings from day providers in 12/24 items (P < 0.05), including "communication during emergency department transfers" (4.81 vs 3.86). All groups ranked 4 to 7am lowest in quality. Nurses, and attending and housestaff physicians lack a shared mental model of off-hours care. Several issues, including emergency department transfers and timeliness of consults, were identified by all providers as problematic, meriting further investigation and intervention.

Bedside interprofessional rounds: perceptions of benefits and barriers by internal medicine nursing staff, attending physicians, and housestaff physicians.

Interprofessional collaboration improves the quality of care, but integration into workflow is challenging. Although a shared conceptualization regarding bedside interprofessional rounds may enhance implementation, little work has investigated providers' perceptions of this activity. To evaluate the perceptions of nurses, attending physicians, and housestaff physicians regarding the benefits/barriers to bedside interprofessional rounds. Observational, cross-sectional survey of hospital-based medicine nurses, attending physicians, and housestaff physicians. Descriptive, nonparametric Wilcoxon rank sum and nonparametric correlation were used. Bedside interprofessional rounds were defined as "encounters including 2 physicians plus a nurse or other care provider discussing the case at the patient's bedside." Eighteen items related to "benefits" and 21 items related to "barriers" associated with bedside interprofessional rounds. Of 171 surveys sent, 149 were completed (87%). Highest-ranked benefits were related to communication/coordination, including "improves communication between nurses-physicians;" lowest-ranked benefits were related to efficiency, process, and outcomes, including "decreases length-of-stay" and "improves timeliness of consultations." Nurses reported most favorable ratings for all items (P < 0.05). Rank order for 3 provider groups showed high correlation (r = 0.92, P < 0.001). Highest-ranked barriers were related to time, including "nursing staff have limited time;" lowest-ranked barriers were related to provider- and patient-related factors, including "patient lack of comfort." Rank order of barriers among all groups showed moderate correlation (r = 0.62-0.82). Although nurses perceived greater benefit for bedside interprofessional rounds than physicians, all providers perceived coordination/teamwork benefits higher than outcomes. To the extent the results are generalizable, these findings lay the foundation for facilitating meaningful patient-centered interprofessional collaboration.

Physician clinical management strategies and reasoning: a cross-sectional survey using clinical vignettes of eight common medical admissions.

BackgroundPhysicians often select clinical management strategies not strongly supported by evidence or guidelines. Our objective was to examine the likelihood of selecting, and rationale for pursuing, clinical management strategies with more or less guideline support among physicians using clinical vignettes of eight common medical admissions.MethodsWe conducted a cross-sectional survey using clinical vignettes of attending physicians and housestaff at one internal medicine program in New York City. Each clinical vignette included a brief clinical scenario and a varying number of clinical management strategies: diagnostic tests, consultations, and treatments, some of which had strong evidence or guideline support (Level 1 strategies) while others had limited evidence or guideline support (Level 3 strategies). Likelihood of selecting a given management strategy was assessed using Likert scales and multiple response options were used to indicate rationale(s) for selections.ResultsOur sample included 79 physicians; 68 (86%) were younger than 40 years of age, 34 (43%) were female. There were 31 attending physicians (39%) and 48 housestaff (61%) and 39 (49%) had or planned to have primarily primary care internal medicine clinical responsibilities. Overall, physicians were more likely to select Level 1 strategies “always” or “most of the time” when compared with Level 3 strategies (82% vs. 43%; p < 0.001), with wide variation across the eight medical admissions. There were no differences between attending and housestaff physician likelihood of selecting Level 3 strategies (47% vs. 45%, p = 0.36). Supportive evidence and local practice patterns were the two most common rationales behind selections; supportive evidence was cited as the most common rationale for selecting Level 1 when compared with Level 3 strategies (63% versus 30%; p < 0.001), whereas ruling out other severe conditions was cited most often for Level 3 strategies.ConclusionsFor eight common medical admissions, physicians selected more than 80% of management strategies with strong evidence or guideline support, but also selected more than 40% of strategies for which there was limited evidence or guideline support. The promotion of evidence-based care, including the avoidance of care that is not strongly supported by evidence or guidelines, may require better evidence dissemination and educational outreach to physicians.

Superiority of targeted neonatal echocardiography for umbilical venous catheter tip localization: accuracy of a clinician performance model

To compare targeted neonatal echocardiography (TnECHO) and antero-posterior (AP) chest radiographs in the localization of the umbilical venous catheter (UVC) tip and to determine the accuracy of UVC tip localization by TnECHO when performed by a trained cohort of pediatric housestaff physicians. Prospective, observational study of consecutive neonates requiring UVC insertion, in a tertiary care center, in an 18-month period. Chest radiographs reporting optimal position of the UVC tip were compared with the TnECHO results of the pediatric cardiologist. The latter was also compared with the results of TnECHO performed by the pediatric housestaff physicians. Thirty neonates with birth weight ranging between 270 and 4490 g and gestational age ranging between 24 and 44 weeks were enrolled. Nine patients (27%) required UVC tip repositioning as the cardiologist performed TnECHO revealed sub-optimal tip position despite optimal position on chest radiography. Among them, four had the UVC tip in the right atrium and five in the left atrium. Compared with the cardiologist, the housestaff physicians had reported TnECHO with a high-accuracy rate (area under the receiver operating characteristic curve=0.81). TnECHO is superior to chest radiography for identifying malpositioned catheters. TnECHO performed by pediatric housestaff physicians with basic training, demonstrated high-accuracy rates.

Vitamin D Deficiency Among Medical Residents and Its Relationship with Metabolic Indices

To evaluate different elements of the calciotropic system in a group of house staff physicians, comparing them with age, gender, and body mass index (BMI) matched controls. We measured vitamin D, calcium, phosphorus, parathyroid hormone (PTH), glucose, insulin (estimating the insulin resistance index by the homeostatic model [HOMA]), and lipid levels in 20 medical residents and 20 age-, gender-, and BMI-matched controls. We looked for correlations between elements of the calciotropic system and metabolic indices. Medical residents and controls were similar in regard to gender distribution, weight, height, BMI, abdominal circumference, as well as systolic and diastolic blood pressure. No differences were found between the two groups in regard to low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol, plasma insulin levels, and HOMA-IR. Vitamin D and calcium levels were significantly lower among the medical residents (P = .001 and P = .003, respectively), whereas PTH concentrations tended to be higher. We found an inverse correlation between triglyceride concentrations and vitamin D (r = -0.31, P = .04). Vitamin D deficiency among resident physicians is frequent and could have metabolic effects. Our findings highlight the consequences of the lack of sun exposure due to occupational reasons. We recommend a higher intake of vitamin D during this period.

Occupational and public health considerations for work-hour limitations policy regarding public health workers during response to natural and human-caused disasters

This article examines the occupational health considerations that might impact the health and wellbeing of public health workers during responses to natural (eg, floods and hurricanes) and human-caused (eg, terrorism, war, and shootings) disasters. There are a number of articles in the medical literature that argue the impact of how working long hours by house staff physicians, nurses, and first-responders may pose health and safety concerns regarding the patients being treated. The question examined here is how working long hours may pose health and/or safety concerns for the public health workers themselves, as well as to those in the communities they serve. The health problems related to sleep deprivation are reviewed. Current policies and legislations regarding work-hour limitations are examined. Policy implications are discussed.