Internal Medicine House Staff Research Articles

Dose adjustment of rheumatology and allergy/immunology medications in chronic kidney disease: awareness and knowledge among internal medicine housestaff

Background Patients with chronic kidney disease (CKD) are at increased risk for adverse drug events due to medication dosing errors. We studied the awareness and knowledge among internal medicine housestaff (IMHS) of proper dose adjustment of commonly used rheumatology and allergy/immunology medications for patients with CKD. Methods We surveyed 353 IMHS to evaluate their awareness of the need for medication dose adjustments for patients with CKD and knowledge for medication adjustment by level of glomerular filtration rate for common rheumatology and allergy/immunology medications. Results There was lack of awareness and knowledge for both rheumatology and allergy/immunology medications. Incorrect awareness and knowledge were as follows: allopurinol, 21.2%, 73.4%; colchicine, 19.0%, 75.9%; diphenhydramine, 34.0%, 34.0%; loratadine, 82.2%, 93.2%; and montelukast, 34.0%, 34.0%, respectively. Exploratory logistic regression analyses showed that PGY1 residents had higher odds for lack of awareness for allopurinol (odds ratio [OR] 24.57, 95% CI [confidence interval] 4.69, 99.13, P < 0.001), colchicine (OR 3.98, 95% CI 1.50, 10.51, P < 0.01), diphenhydramine (OR 2.24, 95% CI 1.10, 4.54, P < 0.04), and montelukast (OR 2.45, 95% CI 1.20, 5.00, P < 0.05) than PGY3 residents. A nephrology rotation in medical school was associated with lower odds for incorrect knowledge for allopurinol (OR 0.46, 95% CI 0.25, 0.87, P < 0.05) and montelukast (OR 0.50, 95% CI 0.27, 0.92, P < 0.05). Conclusion Overall, awareness and knowledge were poor among IMHS for dose adjustments of rheumatology and allergy/immunology medications in patients with CKD. Proper education and exposure to nephrology during training may improve quality and safety of care for patients with CKD.

Editorial introductions.

Editorial introductions.

958. A Required Infectious Diseases Rotation Improves Antimicrobial Stewardship Knowledge for Internal Medicine Interns

BackgroundExposure to Infectious Diseases (ID) education is highly variable in post-graduate medical training. We report our experience with a required one-week ID consult rotation for Internal Medicine (IM) interns with a focus on antimicrobial stewardship education.MethodsSince 2018 all IM interns at our institution have participated in a required one-week ID consult rotation. Antimicrobial stewardship is a core feature of this rotation, with educational resources on antibiotic spectrum and decision-making, and interdisciplinary rounding with ID pharmacists. Between March 2020 and May 2021 we piloted an 11-item pre-rotation and post-rotation quiz with distinct but paired questions on key stewardship topics. The quiz was administered anonymously in SurveyMonkey. Mean pre/post rotation scores were compared using a paired T-test and the McNemar test of paired proportions was used to compare the pre/post change in percentage of correct responses for each topic.ResultsAmong 47 interns who completed the rotation, 16 interns completed both pre- and post-rotation quizzes (response rate=34%). Mean scores on the pre-rotation quiz were 60%, compared to 77% on the post-rotation quiz (p=0.01), indicating significant improvement at the end of the rotation (Figure 1). Among 11 residents who scored below 65% on their pre-rotation quiz, all achieved an increased score on their post-rotation quiz (mean pre-test of 49% to mean post-test 79%). Table 1 displays the question topics and pre/post test change in percentage correct. The most difficult pre-test topics were ‘Recognition of AmpC-Expressing Organisms’ and ‘Antibiotics with activity against Pseudomonas aeruginosa,’ which improved, from 31% to 81% correct (p=0.03) and 50% to 100% correct (p=0.01), respectively. Figure 1. Mean score of interns on pre-rotation vs post-rotation antimicrobial stewardship quiz from March 2020 to May 2021 (n=16; p=0.01).Table 1. Question topics and change in percentage correct on pre-rotation and post-rotation quizzes. ConclusionA required one-week ID consult rotation for IM interns improved antimicrobial stewardship knowledge. Our experience may serve as a model for other institutions interested in increasing IM housestaff exposure to ID and antimicrobial stewardship.Disclosures Kristen Marks, MD, Gilead Sciences (Grant/Research Support)

S3449 Use of Opioids in Patients With Acute Gastroparesis Presenting With Abdominal Pain - An Internal Medicine House-Staff Directed Survey

S3449 Use of Opioids in Patients With Acute Gastroparesis Presenting With Abdominal Pain - An Internal Medicine House-Staff Directed Survey

Resident perspectives on the value of interdisciplinary conference calls for geriatric patients

BackgroundThere are limited competency-based educational curricula for transitions of care education (TOC) for internal medicine (IM) residency programs. The University of Colorado implemented a virtual interdisciplinary conference call, TEAM (Transitions Expectation and Management), between providers on the inpatient Acute Care of the Elder (ACE) unit and the outpatient Seniors Clinic at the University of Colorado Hospital. Residents rotating on the ACE unit participated in weekly conferences discussing Seniors Clinic patients recently discharged, or currently hospitalized, to address clinical concerns pertaining to TOC. Our goals were to understand resident perceptions of the educational value of these conferences, and to determine if these experiences changed attitudes or practice related to care transitions.MethodsWe performed an Institutional Review Board-approved qualitative study of IM housestaff who rotated on the ACE unit during 2018–2019. Semi-structured interviews were conducted to understand perceptions of the value of TEAM calls for residents’ own practice and the impact on patient care. Data was analyzed inductively, guided by thematic analysis.ResultsOf the 32 IM residents and interns who rotated on ACE and were invited to participate, 11 agreed to an interview. Three key themes emerged from interviews that highlighted residents’ experiences identifying and navigating some of their educational ‘blind spots:’ 1) Awareness of patient social complexities, 2) Bridging gaps in communication across healthcare settings, 3) Recognizing the value of other disciplines during transitions.ConclusionsThis study highlights learner perspectives of the benefit of interdisciplinary conference calls between inpatient and outpatient providers to enhance transitions of care, which provide meaningful feedback and serve as a vehicle for residents to recognize the impact of their care decisions in the broader spectrum of patients’ experience during hospital discharge. Educators can maximize the value of these experiences by promoting reflective debriefs with residents and bringing to light previously unrecognized knowledge gaps around hospital discharge.

Awareness and Knowledge Among Internal Medicine House-Staff for Dose Adjustment of Cardiovascular Drugs in Chronic Kidney Disease.

Patients with chronic kidney disease (CKD) are vulnerable to adverse-drug events from cardiovascular drugs. To evaluateawareness and knowledge for appropriate dose adjustment of cardiovascular drugs in CKD patients among Internal Medicine house-staff (IMHS). Cross-sectional convenience sample survey in Fall 2015 among 341 IMHS from multiple academic institutions in the suburban New York City metropolitan area. Awareness was whether drug dose adjustment was needed. Knowledge was correct GFR level for drug dose adjustment. Multivariate logistic regression was conducted. We found overall high percentages and high odds for all cardiovascular drugs for incorrect awareness and knowledge. Postgraduate year (PGY)-1 had greater odds than PGY-3 for Carvedilol (OR: 5.56, 95% CI: 2.19-14.12, p < 0.001) and Digoxin (OR: 3.87, 95% CI: 1.37-10.95, p < 0.05), and lesser odds than PGY3 for Atenolol (OR: 0.31, 95% CI: 0.10-0.91, p < 0.05). Nephrology exposure during medical school rotation, renal clinic, or family history had lesser odds for Carvedilol (OR: 0.45, 95% CI: 0.21-0.97, p < 0.05), Simvastatin (OR: 0.40, 95% CI: 0.16-0.97, p < 0.05), and Hydralazine (OR: 0.31, 95% CI: 0.12-0.81, p < 0.05). Nephrology exposure during residency (OR: 1.96, 95% CI: 1.10-3.50, p < 0.05) and US osteopathic graduates (OR: 2.40, 95% CI: 1.04-5.50, p < 0.05) each had greater odds for Enalapril (OR: 2.40, 95% CI: 1.04-5.50, p < 0.05). International medical graduates had lesser odds than US graduates for Amlodipine (OR: 0.30, 95% CI: 0.11-0.82, p < 0.05). IMHS had overall poor awareness and knowledge for dose adjustment for common cardiovascular drugs in patients with CKD. As the majority of CKD patients are managed by their primary care providers, training programs should ensure that IMHS have adequate education in Nephrology during their residency training.

Dose adjustment of antidiabetic medications in chronic kidney disease.

ABSTRACTPurpose:The purpose of this study is to identify whether Internal Medicine house-staff (IMHS) have awareness and knowledge about the correct dosage of antidiabetic medications for patients with chronic kidney disease (CKD), as dosing errors result in adverse patient outcomes for those with diabetes mellitus (DM) and CKD.Methods:There were 353 IMHS surveyed to evaluate incorrect level of awareness of medication dose adjustment in patients with CKD (ILA) and incorrect level of knowledge of glomerular filtration rate level for medication adjustment (ILK-GFR) for Glipizide, Pioglitazone, and Sitagliptin.Results:Lack of awareness and knowledge was high, with the highest for Pioglitazone at 72.8%. For ILA, the percentages were: Pioglitazone: 72.8%, Glipizide: 43.9%, and Sitagliptin: 42.8%. For ILK-GFR, the percentages were: Pioglitazone: 72.8%, Glipizide: 68.3%, and Sitagliptin: 65.4%.Conclusions:IMHS have poor awareness and knowledge for antidiabetic medication dose adjustment in patients with DM and CKD. Both Electronic Medical Rerecord best practice advisory and physician–pharmacist collaborative drug therapy management can enhance safe drug prescribing in patients with CKD. In addition, IMHS’s practice for antidiabetic medication dose adjustment was better with Nephrology exposure. A formal didactic educational training during medical school and residency for antidiabetic medication dose adjustment in patients with DM and CKD is highly encouraged to prevent medication dosing errors and to more effectively and safely allow IMHS to manage complex treatment regimens.

Dose Adjustment of Rheumatologic and Allergic Medications in CKD: Awareness and Knowledge Among Internal Medicine House Staff

Dose Adjustment of Rheumatologic and Allergic Medications in CKD: Awareness and Knowledge Among Internal Medicine House Staff

Beta Blockers For HFrEF: Are Guidelines Being Followed?

Heart failure (HF) is a chronic health condition that affects over 5 million people annually and is the cause of over one million hospitalizations annually. Patients hospitalized for HF are at high risk for all-cause rehospitalization, with a 1-month readmission rate of 25%. The ACCF/AHA 2013 guidelines made a Class I recommendation for patients with stage B HF with reduced ejection fraction (EF), to utilize specific beta blockers (carvedilol, bisoprolol and metoprolol succinate) to decrease morbidity and mortality from disease, sudden cardiac death, hospitalization rates, and improve heart failure symptoms. Hypothesis We hypothesized that evidence-based management of heart failure is not being followed on discharge for patients with heart failure with reduced EF (HFrEF) at our institution. Methods A retrospective chart review for patients discharged from the medicine service of our urban academic hospital between September 2018 and April 2019 with a primary or secondary discharge diagnosis of HFrEF. Patients with ECHO within the past year with EF 40%, patients transferred to other facilities, left AMA, expired, and those with contraindications to BB therapy (bradycardia unless with pacemaker, decompensated HF, severe hepatic failure, reactive airway disease) were excluded. Variables collected included demographics (age, gender, ethnicity), type of BB on admission, type of BB on discharge, and reasons for non-guideline concordant BB on discharge. Additionally, all internal medicine house staff were anonymously electronically surveyed to assess knowledge and barriers to prescribing the appropriate BB Results There were 267 patients discharged from the Medicine service, 226 of whom met the inclusion criteria. Of those, 110 (48.7%) were on appropriate outpatient BB therapy on admission, however only 113 (50%) were discharged on the appropriate therapy. Further review showed 18 of 110 (16%) patients on appropriate BB on admission were switched to inappropriate BB on discharge. Of those 113 patients not discharged on appropriate BB, 48 (42%) were discharged on metoprolol tartrate, and the commonly cited reasoning documented on discharge summaries for nonadherence to guidelines were discharge on home medications (27%) and hypotension (15%). A total of 64 of 94 (68%) residents completed the survey. Notably, 43 (67.2%) of respondents reported feeling “very” or “somewhat” comfortable with the use of BB for patients with HFrEF, yet only 24 (37.5%) correctly identified all three recommended guideline directed BB. Conclusion About half of the patients with HFrEF (EF

860 A Novel Quality Improvement Initiative to Reduce Inpatient Opioid Analgesic Use in Inflammatory Bowel Disease: The “IBD Pain Ladder”

INTRODUCTION: Opioid analgesic use is associated with increased mortality, higher readmission rates, and reduced quality of life among patients with inflammatory bowel disease (IBD). Evidence-based strategies to reduce inpatient opioid use in this population have been lacking. METHODS: We have initiated a quality improvement study using an educational intervention, targeting internal medicine (IM) and emergency medicine (EM) house staff with a goal to reduce in-hospital opioid use among IBD patients admitted to the gastroenterology (GI) service at our tertiary institution. This educational tool, the “IBD Pain Ladder” (Figure 1), was created using exhaustive literature review and with multi-disciplinary expert opinion. The tool is meant to help guide decisions regarding analgesia in this patient population while sparing opioid use. Pre-intervention data was collected from IBD patients admitted during a nine-month period (5/2018-2/2019). Educational intervention and prospective follow-up data for another 4 months was collected. The primary outcome was reduction in total inpatient opioid use in oral morphine equivalents per patient. Secondary outcomes included length of stay, types of opioid, 90-day readmission rates, outpatient opioid prescriptions provided upon discharge, Clostridium difficiledetection rates, fecal calprotectin, and C-reactive protein (CRP) levels. t tests for continuous variables and Fisher’s exact test for categorical variables were used; a P value &lt; 0.05 was considered significant. RESULTS: A total of 51 patients with 69 hospitalizations were analyzed (Table 2). Hospitalizations before and after our intervention were compared. There was no statistically significant difference in baseline admission characteristics between the two groups (Table 1). Our primary outcome was achieved with a statistically significant reduction in opioid use (39.1 vs 12.4 mg; P &lt; 0.037). Patients were also less likely to receive any opioid during hospitalizations after our intervention (71% vs 43%; P &lt; 0.034.) Length of hospitalization (5.2 vs 3.9 days; P &lt; 0.11) and readmission rates (41% vs 23.5%; P &lt; 0.55) were decreased post-intervention but did not reach statistical significance. CONCLUSION: We believe this intervention, aimed at housestaff education and providing a roadmap for pain management in this patient population, is a cost-effective, readily reproducible strategy that can be widely applied to improve IBD patient care. Results will be published and used for quality improvement in inpatient IBD care.

Improving Compliance of Colorectal Cancer Screening Through Housestaff Education in an Urban Community Hospital: A Quality Improvement Study

Introduction: At Brooklyn Hospital Center’s ambulatory Internal Medicine clinic, from 10/1/2016 to 3/31/2017, the rate of colorectal cancer (CRC) screening was reported to be 61%. We believe the low rate of screening is partially due to a knowledge gap regarding appropriate screening guidelines as well as screening alternatives. It is critical for housestaff to understand these guidelines so that we may provide the best and highest quality of care to our patient population. Our hypothesis is that an educational quality improvement intervention will help increase awareness of these guidelines and in turn, indirectly increase the screening rate for CRC. Methods: All Internal Medicine housestaff attending morning conference were included in the study (total of 39). Pre and post-tests were created (Image 1) to examine housestaff knowledge of current guidelines. The pre-test was administered, followed by a brief lecture on current guidelines, after which the post-test was given. The data was collected and analyzed using two-sided tests for significant differences in proportion between the number correct for each question, with a set p-value of < 0.05. Results: The results have been compiled in Table 1 (Image 2). Questions 3, 9, 13 & 15 showed a significant difference in the pre and post-tests. Most housestaff knew that colonoscopy is the preferred prevention test and that FIT is the preferred detection test (as well as FIT being more specific than FOBT). There was a significant increase in their knowledge of the age in which average CRC risk screening should begin. While there was a significant increase in willingness to discuss screening alternatives with patients, overall knowledge of the available alternatives remained low. Conclusion: While this quality improvement study demonstrates significant increase in housestaff knowledge via an educational intervention, there is room for improvement. With the recent introduction of ambulatory FIT, we have a new pathway for alternative screening. Since housestaff did not have a significant increase in knowledge of alternative testing, we theorize that focusing on the newly available FIT as an alternative will increase screening rates. Along with the increased knowledge on average CRC risk screening, this should increase screening via both colonoscopy as well as its alternatives (mainly FIT in our case). Further studies will investigate this, as well as incorporating patient barriers to screening (which are currently being addressed in a pilot study).305_B Figure 2 No Caption available.

Measuring Medical Housestaff Teamwork Performance Using Multiple Direct Observation Instruments: Comparing Apples and Apples.

To examine the composition and concordance of existing instruments used to assess medical teams' performance. A trained observer joined 20 internal medicine housestaff teams for morning work rounds at Tufts Medical Center, a 415-bed Boston teaching hospital, from October through December 2015. The observer rated each team's performance using nine teamwork observation instruments that examined domains including team structure, leadership, situation monitoring, mutual support, and communication. Observations recorded on paper forms were stored electronically. Scores were normalized from 1 (low) to 5 (high) to account for different rating scales. Overall mean scores were calculated and graphed; weighted scores adjusted for the number of items in each teamwork domain. Teamwork scores were analyzed using t tests, pairwise correlations, and the Kruskal-Wallis statistic, and team performance was compared across instruments by domain. The nine tools incorporated five major domains, with 5 to 35 items per instrument, for a total of 161 items per observation session. In weighted and unweighted analyses, the overall teamwork performance score for a given team on a given day varied by instrument. While all of the tools identified the same low outlier, high performers on some instruments were low performers on others. Inconsistent scores for a given team across instruments persisted in domain-level analyses. There was substantial variation in the rating of individual teams assessed concurrently by a single observer using multiple instruments. Because existing teamwork observation tools do not yield concordant assessments, researchers should create better tools for measuring teamwork performance.

Impact of Pocket Insulin Dosing Guide on Utilization of Basal/Bolus Insulin by Internal Medicine Resident Physicians.

IntroductionBasal/bolus insulin (BBI) is superior to sliding scale insulin (SSI) for diabetic patients admitted to hospital general medicine and surgery services, but little has been published on strategies to promote the utilization of BBI by resident physicians. New approaches that promote the effective management of hyperglycemia in hospitals need to be developed.Materials and methods A prospective study with historical controls was conducted to evaluate the impact of a pocket insulin dosing guide on the diabetes management practices of internal medicine resident physicians at the Southern Illinois University (SIU) School of Medicine, rotating on general medicine. The primary endpoint was the proportion of patients with preexisting diabetes mellitus managed with BBI. Pocket insulin dosing guides with instructions for initiating BBI and daily insulin adjustments were provided to all internal medicine residents in November 2010. BBI utilization rates were monitored over the period November 2010-February 2011 and were compared to the corresponding four-month period over the previous academic year (November 2009-February 2010), which was before the pocket insulin dosing guides were introduced (pilot study). Internal medicine house staff insulin ordering practices were subsequently evaluated for a 12-month period between October 2010-November 2011, with November 2009-October 2010 used as a historical control (study extension). New interns that were starting their residency training from July 2011 were provided with the pocket insulin dosing guides and given the same instructions as the previous academic year’s resident physicians.Results Historical controls (N = 579) and study patients (N = 584) were well matched, with the exception of the male gender (49% vs. 41%, P = 0.01) and diet-managed diabetes (10.5% vs. 6.4%, P = 0.01). During the pilot study, BBI increased from 12.8% of all resident insulin orders in November 2010 to 58.1% of all orders in February 2011 (P < 0.01 for trend). Overall, BBI as a proportion of all resident insulin orders was 35.7% during the pilot phase, which is a six-fold increase over the previous academic year (6%), and was also statistically significant (P<0.01). For the 12-month period of evaluation between November 2010 and October 2011, internal medicine residents ordered BBI for 41.9% of diabetes patients, compared to 16.7% of patients in the 12 months before the pocket insulin dosing guide was introduced (P < 0.01). Patients managed with BBI had higher blood glucose values at admission than patients managed with SSI (195 ± 95 mg/dL vs. 178 ± 83 mg/dL, P < 0.01) and experienced a 41 mg/dL improvement in mean daily capillary blood glucose (CBG) as compared to no change for patients managed with SSI (P = 0.01 for trend). The rate of hypoglycemia, defined as CBG < 70 mg/dL, was 2.4% for both BBI and SSI managed patients (P = 0.93).ConclusionThe SIU pocket insulin dosing guide significantly increased the utilization of BBI, decreased SSI orders, and improved hospital glycemic control for patients with diabetes mellitus. However, over half of the general medicine patients were still managed with SSI despite the pocket insulin dosing guides. Conversion of the insulin dosing guide to a smartphone app might improve utilization of the protocol and further increase the use of BBI for inpatient diabetes management by internal medicine house staff.

Su1046 - Importance of Communication and Consultative Practices: Insights from Internal Medicine Housestaff

Su1046 - Importance of Communication and Consultative Practices: Insights from Internal Medicine Housestaff

Standardization of inpatient CPR status discussions and documentation within the Division of Hematology and Oncology at UPMC Shadyside Hospital.

147 Background: Medical professionals are trained to provide life-sustaining and cardiac resuscitation measures for admitted hospital patients. However, not all patients desire such aggressive measures. Lack of discussion and/or documentation about resuscitation preferences has led to care incongruous with patient’s wishes as previously documented or reported to providers or family members. In December 2016, 49% of adult patients admitted to the inpatient oncology service at UPMC Shadyside had a code status discussion documented prior to discharge. The aim of this project is to improve the quality and rates of CPR status conversations. Methods: A workgroup was formed in January 2017 among key stakeholders representing oncology physicians and fellows, palliative care faculty, oncology nursing, advance practice providers (APPs), and internal medicine house staff. A quality improvement (QI) proposal was developed and approved by the UPMC Quality Improvement Committee in February 2017. All oncology faculty, fellows, housestaff, and APPs were reminded weekly to complete CPR status conversations and documentation. APPs were formally trained by palliative care specialists to discuss and document CPR/code status with all admitted patients. Hospital leadership received a monthly update of CPR status documentation rates. Results: Since project implementation, CPR status assessment rates have improved from 49% to 80% as of June 2017, and an additional 714 patients had a CPR status discussed and documented compared to June 2016. Formal system-wide expectations are being developed by the CPR assessment workgroup that all admitted patients should have CPR/Code status discussions and documentation upon admission. Conclusions: Standardization of CPR status assessment with formal training of clinicians and APPs has resulted in a significant increase in the number of CPR status assessments on the inpatient setting. A formal CPR status assessment expectations document is in the process of being developed among the workgroup. Formal trainings by palliative care specialists for APPs are ongoing. Future trainings are planned for physicians, housestaff and fellows.

A Multicenter Survey of House Staff Knowledge About Sepsis and the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock".

We aimed to assess the knowledge, attitudes, and perceptions of resident physicians regarding sepsis in general and the Surviving Sepsis Campaign Guidelines in particular. After institutional review board approval, we surveyed internal medicine (IM) and emergency medicine (EM) house staff from 3 separate institutions. House staff were notified of the survey via e-mail from their residency director or chief resident. The survey was Internet-based (using http://www.surveymonkey.com ), voluntary, and anonymous. The Surviving Sepsis Campaign Guidelines were used to develop the survey. The survey was open between December 2015 and April 2016. No incentives for participation were given. Reminder e-mails were sent approximately every 3 to 4 weeks to all eligible participants. Comparisons of responses were evaluated using the N-1 2-proportion test. A total of 133 responses were received. These included 84 from IM house staff, 27 from EM house staff, and 22 who selected "other." Eighty (101/126) percent reported managing at least 1 patient with sepsis in the preceding 30 days, 85% (97/114) rated their knowledge of the Surviving Sepsis Guidelines as "very familiar" or at least "somewhat familiar," and 84% (91/108) believed their training in the diagnosis and management of sepsis was "excellent" or at least "good." However, 43% (47/108) reported not receiving any feedback on their treatment of patients with sepsis in the last 30 days, while 24% (26/108) received feedback once. Both IM and EM house staff received comparable rates of feedback (62% vs 48%, respectively; P = .21). For the 3 questions that directly tested knowledge of the guidelines, the scores of the IM and EM house staff were similar. Notably, <20% of both groups correctly identified diagnostic criteria for sepsis. Additional education of IM and EM house staff on the Surviving Sepsis Campaign Guidelines is warranted, along with more consistent feedback regarding their diagnosis and management of sepsis.

Changing the Culture of Inpatient Constipation Management

Introduction: Hospitalized patients are at increased risk for constipation, with a prevalence of 79% in patients on a geriatric ward. Constipation results in greater indirect downstream costs in form of diagnostic tests, treatments, and prolonged hospital stays. However, there is a lack of specific performance improvement measures related to prevention and management of inpatient constipation. We hypothesize that Housestaff overwhelmingly order Senna and Docusate sodium for management of inpatient constipation while research data has not found those medications to be effective and is likely contributing to inefficient health care expenditures. Methods: We performed a retrospective chart review of patients admitted at Lenox Hill Hospital in NY under the general medicine service in January 2016 that were ordered for the following laxatives: Senna, Docusate sodium, and Polyethylene Glycol 3350 (PEG 3350). Patients with a diagnosis of bowel obstruction and perforation were excluded. Risk factors for inpatient constipation as well as comorbidities associated with constipation were collected. A voluntary survey was distributed to Internal Medicine Housestaff to look at their level of confidence and basic knowledge surrounding prevention and management of inpatient constipation. Results: 185 inpatient charts were reviewed. Docusate sodium was the most common laxative ordered, at 82%, followed by Senna at 73% and Polyethylene Glycol 3350 at 37%. Most patients were placed on a laxative combination therapy, commonly Senna and Docusate sodium 42% and also the trio of Senna, Docusate sodium, and PEG 3350 at 20%. 98% of the patients were high risk for inpatient constipation (High risk = 1 or more risk factors), with age and use of a constipation-causing medication being the 2 most common risk factors. 76% of Internal Medicine residents (evenly distributed among all three years of training) completed the survey. Survey report revealed knowledge deficiency in management of inpatient constipation. Conclusion: As shown in our study, the hospitalized population is at high risk for constipation. Furthermore, evidence-based treatment or published algorithm is not being followed. We plan to change the culture in our institution by educating Housestaff and working with nursing staff to not only identify high risk patients but to also help implement nonpharmacologic intervention to prevent and treat inpatient constipation.

Awareness and knowledge among internal medicine house-staff for dose adjustment of commonly used medications in patients with CKD

BackgroundDrug dosing errors result in adverse patient outcomes and are more common in patients with chronic kidney disease (CKD). As internists treat the majority of patients with CKD, we study if Internal Medicine house-staff have awareness and knowledge about the correct dosage of commonly used medications for those with CKD.MethodsA cross-sectional survey was performed and included 341 participants. The outcomes were the awareness of whether a medication needs dose adjustment in patients with CKD and whether there was knowledge for the level of glomerular filtration rate (GFR) a medication needs to be adjusted.ResultsThe overall pattern for all post-graduate year (PGY) groups in all medication classes was a lack of awareness and knowledge. For awareness, there were statistically significant increased mean differences for PGY2 and PGY3 as compared to PGY1 for allergy, endocrine, gastrointestinal, and rheumatologic medication classes but not for analgesic, cardiovascular, and neuropsychotropic medication classes. For knowledge, there were statistically significant increased mean differences for PGY2 and PGY3 as compared to PGY1 for allergy, cardiovascular, endocrine, and gastrointestinal, medication classes but not for analgesic, neuropsychotropic, and rheumatologic medication classes.ConclusionsInternal Medicine house-staff across all levels of training demonstrated poor awareness and knowledge for many medication classes in CKD patients. Internal Medicine house-staff should receive more nephrology exposure and formal didactic educational training during residency to better manage complex treatment regimens and prevent medication dosing errors.

A Multidisciplinary Quality Improvement Initiative for Influenza Disease Management Lead by Internal Medicine House Staff.

A Multidisciplinary Quality Improvement Initiative for Influenza Disease Management Lead by Internal Medicine House Staff.

Resilience of internal medicine house staff and its association with distress and empathy in an oncology setting.

Resilience is a beneficial trait for resident physicians who are exposed to adversity through their work with patients. Inpatient hematology-oncology produces vicarious trauma for physicians in training. Physician distress and empathy influence patient care and may be associated with respectively lower and greater levels of resilience. We collected measures of resilience (Connor-Davidson Resilience Scale), distress (Impact of Events Scale - Revised), and rotation-specific information (e.g., number of death encounters, death stress, and meaning) at the end of a routine hematology-oncology ward rotation. Empathy (Interpersonal Reactivity Index) was measured both before and after the rotation. Fifty-six out of 96 residents completed the study with an overall response rate of 58%. Resilience was negatively correlated with distress (r = -0.306, p = 0.023) but not with empathy (r = 0.172, p = 0.204) and nor with change in empathy over the course of the rotation (r = -0.122, p = 0.374). When separated by sex, male resilience was negatively correlated with distress (r = -0.389, p = 0.04), but female resilience was not. Resident distress levels were in a clinically significant (76%) or posttraumatic stress disorder range (17%), and resident empathy decreased during the rotation (p = 0.018). Resilience levels were similar in those who reported that death events were the most stressful experiences of the rotation and those who derived a sense of meaning from working with dying patients. Resident physicians experienced clinically relevant distress and a decrease in empathy. Resilient resident physicians were less likely to experience distress. This study provides evidence for the salutary effects of resilience on physician distress. Copyright © 2016 John Wiley & Sons, Ltd.