Internal Medicine Resident Physicians Research Articles

The Impact of a 4-Domain Wellness-Initiative Curriculum on Internal Medicine Resident Physicians.

There is a trend toward fostering well-being, or the state of being happy and healthy, within the medical community. Historically, resident physicians have faced high rates of distress during training. A structured well-being curriculum in residency programs may shift residents' mindsets from survival and resilience to one centered on purpose, engagement, and joy. An original well-being curriculum was administered to residents in person at a single institution every 5 weeks for approximately 10 well-being workshops, totaling around 20 hours of curriculum exposure during every academic year. The well-being curriculum was divided into 4 domains: cognitive distortions and problematic mindsets, mindfulness and meditation, creative outlets, and self-compassion.Residents exposed to at least 1 year of the well-being curriculum were asked to answer an anonymous survey. Four questions were asked for each of the 4 domains. The first and second questions asked how familiar they were with the topic before and after the workshops on a scale of 1-5 of familiarity. The third and fourth questions asked how much the knowledge acquired influenced their professional and personal life on a scale of 1-5 of influence. Before curriculum exposure, the average for moderate or higher levels of knowledge across all domains was 22.7%, which improved to 77.3% after curriculum completion. Overall, 58.6% of participants felt the knowledge of the domains was moderately or extremely influential in their professional lives and 83.6% in their personal lives. There were no significant differences between post-graduate year 2 and post-graduate year 3 residents for any domains examined before and after the wellness workshops. A 4-domain well-being curriculum practiced in a group setting positively impacted participating residents in their personal and professional lives. Further studies need to be performed on a larger scale to assess if the curriculum fits the needs of the broader medical community.

Establishing the Problem: Identifying Barriers to Workflow Among Internal Medicine Resident Physicians Within the VA Medical Center

Establishing the Problem: Identifying Barriers to Workflow Among Internal Medicine Resident Physicians Within the VA Medical Center

Resident Burnout, Wellness, Professional Development, and Engagement Before and After New Training Schedule Implementation

Burnout is a work-related syndrome of depersonalization (DP), emotional exhaustion (EE), and low personal achievement (PA) that is prevalent among internal medicine resident trainees. Prior interventions have had modest effects on resident burnout. The association of a new 4 + 4 block schedule (4 inpatient weeks plus 4 outpatient weeks) with resident burnout has not previously been evaluated. To evaluate the association of a 4 + 4 block schedule, compared with a 4 + 1 schedule, with burnout, wellness, and self-reported professional engagement and clinical preparedness among resident physicians. This nonrandomized preintervention and postintervention survey study was conducted in a single academic-based internal medicine residency program from June 2019 to June 2021. The study included residents in the categorical, hospitalist, and primary care tracks in postgraduate years 1 and 2 (PGY1 and PGY2). Data analysis was conducted from October to December 2022. In the 4 + 4 structure, resident schedules alternated between 4-week inpatient call-based rotations and 4-week ambulatory non-call-based rotations. The primary outcome was burnout, assessed using the Maslach Burnout Inventory subcategories of EE (range, 0-54), DP (range, 0-30), and PA (range, 0-48), adjusted for sex and PGY. Secondary outcomes included In-Training Examination (ITE) scores and a questionnaire on professional, educational, and health outcomes. Multivariable logistic regression was used to assess the primary outcome, 1-way analysis of variance was used to compare ITE percentiles, and a Bonferroni-adjusted Kruskal Wallis test was used for the remaining secondary outcomes. The findings were reexamined with several sensitivity analyses, and Cohen's D was used to estimate standardized mean differences (SMDs). Of the 313 eligible residents, 216 completed the surveys. A total of 107 respondents (49.5%) were women and 109 (50.5%) were men; 119 (55.1%) were PGY1 residents. The survey response rates were 78.0% (85 of 109) in the preintervention cohort and 60.6% (63 of 104) and 68.0% (68 of 100) in the 2 postintervention cohorts. The PGY1 residents had higher response rates than the PGY2 residents (119 of 152 [78.2%] vs 97 of 161 [60.2%]; P < .001). Adjusted EE scores (mean difference [MD], -6.78 [95% CI, -9.24 to -4.32]) and adjusted DP scores (MD, -3.81 [95% CI, -5.29 to -2.34]) were lower in the combined postintervention cohort. The change in PA scores was not statistically significant (MD, 1.4 [95% CI, -0.49 to 3.29]). Of the 15 items exploring professional, educational, and health outcomes, a large positive association was observed for 11 items (SMDs >1.0). No statistically significant change in ITE percentile ranks was noted. In this survey study of internal medicine resident physicians, a positive association was observed between a 4 + 4 block training schedule and internal medicine resident burnout scores and improved self-reported professional, educational, and health outcomes. These results suggest that specific 4 + 4 block combinations may better improve resident burnout than a 4 + 1 combination used previously.

Wall-mounted folding chairs to promote resident physician sitting at the hospital bedside.

Sitting at the bedside may improve patient-clinician communication; however, many clinicians do not regularly sit during inpatient encounters. To determine the impact of adding wall-mounted folding chairs inside patient rooms, beyond any impact from a resident education campaign, on the patient-reported frequency of sitting at the bedside by internal medicine resident physicians. Prospective, controlled pre-post trial between 2019 and 2022 (data collection paused 2020-2021 due to COVID-19) at an academic hospital in Baltimore, Maryland. Folding chairs were installed in two of four internal medicine units and educational activities were delivered equally across all units. Patient-reported frequency of sitting at bedside, assessed as means on Likert-type items with 1 being "never" and 5 being "every single time." We also examined the frequency of other patient-reported communication behaviors. Two hundred fifty six and 206 patients enrolled in the pre and post-intervention periods, respectively. The mean frequency of patient-reported sitting by resident physicians increased from 1.8 (SD 1.2) to 2.3 (1.2) on education-only units (absolute difference 0.48 [95% CI: 0.21-0.75]) and from 2.0 (1.3) to 3.2 (1.4) on units receiving chairs (1.16, [0.87-1.45]). Comparing differences between groups using ordered logistic regression adjusting for clustering within residents, units with added chairs had greater increases in sitting (odds ratio 2.05 [1.10-3.82]), spending enough time at the bedside (2.43 [1.32-4.49]), and checking for understanding (3.04 [1.44-6.39]). Improvements in sitting and other behaviors were sustained on both types of units. Adding wall-mounted folding chairs may help promote effective patient-clinician communication.

SINGING WITH DEMENTIA: CREATING AND PILOT TESTING A VIDEO TO CHANGE ATTITUDES OF MEDICAL RESIDENTS

Abstract As part of the “Creativity in Aging” project at Yale Geriatrics, we are making a series of short videos highlighting individuals and programs that transcend dementia through music. The target audience includes health trainees and professionals who care for older adults. The first video, made by a PhD candidate and an internal medicine resident physician, features The Recollections: a chorus of community dwelling people with dementia, their caregivers, and college students. Video learning objectives are to 1) change dementia attitudes; 2) demonstrate preserved skills and abilities of persons with dementia; and 3) raise awareness about local initiatives for music in dementia and how to refer patients. We interviewed the chorus founder, a geriatric psychiatrist, who described the creative process, including logistics and vision, and provided advice to caregivers and medical residents. Live clips from chorus rehearsals were shown, including singing and dancing, with voiceovers describing participant stories. Slides reinforced key points. The video was pilot tested on a group of residents from the Internal Medicine and Psychiatry programs. All respondents (N=6) used positive words such as “optimistic” and “inspired” to describe how the video made them feel. Most indicated it was moderately relevant to their care of patients with dementia and several provided suggestions on how to increase relevance. Constructive feedback included parts to compress or expand, overall length, visual aspects, and desire for more ‘how to’ guidance. Future plans include sharing a revised version with the broader residency program with pre-and-post dementia attitudes surveys.

Management of the Electronic Health Record Inbox: Results From a National Survey of Internal Medicine Program Directors.

Background Internal medicine (IM) resident physicians spend a considerable amount of time managing their inbox as part of their longitudinal continuity clinic experience. There are no standardized guidelines for how programs should train, monitor, or supervise residents in this type of patient care. Objective To understand how IM residency programs educate, monitor, and supervise resident electronic health record (EHR) inbox management as part of their longitudinal continuity clinic and determine whether patient safety events have occurred due to EHR inbox-related patient care decisions made by unsupervised resident physicians. Methods In August 2021, 439 program directors at accredited US IM residency programs who were members of the Association of Program Directors in Internal Medicine (APDIM) were asked 12 questions developed by the study authors and APDIM survey committee members regarding resident EHR inbox management as part of the annual APDIM survey. Results Two hundred and sixty-seven (61%) PDs responded. The majority (224 of 267, 84%) of programs provided guidelines for expected message response times; less than half (115, 43%) monitored timeliness metrics. Only half (135; 51%) of programs required faculty supervision of inbox messages for all residents; 28% (76) did not require supervision for any residents. Twenty-one percent of PDs (56) reported awareness of a patient safety event occurring due to an unsupervised resident inbox-related patient care decision. Conclusions Substantial variability exists in how IM residency programs train, monitor, supervise, and provide coverage for resident inbox work. Program directors are aware of patient safety events resulting from unsupervised resident inbox management.

Provider Perceptions of a Novel Inpatient Co-Rounding Model Integrating Medical Oncology, Neuro-Oncology, and Radiation Oncology for the Care of Patients with Advanced Cancer

Patients (pts) with advanced cancer require interdisciplinary care. Although tumor boards are well-established in the outpatient setting, few studies have evaluated interventions for improving consultative care coordination for hospitalized pts with cancer. The purpose of this study was to evaluate a novel inpatient co-rounding model of care in which medical-, neuro-, and radiation-oncology consult teams rounded jointly, with the hypothesis that primary referring team perception of the alignment of the recommendations from these consult services would improve post-implementation. An inpatient co-rounding model was implemented in September 2021 for hospitalized pts with solid malignancies at a tertiary medical center. Attending physicians, nurse practitioners, fellows, and residents from oncologic consulting services met virtually twice weekly to discuss pt care. Providers from the two most common primary services for pts with cancer at this hospital (hospital medicine and neurosurgery) were surveyed via institutional email listservs. The survey included Likert-type questions about the quality of inpatient consultation and the alignment of recommendations across three consulting oncological specialty services. The pre-intervention survey was distributed prior to model implementation, and the post-intervention survey was distributed 9 months later. Wilcoxon rank-sum tests were used to compare responses from the pre-and post-intervention surveys. At each session, a median of 6 providers attended (range, 4-8 providers), and a median of 6 pts were discussed (range, 4-8 pts). Among 331 providers surveyed, 119 completed the pre-intervention survey (36% response rate), and 34 completed the post-intervention survey (10% response rate). Respondents were 81 (53%) internal medicine attending physicians/hospitalists, 55 (36%) internal medicine resident physicians, 6 (4%) neurosurgery advanced practice providers, 6 (4%) neurosurgery attending physicians, and 5 (3%) neurosurgery resident physicians. When asked to rate agreement with the statement that consultant recommendations from medical-, neuro-, and radiation-oncology were aligned, respondents were significantly more likely to perceive alignment 9 months post-implementation (67% strongly agree) compared to pre-implementation (23% strongly agree, p = 0.0001). There was high satisfaction with the quality of medical-, neuro-, and radiation-oncology consultations at both time points, with no statistical difference pre- vs. post-implementation of the co-rounding model. A novel inpatient co-rounding model of care was successfully launched between medical-, neuro-, and radiation-oncology. Primary teams perceived greater alignment in recommendations between these consulting services after project implementation. Future directions include evaluating the impact of this co-rounding model on patient outcomes.

Burnout and fatigue amongst internal medicine residents: A cross-sectional study on the impact of alternative scheduling models on resident wellness.

Fatigue and burnout are prevalent among resident physicians across Canada. Shifts exceeding 24 hours are commonly purported as detrimental to resident health and performance. Residency training programs have employed strategies towards understanding and intervening upon the complex issue of resident fatigue, where alternative resident scheduling models have been an area of active investigation. This study sought to characterize drivers and outcomes of fatigue and burnout amongst internal medicine residents across different scheduling models. We conducted cross-sectional surveys were among internal medicine resident physicians at the University of Alberta. We collected anonymized socioeconomic demographics and medical education background, and estimated associations between demographic or work characteristics and fatigue and burnout outcomes. Sixty-nine participants competed burnout questionnaires, and 165 fatigue questionnaires were completed (response rate of 48%). The overall prevalence of burnout was 58%. Lower burnout prevalence was noted among respondents with dependent(s) (p = 0.048), who identified as a racial minority (p = 0.018), or completed their medical degree internationally (p = 0.006). The 1-in-4 model was associated with the highest levels of fatigue, reported increased risk towards personal health (OR 4.98, 95%CI 1.77-13.99) and occupational or household harm (OR 5.69, 95%CI 1.87-17.3). Alternative scheduling models were not associated with these hazards. The 1-in-4 scheduling model was associated with high rates of resident physician fatigue, and alternative scheduling models were associated with less fatigue. Protective factors against fatigue are best characterized as strong social supports outside the workplace. Further studies are needed to characterize the impacts of alternative scheduling models on resident education and patient safety.

Abstract P117: Improving Hypertension Control In A Veterans Affairs Resident Primary Care Clinic, A Mixed-Methods Study

Introduction: Hypertension (HTN) is a critical modifiable risk factor for cardiovascular disease (CVD). In 2017, ACC/AHA guidelines recommended a blood pressure (BP) target of ≤ 130/80 mmHg for patients with high CVD risk. Prior research in the primary care clinic showed poor adherence with up-to-date guidance for BP control. The current study targets resident physician prescribing barriers to improve HTN control. Method: The study was conducted in a large Midwest VA Patient Aligned Care Team (PACT) staffed by 49 Internal Medicine resident physicians and 10 supervising physicians. Physician prescribing barriers were identified via semi-structured interviews. Interventions included physician education on BP goals and treatment, guided self-audit exercise, and revised implementation of EMR HTN order menu. Therapeutic inertia (TI) data was collected weekly from October 2022 to May 2023. Results: Major themes of prescribing barriers identified by physician interviews were patient non-adherence, lack of guideline-integrated practices, and lack of knowledge of single-pill combination agents (Table 1). Therapeutic inertia was examined for patients with high CVD risk and uncontrolled BP at a PACT visit. Baseline TI from June to October 2022 was 88.2% (128 of 145 patients had no change in antihypertensive therapy). Post-intervention TI was 88.4% (107 of 121 patients had no change in antihypertensive therapy). Conclusion: This study highlights the ongoing need to engage resident physicians with interactive tools to increase awareness of updated HTN guidelines. Identifying barriers to resident prescribing behaviors can be used to target interventions.

SPCR-10 CANCER CO-ROUNDS: A NOVEL INPATIENT MULTIDISCIPLINARY ONCOLOGY ROUNDING MODEL

Abstract BACKGROUND Although tumor boards are well-established for coordinating care of patients with cancer in the outpatient setting, few studies have evaluated interventions for improving consultative care coordination for hospitalized patients. This study evaluated the hypothesis that implementation of an inpatient co-rounding model of care including medical-, neuro-, and radiation-oncology consult teams would improve the alignment of recommendations from these oncologic services, as perceived by primary teams. METHODS A co-rounding model was implemented in September 2021 for hospitalized patients with cancer at a tertiary medical center. The oncologic consulting services met virtually twice weekly to discuss patient care. Providers from the most common primary services for patients with cancer, internal medicine (IM) and neurosurgery, were surveyed via institutional email listservs. The survey included Likert-type questions about the alignment of recommendations across services and open-ended questions for feedback on collaboration among these services. Pre-intervention surveys were distributed, and post-intervention surveys were distributed 9 months later. Wilcoxon rank-sum tests were used to compare responses pre- and post-intervention. RESULTS At each session, a median of 6 providers attended (range, 4-8 providers), and a median of 6 patients were discussed (range, 4-8 patients). Of the 331 providers surveyed, there were 119 (36%) respondents pre-intervention and 34 (10%) respondents post-intervention. The 132 unique respondents comprised 68 (52%) IM attending physicians, 48 (36%) IM resident physicians, 6 (5%) neurosurgery advanced practice providers, 6 (5%) neurosurgery attendings, and 4 (3%) neurosurgery residents. Post-intervention, respondents were significantly more likely to perceive alignment in oncologic consultant recommendations (67% strongly agree) compared to pre-intervention (23% strongly agree, p&amp;lt;0.01). CONCLUSIONS A novel inpatient co-rounding model was successfully implemented between medical-, neuro-, and radiation-oncology. Primary teams perceived greater alignment in recommendations among these consulting services after implementation. Future directions include evaluation of the impact of this model on patient outcomes.

Establishing the Problem: Identifying Barriers to Workflow Among Internal Medicine Resident Physicians within the VA Medical Center

Establishing the Problem: Identifying Barriers to Workflow Among Internal Medicine Resident Physicians within the VA Medical Center

Cancer co-rounds: A novel inpatient multidisciplinary oncology rounding model.

e13526 Background: Although tumor boards are well-established for coordinating care of patients (pts) with cancer in the outpatient setting, few studies have evaluated interventions for improving consultative care coordination for hospitalized pts, where coordination can be particularly complex. This study evaluated the hypothesis that implementation of an inpatient co-rounding model of care including medical-, neuro-, and radiation-oncology consult teams would improve the alignment of recommendations from these oncologic services, as perceived by primary teams. Methods: A co-rounding model was implemented in September 2021 for hospitalized pts with cancer at a tertiary medical center. The oncologic consulting services met virtually twice weekly to discuss pt care. Providers from the most common primary services for pts with cancer, internal medicine (IM) and neurosurgery (NSGY), were surveyed via institutional email listservs. The survey included Likert-type questions about the alignment of recommendations across the oncologic services and open-ended questions asking for feedback on collaboration among these services. Pre-intervention surveys were distributed, and post-intervention surveys were distributed 9 months later. Thematic analysis was performed on the pre-intervention free-text responses; post-intervention free-text responses were not analyzed due to limited number. Wilcoxon rank-sum tests were used to compare responses pre- and post-intervention. Results: At each session, a median of 6 providers attended (range, 4-8 providers), and a median of 6 pts were discussed (range, 4-8 pts). Of the 331 providers surveyed, there were 119 (36%) respondents pre-intervention and 34 (10%) respondents post-intervention. The 132 unique respondents comprised 68 (52%) IM attending physicians, 48 (36%) IM resident physicians, 6 (5%) NSGY advanced practice providers, 6 (5%) NSGY attendings, and 4 (3%) NSGY residents. There were 35 total free-text responses (29 pre-intervention and 6 post-intervention). Prior to implementation, common suggested areas for improvement included: coordination between inpatient and outpatient oncologic providers (N=7), communication among inpatient oncologic services (N=6), timeliness of response to consults (N=5), and documentation of recommendations (N=4). Post-intervention, respondents were significantly more likely to perceive alignment in oncologic consultant recommendations (67% strongly agree) compared to pre-intervention (23% strongly agree, p&lt;0.01). Conclusions: A novel inpatient co-rounding model was successfully implemented between medical-, neuro-, and radiation-oncology. Primary teams perceived greater alignment in recommendations among these consulting services after implementation. Future directions include continued improvement upon the co-rounding model, and evaluation of the impact of this model on patient outcomes.

Burnout syndrome in internal medicine resident physicians

Introducción: el síndrome de Burnout se define como una respuesta al estrés laboral crónico, integrado por actitudes y sentimientos negativos hacia las personas con las que se trabaja y hacia el propio rol profesional. Se considera como la fase avanzada del estrés profesional.

A Quality Improvement Approach to Decrease the Utilization of Docusate in Hospitalized Patients.

Docusate sodium is a commonly prescribed medication to relieve constipation, but several studies have demonstrated its ineffectiveness. Its continued use in the hospital setting adds unnecessary cost and risk to patients. At the Mayo Clinic Florida campus, docusate was ordered for 9.7% of patients admitted to the internal medicine resident (IMED) teaching services during the month of January 2020, and the average hospital length of stay (LOS) was 3.1 days. A multidisciplinary team of internal medicine resident physicians and pharmacists collaborated to address this quality gap through a quality improvement project. It sought to reduce the number of patients admitted to the IMED teaching services who had an order placed for docusate by 50% in less than 6 months without adversely impacting hospital LOS. Two separate interventions were devised using Six Sigma methodology and implemented to reduce the frequency of docusate orders, which involved educating internal medicine residents and hospital pharmacists, and creating an additional process-related barrier to docusate orders. The percentage of docusate orders decreased from 9.7% to 2.4% ( P = .004) with a grossly unchanged LOS of 3.1 days to 2.7 days ( P = .12) after 5 weeks. The implementation of a dual-pronged intervention successfully decreased the use of an ineffective medication in hospitalized patients without impacting the balancing measure, and serves as a model that can be adopted at other institutions with the hope of promoting evidence-based medical care.

Association between hospital internal medicine physician workforce and patient admissions during the COVID-19 pandemic in Japan

BackgroundHospital physician workforce in Japan is the lowest among developed countries. Many patients with novel coronavirus disease 2019 (COVID-19) with high risk of mortality could not be hospitalized during case surges in Japan and only about 5% of total acute care beds were used as COVID-19 beds nationwide. However, the relationship between the number of hospital physicians and patient admissions remains unclear. Thus, we aimed to evaluate this relationship in areas with the highest incidences during the surges.MethodsData collection was performed for teaching hospitals accredited with the specialty of internal medicine in three prefectures which experienced the highest COVID-19 incidences in Japan (Tokyo, Osaka, Okinawa). Association was examined between the number of full-time physicians (internal medicine staff physicians and residents) and admissions of internal medicine patients through ambulance transport from April 2020 to March 2021. Analysis was conducted separately for community hospitals and university hospitals because the latter have roles as research institutions in Japan. Community hospitals included private, public, and semi-public hospitals.ResultsOf 117 teaching hospitals in three prefectures, data from 108 teaching hospitals (83 community hospitals and 25 university hospitals) were available. A total of 102,400 internal medicine patients were admitted to these hospitals during the one-year period. Private hospitals received the greatest mean number of patient admissions (290 per 100 beds), followed by public hospitals (227) and semi-public hospitals (201), and university hospitals (94). Among community hospitals, a higher number of resident physicians per 100 beds was significantly associated with a greater number of patient admissions per 100 beds with beta coefficient of 11.6 (95% CI, 1.5 to 21.2, p = 0.025) admissions by one physician increase per 100 beds. There was no such association among university hospitals.ConclusionsCommunity hospitals with many resident physicians accepted more internal medicine admissions through ambulance transport during the COVID-19 pandemic. An effective policy to counter physician shortage in hospitals in Japan may be to increase internal medicine resident physicians among community hospitals to save more lives.

Guardianship: The Implications of Resident Physician Perceptions of Caring for Incapacitated Older Adults Without Advocates.

As the incidence of dementia rises, increased utilization of surrogate decision-makers, including legal guardians, is anticipated. This manuscript presents an analysis of resident physicians' experiences and perceptions regarding requirements, roles, and responsibilities of caring for older adults in need of, or already under, legal guardianship. This is a cross-sectional study, conducted at a tertiary academic medical center. A survey was sent, via Qualtrics, to all emergency medicine, family medicine, internal medicine, general surgery, and medicine-pediatric resident physicians. Eighty-eight out of three hundred thirty-three (26.4%) eligible residents physicians completed the survey. Most (98.9%) reported caring for patients under guardianship, yet many resident physicians reported significant uncertainty regarding the roles and responsibilities of guardianship, including its potential benefits and limitations. They also displayed misconceptions and overconfidence about guardians' abilities to facilitate disposition, ensure financial security, and assign code status, among other matters. Our study highlights the importance of structured and directed education on the topic of guardianship for medical trainees.

Association of Hoover's Sign with Maximal Expiratory-to-Inspiratory Pressure Ratio in Patients with COPD.

In chronic obstructive pulmonary disease (COPD) some patients develop paradoxical inspiratory rib motion, which is termed Hoover's sign. Our objective was to determine whether Hoover's sign is associated with a difference in the maximal expiratory pressure (MEP), the maximal inspiratory pressure (MIP), the MEP/MIP ratio, and other features on pulmonary function tests (PFTs). This observational prospective single-center cohort study enrolled patients with an established diagnosis of COPD with Global initiative for chronic Obstructive Lung Disease (GOLD) stage 3 (severe) and 4 (very severe) based on PFTs. Respiratory pressure measurements were also collected. Patients were examined for the presence or absence of Hoover's sign on physical examination by 2 internal medicine resident physicians trained in examining for Hoover's sign by a pulmonologist. A total of 71 patients were examined for the presence of Hoover's sign. Hoover's sign was present in 49.3% of patients. Observer agreement (k statistic) was 0.8 for Hoover's sign. Median MEP/MIP was significantly greater in patients with Hoover's sign than those without Hoover's sign (1.88 versus 1.16, p<0.001). Patients with Hoover's sign also had a significantly lower MIP (39.0 versus 58.0, p<0.001) and higher residual volume (RV) to total lung capacity (TLC) ratio indicating a higher degree of air trapping (65 versus 59.5, p<0.014). The presence of Hoover's sign in patients with COPD is associated with a higher MEP/MIP ratio. This suggests respiratory pressure measurements can predict diaphragm dysfunction in patients with GOLD stage 3 and 4 COPD. Patients with Hoover's sign were also found to have a lower MIP and more air trapping.

Central Venous Access: Conventional Seldinger Versus Ultrasound-Guided Technique to Reduce Associated Complications in A School Hospital

Hypertension and diabetes are the main comorbidities and risk factors for complications related to the placement of central venous accesses,these complications are extremely frequent when performed by the conventional Seldinger technique. Through this study, an attempt was made to establish the frequency and reduction of complications when comparing placement by internal medicine resident using conventional marking techniques of seldinger versus ultrasound guided in emergency service in 76 patients. The results through the chi square test with a p value of 0.05, showed successful placement: Increases the chance of success when using Ultrasound by 57% (RR: 1.57) successful placement rate was achieved with the use of ultrasound of 91.6% versus 52% in patients with conventional technique, the Reduction of risk of arterial complications with the use of ultrasound was 26% (RR: 0.74), the reduction risk of pneumothorax with ultrasound was 86% (RR: 0.14) and reduction of infectious complications with Ultrasound was 86% (RR: 0.14). Time required for placement of the central venous access was significantly shorter with ultrasound when analyzed with U-Mann Whitney with P value: 0.002, There were 6 catheter-associated infections per thousand catheter days in the conventional technique group versus 1 in the Ultrasound group (with an average hospital days associated with infection of 11.2). The main associated comorbidities HBP, DM-2, Cancer and Obesity, with higher prevalence in the ultrasound placement group. Ultrasound considerably reduced the number of mechanical, vascular or infectious complications associated with placement of central venous accesses, becoming a valuable tool for internal medicine resident physicians.

S1442 Knowledge, Attitude, and Practice of Internal Medicine and Family Medicine Resident Physicians on Non-Alcoholic Fatty Liver Disease

S1442 Knowledge, Attitude, and Practice of Internal Medicine and Family Medicine Resident Physicians on Non-Alcoholic Fatty Liver Disease

Multimodal Intervention Assessing the Appropriateness of Acid Suppression Therapy is Associated With Reduced Prescriptions at the Time of Discharge for Hospitalized Inpatients.

Acid suppression therapy (AST), including proton pump inhibitors and histamine 2 receptor antagonists, are an overused class of medications. When used inappropriately, AST leads to polypharmacy, increased healthcare costs, and possible negative health consequences. To assess whether an intervention including prescriber education combined with a pharmacist-driven protocol was effective in reducing the percentage of patients who were discharged with inappropriate AST. This was a prospective pre-post study of adult patients who were prescribed AST before or during their admission to an internal medicine teaching service. All internal medicine resident physicians received education on appropriate AST prescribing. During the 4-week intervention period, dedicated pharmacists assessed the appropriateness of AST and made recommendations regarding deprescribing if no appropriate indication was identified. During the study period, there were 14 166 admissions during which patients were prescribed AST. Out of the 1143 admissions during the intervention period, appropriateness of AST was assessed by a pharmacist for 163 patients. AST was determined to be inappropriate for 52.8% (n = 86) of patients and discontinuation or de-escalate of therapy occurred in 79.1% (n = 68) of these cases. The percentage of patients discharged on AST decreased from 42.5% before the intervention to 39.9% after the intervention (P = .007). This study suggests that a multimodal deprescribing intervention reduced prescriptions for AST without an appropriate indication at the time of discharge. To increase the efficiency of the pharmacist assessment several workflow improvements were identified. Further study is necessary to understand the long-term outcomes of this intervention.