Staff Physicians Research Articles

Is Resectoscopic Hysteroscopy a Dying Art? Creation of an Educational Instructional Video [ID 2683474

INTRODUCTION: Resectoscopic hysteroscopy is a valuable surgical technique for addressing intrauterine pathology. Within our institution, most operative hysteroscopies are performed using newer non-resectoscopic systems, potentially creating a gap in resident surgical education. We developed a novel instructional video demonstrating the components and capabilities of the resectoscopic hysteroscope. Our aim is to assess whether the instructional video increased surgeon comfort using the resectoscopic hysteroscope. METHODS: A pilot cohort study was performed with gynecologic surgery and obstetrics (GS&O) residents and staff physicians at Brooke Army Medical Center. Participants were provided access to the resectoscope surgical set throughout the study, completed a baseline survey assessing surgeon comfort, and then repeated the survey after watching the instructional video. The survey used a 5-point Likert scale with 1) very uncomfortable, 3) neutral, and 5) very comfortable. RESULTS: Of the 20 participants, 85% lacked formal resectoscope training and 45% had no prior resectoscope experience. Prior experience was limited: 55% used it less than five times and 64% had no use in the last year. At baseline, few were comfortable with setup (15%) and troubleshooting (5%). The instructional video significantly increased surgeon comfort with resectoscope setup (P<.001) and troubleshooting (P<.001). Surgeon comfort supervising a resident doubled after the instructional video (33–66%). All participants felt the video was helpful and would recommend it to others (100%; P<.01). Finally, 80% of participants would like more formal training opportunities for other surgical devices. CONCLUSION: This survey demonstrated a gap in surgical experience and comfort using the resectoscope at our institution. The novel instructional resectoscope video improved GS&O resident and staff comfort with setting up and troubleshooting the resectoscope. Staff comfort with supervising a resident using the resectoscope also increased. Future directions include expanding study population to include operating room staff and assessing post-intervention resectoscope utilization rates.

The analysis of demand in pathoanatomists applying staff standards

The objective analysis of state of medical personnel, along with assessment of real need for specialists, is the basis of improving activities of any health care service. In relation to pathologists, there is unique opportunity to perform similar analysis, based on application of current corresponding staff standards that consider volume of workload of physicians in order to determine required number of positions. The implementation of corresponding original methodology permitted to establish that the actual number of staff positions of pathologists in 2022 amounted up to average 40.6% of the number required according to staffing standards in the Irkutsk Oblast. The physician staffing ratio, calculated on the basis of required number of positions found according to proposed methodology, decreases to 29.1% and staffing with physicians excluding combined jobs to 17.1%. At that, implemented workload per one pathologist reaches 5.9 of standard positions. The deficiency of representatives of this specialty in the region, even if current combined jobs ratio is maintained, is 154 specialists.

The influence of viewing time on visual diagnostic accuracy: Less is more.

Understanding the factors that contribute to diagnostic errors is critical if we are to correct or prevent them. Some scholars influenced by the default interventionist dual-process theory of cognition (dual-process theory) emphasise a narrow focus on individual clinician's faulty reasoning as a significant contributor. In this paper, we examine the validity of claims that dual process theory is a key to error reduction. We examined the relationship between a clinical experience (staff and resident physicians) and viewing time on accuracy for categorising chest X-rays (CXRs) and electrocardiograms (ECGs). In two studies, participants categorised images as normal or abnormal, presented at viewing times of 175, 250, 500 and 1000 ms, to encourage System 1 processing. Study 2 extended viewing times to 1, 5, 10 and 20 s to allow time for System 2 processing and a diagnosis. Descriptives and repeated measures analysis of variance were used to analyse the proportion of true and false positive rates (TP and FP) as well as correct diagnoses. In Study 1, physicians were able to detect abnormal CXRs (0.78) and ECGs (0.67) with relatively high accuracy. The effect of experience was found for ECGs only, as staff physicians (0.71, 95% CI =0.66-0.75) had higher ECG TP than resident physicians (0.63, 95% CI =0.58-0.68) in Study 1, and staff had lower ECG FP (0.10, 95% CI =0.03-0.18) than resident physicians (0.27, 95% CI =0.20-0.33) in Study 2. In other comparisons, experience was equivocal for ECG FPs and CXR TPs and FPs. In Study 2, overall diagnostic accuracy was similar for both ECGs and CXRs, (0.74). There were small interactions between experience and time for TP in ECGs and FP in CXRs, which are discussed further in the discussion and offer insights into the relationship between processing and experience. Overall, our findings raise concerns about the practical application of models that link processing type to diagnostic error, or to specific diagnostic error reduction strategies.

Impact of a Strategy for Improving Early Management of Acute Pain in the Pediatric Emergency Department.

The objective of this study was to measure the impact of an intervention on pain treatment in a pediatric emergency department (ED). The application of interventions to improve pain management in DE has demonstrated diverse effects so far, most of them successful. This is a quasi-experimental before-and-after, longitudinal, prospective study.Patients were collected between January 2020 and December 2021. Principal outcome was the number of patients with moderate or severe pain who received analgesia before 30 minutes to the ED arrival. The intervention consisted of several training sessions for nursing staff, pediatricians, and trauma physicians. A total of 515 patients were enrolled, 230 during preintervention period and 285 during postintervention period. The percentage of patients receiving analgesia before 30 minutes increased from 24% to 29% and before 60 minutes increased from 31% to 42%. Time to analgesia administration decreased from 43 to 39 minutes.Only 254 patients (49%) received analgesia at some point during their stay in the ED, 137 (26.6%) before 30 minutes and 193 (37.5%) before 60 minutes. The probability of receiving analgesia was greater in patients seen by a pediatrician rather than an orthopedist (59%-37%). Metamizole was the most commonly used drug (48%), followed by ibuprofen and acetaminophen. The application strategies to enhance early pain treatment in the ED can improve analgesia administration. Training strategies aimed at healthcare personnel working in the ED can change the way they work and achieve clear benefits for the patient. The treatment of pain in the ED should begin as soon as possible, and in this objective, the involvement of the nursing staff is a priority, because they are the professional who has the best opportunity for the detection and treatment of pain from the moment of triage.

Patient Experience With Resident Versus Staff Physicians: Results From a Cross-Sectional Patient Survey From Canadian Family Medicine Residencies.

We compared experiences of patients who reported usually being seen by a resident with those usually seen by a staff physician. We analyzed responses to a patient experience survey distributed at 13 family medicine teaching practices affiliated with the University of Toronto between May and June 2020. We analyzed responses to seven questions pertaining to timely access, continuity, and patient-centeredness. We compared responses between two types of usual primary care clinicians and calculated odds ratios before and after adjustment for patient characteristics. We analyzed data from 6,545 unique surveys; 18.6% reported their usual clinician was a resident physician. Resident patients were more likely to be older, born outside of Canada, report a high school education or less, and report having difficulty making ends meet. Compared to patients of staff physicians, patients of resident physicians had lower odds of being able to see their preferred primary care clinician and lower odds of getting nonurgent care in a reasonable time. They also had lower odds of reporting patient-centered care, but we found no significant differences in whether the time for an urgent appointment was about right or whether accessing care after hours was easy. In our setting, patients who reported usually seeing resident physicians had worse continuity of care and timeliness for nonurgent care than patients who reported usually seeing staff physicians despite resident patients being older, sicker, and having a lower socioeconomic position. Postgraduate training programs need to test models to support access and continuity for resident patient panels.

Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management.

Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management.

Workforce strategies during the first wave of the COVID-19 pandemic: a retrospective online survey at intensive care units in Germany

BackgroundAs the COVID-19 pandemic swept across the globe at the beginning of 2020, healthcare systems were forced to rapidly adapt and expand to meet the sudden surge in demand for intensive care services. This study is the first systematic analysis of the strategies employed by German hospitals to recruit personnel and expand bed capacities during the first wave of the pandemic, and to evaluate the effectiveness of those recruitment measures.Methods152 German hospitals with intensive care capacities were selected and invited to participate in an online-based retrospective survey. Factors like the geographic distribution, individual COVID burden and level of care were considered for inclusion in the sample. The data were analyzed descriptively.ResultsA total of 41 hospitals participated in the survey. The additional demand for intensive care beds was met primarily by activating intensive care beds that were previously considered as non-operational in existing intensive care units (81% of respondents) and by upgrading recovery rooms (73%). The physician staffing requirements were met at approximately 75%, while the nursing staffing requirements were only met by about 45%. Staffing needs were met through reallocations/transfers (85%), staff recruitment from parental leave or retirement (49%), increased hours worked by internal staff (49%), new staff hiring (44%) and increased use of temporary staff (32%). Staff reallocations/transfers to critical care within a hospital were rated as the most effective measure. In this context, specialized personnel mostly from anesthesiology departments were appointed to intensive care medicine.ConclusionsDespite multiple recruitment efforts, the pandemic has exacerbated the nursing staff shortage. The reallocation of existing staff within hospitals was a key element in covering the staffing needs. However, additional measures and efforts are required in order to ensure that critically ill patients can be cared for without compromise. The results of this study may have important implications for healthcare providers and policymakers, offering an evidence-based foundation for responding to future public health emergencies with agility, efficiency, and success.

Coronavirus Disease 2019 Infections Among Emergency Health Care Personnel: Impact on Delivery of United States Emergency Medical Care, 2020

ObjectiveIn the early months of the COVID-19 pandemic and prior to vaccine availability, there were concerns that infected emergency department (ED) healthcare personnel (HCP) could present a threat to the delivery of emergency medical care. We examined how the pandemic affected staffing levels and whether COVID-19 positive staff were potentially infectious at work in a cohort of U.S. ED HCP in 2020. MethodsThe COVID-19 Evaluation of Risks in Emergency Departments (Project COVERED) project was a multicenter prospective cohort study of U.S. ED HCP conducted from May to December 2020. During surveillance, HCP completed weekly electronic surveys and underwent periodic serology and nasal RT-PCR testing for SARS-CoV-2, and investigators captured weekly data on healthcare facility COVID prevalence and HCP staffing. Surveys asked about symptoms, potential exposures, work attendance, personal protective equipment (PPE) use, and behaviors. ResultsWe enrolled 1,673 HCP who completed 29,825 person-weeks of surveillance. Eighty-nine (5.3%) HCP documented 90 (0.3%; 95% CI 0.2-0.4%) person-weeks of missed work related to documented or concerns for COVID-19 infection. HCP experienced symptoms of COVID-19 during 1,256 (4.2%) person-weeks and worked at least one shift while symptomatic during 1,042 (83.0%) of these periods. Seventy-five (4.5%) participants tested positive for SARS-CoV-2 during the surveillance period, including 43 (57.3%) who indicated they never experienced symptoms; 74 (98.7%; 95% CI 90.7%-99.9%) infected HCP worked at least one shift during the initial period of infection, and 71 (94.7%) continued working until laboratory confirmation of their infection. Physician staffing was not associated with the facility or community COVID-19 levels within any time frame studied (Kendall tau’s 0.02, 0.056, and 0.081 for no shift, one-week time-shift, and two-week time shift, respectively). ConclusionDuring the first wave of the pandemic, COVID-19 infections in ED HCP were infrequent, and the time lost from the workforce was minimal. HCP frequently reported for work while infected with SARS-CoV-2 prior to lab confirmation. ED staffing levels were poorly correlated with facility and community COVID-19 burden.

Online ratings and narrative comments of American Head and Neck Society surgeons.

We analyzed online rating scores and comments of head and neck surgeons to understand factors that contribute to higher ratings. Numerical ratings and comments for American Head and Neck Society physicians were extracted from Healthgrades, Vitals, RateMDs, and Yelp, with narrative comments categorized based on content. Physician practice location, education, and residency training were also compiled. Patient ratings were significantly higher with supportive staff and affable physician demeanor but showed significant drops with longer wait times and difficulties scheduling appointments or follow-ups. Physician education and postgraduate training did not significantly affect ratings. Online ratings and comments correlated to modifiable factors in clinical practice and may be informative in understanding patient needs.

Athlete Health and Human Performance Will Not Improve Without Transdisciplinary Collaboration and Data Sharing in Elite Sport.

There are two largely competing models for an athletics organization at both the collegiate and professional levels: the High Performance Model and the Medical Model. The High Performance Model arises from international Football perspective that places a "Performance Director" at the center of teams supporting the athletes. The Medical Model, supported by both the National Athletic Trainers Association and the NCAA, separates off medical staff (athletic trainers, physical therapists, and physicians, predominantly) and emphasizes the autonomy of medical decisions. The Medical Model has left clinicians in a "medical silo", limiting our ability to care for the individual athletes as holistic people and limits our wider impact in the field of athlete health and injury mitigation. We argue that Medical. Model is consistent with the High Performance Model only if we reject the notion that the "Performance Director" is an administrative person and instead conceptualize this as a "Health and Performance Information Hub" which facilitates transdisciplinary collaboration. This Commentary details how a data broker system can be used to accelerate transdisciplinary collaboration within an athletic organization, leading to better healthcare for athletes and improved team and individual performance. Furthermore, a transdisciplinary organization with data sharing is able to turn real-world data into real-world evidence, enhancing the care and performance of athletes locally as well as facilitating the creation of generalizable knowledge in the area of sports medicine and human performance.

Laboratory stewardship perceptions and testing patterns at a pediatric tertiary care center.

Despite stewardship efforts, laboratory testing overuse persists across medicine. To understand laboratory stewardship perceptions and testing patterns at a tertiary care pediatric hospital so that we could identify potential improvement opportunities. An electronic survey exploring laboratory stewardship was sent to all pediatric medicine resident and staff physicians. Laboratory testing data were also assessed for patterns of testing and overuse. The survey response rate was 54% (43/80). The results indicated good familiarity with stewardship but poor familiarity with testing specifics (eg, cost). A mobile reference application was the most preferred quality improvement intervention, and online modules were the least desired. Overuse was apparent, with as many as 53% of laboratory tests being repeated within 7 days and only half of repeated tests subsequently yielding abnormal results. Altogether, the data we collated demonstrated poor understanding of laboratory stewardship and substantial repeat testing with few abnormal results. These study findings suggest that laboratory stewardship is lacking at our center, and that multiple improvement opportunities exist.

Learning to Lead: An Exploration of Leadership Development in Obstetrics and Gynaecology

Despite the demonstrated value of leadership in medicine, there is limited research on how physicians develop leadership skills. We administered a national survey (225 respondents) and conducted eight interviews of residents, fellows, and staff physicians in obstetrics and gynaecology to explore leadership skill development. Most (87%) positively rated the effectiveness of their leadership skills; however, the majority (98%) stated they would benefit from further training. Interview themes indicated that leadership skills can be taught, leadership training and roles should be intentional, training should be longitudinal, and barriers to training can be overcome with changes to the current model.

Abstract 34: Achieving a 30 Minute Door to Needle Time in a Primary Stroke Center via Telestroke

Background: Despite efforts made within the Emergency Department (ED), delays in the administration of thrombolytic time via telestroke remain. A Primary Stroke Center (PSC) aimed to reduce door-to-needle time (DTN) by focusing on ED, EMS, CT and physician staff regarding: door-to-CT process, importance of time goals, IV thrombolysis, and early activation of Telestroke. Methods: A retrospective analysis examined patients who arrived to a PSC and received a telestroke consult in the ED from January 2020 to June 2023. A change in the stroke alert process (January 2023) focused on early notification of stroke alert, CT and telestroke. Thus we compared data from prior to the change in process (January 2020 - December 2022) to after changing the process (January 2023 - June 2023). Primary outcome was a comparison of door-to-needle time (DTN) before and after changing the stroke alert process which was analyzed using a quantile regression specifying the median. Secondary outcomes included: DTN goals within 30, 45, 60 minutes and proportion of IV thrombolysis utilizing hierarchical binomial logistic regressions. Additional outcomes were door-to-CT head (DTCT) and door-to-telestroke (DTSR) analyzed via median regression adjusted for age, NIHSS and arrival modality. All outcomes were adjusted for age, NIHSS and arrival modality (EMS versus private vehicle). Results: Overall 1160 ED telestroke consults occurred the study, with a mean age ± SD of 68.75 ± 15.48. There were 989 consults before and 171 consults after the process change. After changing the ED stroke process, there was a reduction in DTN of 29.26 minutes [95% Confidence Interval (CI), 17.45 - 41.08], p < 0.0001. DTN goals of 30, 45 and 60 minutes were met more often after the change compared to prior, all adjusted p < 0.005. A higher proportion of IV thrombolysis rates occurred after the process change [21 (12.3%) versus 79 (8.0%)], adjusted Odds Ratio (aOR) = 2.18 [95%CI 1.27 - 3.75], p = 0.005. There were significant reductions in DTCT and DTSR after changing the process, all p < 0.001. Conclusion: A standardized workflow with emphasis on early stroke alert and CT resulted in a significant reduction of DTN, and allowed a PSC with telestroke to consistently achieve DTN < 30 minutes.

Reflect, Inspire, Strengthen, and Empower 2.0 Program: Advancing Careers and Leadership for Women Physician Staff in an Academic Institution.

To study the effects of the Reflect, Inspire, Strengthen, and Empower (RISE) 2.0 Program designed for professional development of women staff. Topics included emotional intelligence, appreciative coaching, resilience, and strategic career development. The RISE 2.0 program was held between September 2020 and February 2021. After each session, program satisfaction surveys were sent to evaluate whether session objectives were met. Professional network, professional mentor, and professional goals were surveyed at the introductory session and at 1 month after the program ended. Survey data about leadership self-efficacy, motivation to lead, and well-being were collected at the introductory session (baseline) and at months 1 and 3 to evaluate the sustainability of program outcomes. Of the 71 notified, 41 (58%) committed to the program. Results increased for having a robust professional network from baseline to month 1 for very good (7.3% to 13.3%) and excellent (19.5% to 40%). Those who responded favorably to setting and attaining ambitious goals increased from 78.1% to 93.3%. For leadership self-efficacy, all except 2 respondents reported an increase in ratings from baseline to month 3. Motivation to lead changed only slightly. Well-being scores fluctuated as affected by daily needs and fulfillment. For 10 of 15 respondents, well-being increased overall from baseline to month 1 or 3, from month 1 to 3. Based on participant evaluations and feedback, the RISE 2.0 program received positive responses overall in achieving its learning goals. The program exhibited promise in fostering career advancement and leadership development, particularly when assessed using indicators predictive of successful leadership, such as self-efficacy, motivation to lead, and overall wellbeing.

Design of a model for improving emergency room performance using a colored Petri net

Emergency rooms are one of the most complex and vital areas of healthcare institutions, which have presented overcrowding, long waiting, and length of stay times, affecting the timeliness, responsiveness, and quality of service. This research aimed to design a detailed patient flow model to improve emergency room performance using the hierarchical timed colored Petri nets. Then, the model was simulated to evaluate scenarios considering tactical decisions such as physician staff planning, operational decisions such as adjusting work schedules, and strategic decisions such as increasing observation beds. The best scenario would reduce the average waiting times for triage II patients by 17.30 % and 47.57 %, and triage III by 33.49 % and 43.49 % for medical consultation in the office or the minor surgery room, respectively. In addition, the waiting time in observation and the rate of patients left without being seen by a physician would be reduced by 92.45 % and 74.67 %, respectively. These results improve the quality and timeliness of the service and avoid putting the patient's health and life at risk. The designed model included more attributes for patients concerning the place of medical care in the emergency room, the number of visits to the physician, and the physician who will care for the patient. Moreover, the simulation model includes observation beds as a limited resource blocking new patient admission. Finally, this model is a tool to support emergency room managers in making short, medium, and long-term decisions to address problems such as overcrowding, long waiting and length of stay times, and high rates of patients left without being seen by a physician

Associations of Primary Care Provider Burnout with Quality Improvement, Patient Experience Measurement, Clinic Culture, and Job Satisfaction

BackgroundBurnout among providers negatively impacts patient care experiences and safety. Providers at Federally Qualified Health Centers (FQHC) are at high risk for burnout due to high patient volumes; inadequate staffing; and balancing the demands of patients, families, and team members.ObjectiveExamine associations of provider burnout with their perspectives on quality improvement (QI), patient experience measurement, clinic culture, and job satisfaction.DesignWe conducted a cross-sectional provider survey about their perspectives including the single-item burnout measure. We fit separate regression models, controlling for provider type, gender, being multilingual, and fixed effects for clinic predicting outcome measures from burnout.ParticipantsSeventy-four providers from 44 clinics in large, urban FQHC (52% response rate; n = 174).Main MeasuresSurvey included a single-item, self-defined burnout measure adapted from the Physician Worklife Survey, and measures from the RAND AMA Study survey, Heath Tracking Physician survey, TransforMed Clinician and Staff Questionnaire, Physician Worklife Survey, Minimizing Errors Maximizing Outcomes survey, and surveys by Friedberg et al. 31 and Walling et al. 32ResultsThirty percent of providers reported burnout. Providers in clinics with more facilitative leadership reported not being burned out (compared to those reporting burnout; p-values < 0.05). More pressures related to patient care and lower job satisfaction were associated with burnout (p-values < 0.05).ConclusionsCreating provider-team relationships and environments where providers have the time and space necessary to discuss changes to improve care, ideas are shared, leadership supports QI, and QI is monitored and discussed were related to not being burned out. Reducing time pressures and improving support needed for providers to address the high-need levels of FQHC patients can also decrease burnout. Such leadership and support to improving care may be a separate protective factor against burnout. Research is needed to further examine which aspects of leadership drive down burnout and increase provider involvement in change efforts and improving care.

The relationship between perceptions of electronic health record usability and clinical importance of social and environmental determinants of health on provider documentation.

Social and environmental determinants of health (SEDH) data in the electronic health record (EHR) can be inaccurate and incomplete. Providers are in a unique position to impact this issue as they both obtain and enter this data, however, the variability in screening and documentation practices currently limits the ability to mobilize SEDH data for secondary uses. This study explores whether providers' perceptions of clinical importance of SEDH or EHR usability influenced data entry by analyzing two relationships: (1) provider charting behavior and clinical consideration of SEDH and (2) provider charting behavior and ease of EHR use in charting. We performed a cross-sectional study using an 11-question electronic survey to assess self-reported practices related to clinical consideration of SEDH elements, EHR usability and SEDH documentation of all staff physicians, identified using administrative listserves, at Penn State Health Hershey Medical Center during September to October 2021. A total of 201 physicians responded to and completed the survey out of a possible 2,478 identified staff physicians (8.1% response rate). A five-point Likert scale from "never" to "always" assessed charting behavior and clinical consideration. Responses were dichotomized as consistent/inconsistent and vital/not vital respectively. EHR usability was assessed as "yes" or "no" responses. Fisher's exact tests assessed the relationship between charting behavior and clinical consideration and to compare charting practices between different SEDHs. Cumulative measures were constructed for consistent charting and ease of charting. A generalized linear mixed model (GLMM) compared SDH and EDH with respect to each cumulative measure and was quantified using odds ratios (OR) and 95% confidence intervals (CI). Our results show that provider documentation frequency of an SEDH is associated with perceived clinical utility as well as ease of charting and that providers were more likely to consistently chart on SDH versus EDH. Nuances in these relationships did exist with one notable example comparing the results of smoking (SDH) to infectious disease outbreaks (EDH). Despite similar percentages of physicians reporting that both smoking and infectious disease outbreaks are vital to care, differences in charting consistency and ease of charting between these two were seen. Taken as a whole, our results suggest that SEDH quality optimization efforts cannot consider physician perceptions and EHR usability as siloed entities and that EHR design should not be the only target for intervention. The associations found in this study provide a starting point to understand the complexity in how clinical utility and EHR usability influence charting consistency of each SEDH element, however, further research is needed to understand how these relationships intersect at various levels in the SEDH data optimization process.

Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training

BackgroundHealth care routinely fails Indigenous peoples and anti-Indigenous racism is common in clinical encounters. Clinical training programs aimed to enhance Indigenous cultural safety (ICS) rely on learner reported impact assessment even though clinician self-assessment is poorly correlated with observational or patient outcome reporting. We aimed to compare the clinical impacts of intensive and brief ICS training to control, and to assess the feasibility of ICS training evaluation tools, including unannounced Indigenous standardized patient (UISP) visits.MethodUsing a prospective parallel group three-arm randomized controlled trial design and masked standardized patients, we compared the clinical impacts of the intensive interactive, professionally facilitated, 8- to10-h Sanyas ICS training; a brief 1-h anti-bias training adapted to address anti-Indigenous bias; and control continuing medical education time-attention matched to the intensive training. Participants included 58 non-Indigenous staff physicians, resident physicians and nurse practitioners from family practice clinics, and one emergency department across four teaching hospitals in Toronto, Canada. Main outcome measures were the quality of care provided during UISP visits including adjusted odds that clinician would be recommended by the UISP to a friend or family member; mean item scores on patient experience of care measure; and clinical practice guideline adherence for NSAID renewal and pain assessment.ResultsClinicians in the intensive or brief ICS groups had higher adjusted odds of being highly recommended to friends and family by standardized patients (OR 6.88, 95% CI 1.17 to 40.45 and OR 7.78, 95% CI 1.05 to 58.03, respectively). Adjusted mean item patient experience scores were 46% (95% CI 12% to 80%) and 40% (95% CI 2% to 78%) higher for clinicians enrolled in the intensive and brief training programs, respectively, compared to control. Small sample size precluded detection of training impacts on clinical practice guideline adherence; 100% of UISP visits were undetected by participating clinicians.ConclusionsPatient-oriented evaluation design and tools including UISPs were demonstrated as feasible and effective. Results show potential impact of cultural safety training on patient recommendation of clinician and improved patient experience. A larger trial to further ascertain impact on clinical practice is needed.Trial registrationClinicaltrials.org NCT05890144. Retrospectively registered on June 5, 2023.

A mixed-methods needs assessment for an antimicrobial stewardship curriculum in pediatrics.

Antimicrobial stewardship (AS) education initiatives for multidisciplinary teams are most successful when addressing psychosocial factors driving antimicrobial prescribing (AP) and when they address the needs of the team to allow for a tailored approach to their education. We conducted a mixed-methods embedded study as a needs assessment, involving quantitative analysis of AS concerns observed by pharmacists through an audit while attending clinical team rounds, as well as qualitative semi-structured interviews based on the Theoretical Domain Framework (TDF) to identify psychosocial barriers and facilitators for antimicrobial prescribing for an inpatient general pediatric service. We analyzed the data using deductive and inductive methods by mapping the TDF to a model for social determinants of antimicrobial prescribing (SDAP) in pediatric inpatient health care teams. The Clinical Teaching Unit (CTU) and Pediatric Intensive Care Unit (PICU), at a tertiary care pediatric hospital in Canada. Interviews (n = 23) with staff and resident physicians, nurse practitioners, and pharmacists. Psychosocial facilitators and barriers for AS practice in the PICU and CTU which were identified included: collaboration, shared decision-making, locally accessible guidelines, and an overarching goal of doing right by the patient and feeling empowered as a prescriber. Some of the barriers identified included the norm of noninterference, professional comparisons, limited resources, feeling inadequately trained in AS, emotional prescribing, and a pejorative monitoring system. Our findings identified barriers and facilitators to AS decisions on pediatric inpatient teams as well as actionable needs in psychosocial-based AS education.

Emergency Department Recognition of Delirium: Quality Improvement Towards a Geriatric-Friendly ED

Introduction: Delirium is a common yet often undetected condition in the elderly, particularly in the Emergency Department (ED). Its subtle presentation makes timely recognition challenging. Literature shows up to 10% of older patients presenting to the Emergency Department will have Delirium, but typically only 30% of these cases are identified in the Emergency Department. Aims/Objectives: To implement quality improvement measures for early recognition of delirium in geriatric patients aged 65+ in a single center ED. Specific objectives include staff training on delirium identification, enhancing screening protocols, and implementing interventions to address delirium promptly. Materials/Methods: ED staff providers underwent systematic training to optimize integration of Delirium Triage Screening (DTS) and Confusion Assessment Method (CAM), customized to the UAE patient population, into the geriatric ED workflow. A multidisciplinary team consisting of Geriatrics, Internal Medicine, ED Staff Physicians &amp; Nurses established Quality Improvement Projects as part of a transition to a geriatric-friendly ED. Patients diagnosed with Delirium were retrospectively studied across 3 months to assess for use of DTS and CAM in ED evaluation. Results: The collected data demonstrates a small percentage of patients with a diagnosis of Delirium. Given that the average frequency of Delirium tends to be around 10% in geriatric patients presenting to the ED, the presence of Delirium at our ED at 0.97% may represent a possible under-diagnosis of the condition. Documentation for both DTS and CAM was suboptimal, well below the target of at least 90%. While the policy prepared was comprehensive, communication of the recognition and assessment pathways could be improved. Discussion: Following suboptimal initial results, dedicated internal departmental learning lectures were organized that focused specifically on the DTS and CAM assessments, with ample time for questions and answers with discussion to best understand and integrate these assessments into our ED workflow. Conclusion: An improved understanding of Delirium, followed by an enhanced integration of validated screening tools will invariably improve ED recognition of Delirium, thereby improving patient-oriented outcomes for elderly individuals presenting to the ED.