Resident Teams Research Articles

Specialized Resident Force in Internal Medicine Residency Program Helps Modify Risk of Heart Failure Readmissions: A Performance Improvement Project

Introduction Heart Failure (HF) is a leading cause of hospitalization, mortality and health care costs in the U.S. HF is the most common cause of readmissions in Medicare patients, with >20% readmitted within 30 days of hospital discharge. Several interventions have been tried to lower readmissions involving patient, provider and related disciplines, without significant long-term impact. Hypothesis Development of a specialized team of internal medicine residents trained to educate and counsel HF patients, will enhance disease state knowledge of the disease, improve self-care and reduce hospital readmissions among patients admitted with acute decompensated HF (ADHF). Methods In August 2017, a team of 9 Internal Medicine residents were recruited to create a Specialized Resident Force (SRF). The residents received individual hands-on training sessions in counseling HF patients and met with a mentor weekly initially, later monthly. Patients on 2 selected medicine units with a high volume of HF admissions were counseled by the SRF on diet, activity, medication use, weight monitoring and outpatient follow-up. Demographic data, comorbidities and HF specific data was gathered and compared to patients receiving standard education. Patients were evaluated for cognition and advance directives. In the cognitively impaired, education was offered to the caregiver, if available. A tool was developed to document data; a booklet on HF education and a 2 page easy to use script to help counsel patients at bedside was provided to each resident. Results Enhanced SRF education was provided to 44 patients between September and December 2017. Education provided by the SRF resulted in 55.7% reduction in the 30 day all cause readmission rate (see Table 1 ) Observations by the mentor suggested that knowledge base of SRF trainees improved as a result of participation. Conclusions Specialized internal medicine resident teams providing bedside education to patients with ADHF may favorably influence HF readmissions, while simultaneously enhancing resident knowledge base on HF management; Academic medical centers can easily incorporate resident driven patient education into existing readmission reduction efforts

Identifying Addressable Factors That Impact Heart Failure Readmissions: Cognitive Impairment, Anemia And Chronic Kidney Disease

Introduction Heart Failure (HF) is a leading cause of hospitalization, 30 day readmissions and a health care burden. Preventing readmissions is priority. Although immediate management and counseling of patients occurs routinely, several comorbid factors may not receive recognition or be adequately addressed. Hypothesis Non-adherence to diet and medications is well recognized as contributory to readmissions for HF. Many other factors may impact HF readmissions, warranting consideration. As a QI project, we studied the prevalence of the following 4 factors in patients with HF, that were addressable during or after hospitalization. Cognitive impairment: adversely influences adherence to diet, medications, follow-up; Anemia: adversely affects cardiac function and may be treatable; Chronic Kidney Disease (CKD): warrants revisions of medication regimens, especially diuretics, ACE inhibitors, etc; Advance directives: presence or absence alters management approaches Methods In August 2017, a team of 9 Internal Medicine Residents were provided individual hands-on sessions in evaluating and counseling HF patients in 2 medicine units. As a QI project, data was gathered on age, gender, comorbidity and basic lab including hemoglobin, serum creatinine. If anemic, a search for etiology was prompted. Residents were taught to evaluate for cognition using the Mini-Cog (3 item recall + clock drawing). In the cognitively impaired, education was offered to the caregiver, if available. CKD was identified. Patients were asked about advance directives with opportunity to implement if interested. Results The trained resident team evaluated 44 patients with HF (Sept - Dec 2017) and addressed the 4 factors stated above. See table. Conclusions Although age is non-modifiable, several addressable factors that impact outcomes, including readmissions, are prevalent in patients with HF. The findings call for targeted approaches: o counsel the caregiver if patient is cognitively impaired; o evaluate etiology of anemia; attempt correction if appropriate; o revise medication regimens in those with CKD; o and address advance directives.

The effectiveness of a station-based education program in rural Honduras

Background: Over the past decade, medical students and residents have been increasingly involved in global health programs. The Global Health and Health Disparities Pathway (GH2DP) at Virginia Commonwealth University (VCU) operates free clinics in La Hicaca, Honduras. GH2DP has been sending teams of medical students, residents and pharmacy students to the area to provide healthcare. GH2DP has a tripartite mission: to improve the health of impoverished people, the education of health science trainees and research. In 2010 GH2DP clinics moved to a “Station-Based” clinical care model. Learners who rotate through each clinical station are expected to learn core material specific to that station; the effectiveness of this approach has not been formally studied previously. Methods & Materials: Medical students and residents participated in a health outreach trip to Yoro, Honduras, in June 2015. All learners took a pretest with questions pertaining to dermatology, physical exam, chronic diseases, GI, infectious diseases and demographics. They rotated through the following clinical stations: 1) dermatology/physical exam 2) screening for diabetes/hypertension 3) gastrointestinal issues. Once a learner had completed rotating through all of the stations they took a post-test survey. These data were evaluated for exam performance by learner type for core knowledge specific to the stations (“Derm/PE/chronic diseases/GI”) and knowledge that was emphasized on the trip but not formally taught (“ID/demographics”). Results: Table 1, Table 2Table 1Medical StudentsCategoryPretestPosttest% changeP-valueDerm/PE/chronic diseases/GI(21 Qs)58/105(55.2%)90/105(85.7%)30.5 < 0.0001ID/demographics (9Qs)25/45(55.6%)38/45(84.4%)28.80.0028 Open table in a new tab Table 2Medical ResidentsCategoryPretestPosttest% changeP-valueDerm/PE/chronic diseases/GI(21 Qs)58/84(69.0%)80/84(95.2%)26.2 < 0.0001ID/demographics (9Qs)15/36(41.7%)26/36(72.2%)30.50.0088 Open table in a new tab Conclusion: The effectiveness of educational activities associated with a Station Based care delivery model on short-term health outreach trips has never been formally assessed. This may serve as a useful tool in enhancing the educational value of outreach trips for medical students and residents.

Use of a daily rounding checklist on the Clinical Teaching Unit improves interdisciplinary communication around discharge

Abstract BACKGROUND As the care needs of the paediatric inpatient population become increasingly complex, demands for hospitalization and efficient patient flow have resulted in the need for increased attention to discharge processes. Inefficient discharges impact flow throughout the healthcare system, extend length of stay, increase health care costs and decrease patient satisfaction. As a large inpatient service with high staff turnover, our Clinical Teaching Unit (CTU) experiences considerable variability in approach to discharge planning. Prior work at our institution has recognized inconsistent practice and gaps in communication around discharge planning as challenges to efficient patient discharge. OBJECTIVES Using quality improvement (QI) methodology, we aimed to decrease discharge delays on CTU, by implementing a process to identify and document patient specific discharge criteria. By focusing on discharge criteria, we sought to improve communication regarding discharge goals and patient readiness between care members, encouraging early discharge planning. DESIGN/METHODS We implemented a standardized CTU rounding checklist for use during daily inpatient rounds. On this checklist, physicians were instructed to document clear, patient-specific discharge criteria. Use of the checklist was encouraged through multiple avenues, including announcements at educational events, real time feedback on use to the front-line care teams and a monthly competition between resident teams. Through Plan-Do-Study-Act (PDSA) cycles, we collected feedback from the multidisciplinary team, and the checklist underwent multiple iterations to optimize use. CTU inpatient rounds were observed weekly and outcome, process and balance measures were collected. RESULTS With implementation of the checklist, a cultural shift towards explicit, thoughtful discussion of discharge criteria and planning was observed on daily patient rounds. Identification of patient specific discharge criteria increased from less than 30% to over 90% after implementation of the checklist. The purposeful documentation of discharge criteria received positive nursing feedback, and nursing awareness of discharge goals improved from 20–30% to over 70%. Improvements were sustained over a six-month period. CONCLUSION This QI project utilized a daily rounding checklist to engage care teams in purposeful conversations around discharge on rounds. By documenting patient-specific discharge criteria, interdisciplinary communication was improved and bedside nurses felt better informed of discharge goals. Future project directions include the development of diagnosis specific standardized discharge criteria, exploration of specific discharge barriers, and identification of institution-specific resources that may help alleviate these delays to further improve discharge efficiency.

Geographically Localized Medicine House-Staff Teams and Patient Satisfaction.

Background:Geographically localized care teams may demonstrate improved communication between team members and patients, potentially enhancing coordination of care. However, the impact of geographically localized team on patient experience scores is not well understood.Objective:To compare experience scores of patients on resident teams home clinical units with patients assigned to them off of their home units over a 10-year period.Participants:Patients admitted to any of the 4 chief resident staffed internal medicine inpatient service were included. Patients admitted to the house-staff teams’ home clinical unit comprised the exposure group and their patients off of their home units comprised the control patients.Measurement:Top-box experience scores calculated from the physician Hospital Consumer Assessment of Healthcare and Provider Systems (HCAHPS) and Press Ganey patient satisfaction surveys.Results:There were 3012 patients included in the study. There were no significant differences in experience scores with physician communication, nursing communication, pain, or discharge planning between the 2 groups. Patients did not report satisfaction more often with the time physicians spent with them on localized teams (48.6% vs 47.5%; P = .54) or that staff were better at working together (63.2% vs 61.3%; P = .29). This did not change during a 45-month period when the proportion of patients on home units exceeded 75% and multidisciplinary rounds were started.Conclusion:Patients cared for by geographically localized teams did not have better patient experience. Other factors such as physician communication skills or limited time spent in direct care may overshadow the impact of having localized teams. Further research is needed to better understand organizational, team, and individual factors impacting patient experience.

Reflection on and Exploration of a Standardized Resident Training Programme Based on a Comprehensive Examination of Clinical Skills

To identify the optimal clinical skills training programme for internal medicine residents by reflecting upon and analysing the usual training plan and arrangement, and practical tests according to the national standardized resident training policies and requirements. The 3-year-rotation and training plan of the 2013 and 2014 internal medicine resident cohorts, the basic skills and case analysis scores on the basic entrance examination and final graduation examination were reflected, summarized and compared with the ultimate purpose of evaluating standardized resident training. This knowledge was used to perfect a competency-oriented training system that integrated clinical theory, clinical scenarios, clinical skills, bedside teaching, learning, etc. After a 3-year programme of standardized training, the residents’ clinical skills were significantly improved. Statistically significant enhancements (P&lt;0.05) were observed in the case analysis and clinical skills test scores between the basic entrance and graduation examinations of the trainees in both the 2013 and 2014 cohorts. No significant differences (P&gt;0.05) were observed between the trainees in the 2013 and 2014 cohorts in their graduation scores on the clinical skills and case analysis tests, suggesting that both cohorts achieved the same level of mastery and reached the standardized training target, which also reflected the homogeneity of the residency training programme. While this study indicated that the training method was effective, exploring better models in the future is warranted. In conclusion, as a national policy, continuously incorporating reflection and exploration is necessary for designing a reasonable programme for standardized resident training. In this study, analysis of the basic entrance and graduation examinations of comprehensive clinical skills were important for developing an effective standardized resident training programme and training team with satisfactory teaching effects. By this way, implementing and starting new training methods gradually will be improved and especially carried out from 2015 cohorts. Therefore, the residents' clinical competence will be enhanced and also for undergraduates’ and postgraduates’ education as well. At last, the national education criteria for residency will be met.

Bring Yourself to Work.

Bring Yourself to Work.

A Food Poisoning Outbreak in Al-Khazir U2 Camp of Internally Displaced Persons - Iraq, Summer 2017

Background Globally, about 600 million fall ill and 420,000 die every year after eating contaminated food. On June 12, 2017, Iraq CDC informed about a food poisoning outbreak among internally displaced persons (IDPs) in Al-Khazir camp, Northern Iraq after consuming “Iftar” (Ramadan breakfast) provided by an NGO. “Iftar” was composed of rice, white bean broth, chicken, yogurt, date and bread. Objective The objective was to describe the outbreak, identify the causative agent and recommend preventive measures. Methods A team of FETP residents dispatched to investigate the outbreak. The case patient was defined as any person in the camp who ate “Iftar” and developed nausea/vomiting or diarrhea or abdominal pain. A retrospective cohort study was initiated. Results Conclusions The large number of ordered meals from a single restaurant led to suboptimal food preparation and storage. We recommended rigorous implementation of food handing instructions and health education of the food handlers.

Assessing nontechnical skills in otolaryngology emergencies through simulation-based training.

Nontechnical skills (NTS) are essential to emergency crisis management. Due to the rarity of true emergencies, they are challenging to teach and assess within a competency-based curriculum. Our purpose is to evaluate the utility of the Non-Technical Skills in Surgery (NOTSS) scale in NTS assessment in simulated otolaryngology and head and neck surgery (OTO-HNS) emergencies and identify common challenges that residents encounter. Mixed methods analysis of 15 junior OTO-HNS resident teams in four simulated emergency scenarios. Six raters rated resident NTS performance using the NOTSS score. Constructivist-grounded theory was used to analyze scenario video transcripts to identify areas of learner difficulty to guide future simulation development. Residents scored highest in situational awareness and lowest in leadership domains. Raters showed good consistency and reliability overall (Cronbach's alpha = 0.885). There was no statistical difference in ratings between surgical experts and nonexperts. Qualitative analysis demonstrated challenges with closed-loop communication and handling transitions of leadership with the scenarios. Simulation-based training is an effective modality to teach NTS in crisis resource management. The NOTSS rating scale is a reliable instrument for assessing NTS in simulated OTO-HNS emergencies. Incorporating the NOTSS scale for NTS assessment within a competency-based curriculum is recommended. NA. Laryngoscope, 128:2301-2306, 2018.

Impact of a pharmacy team-led intervention program on the readmission rate of elderly patients with heart failure.

The results of a study to determine whether pharmacy team-led postdischarge intervention can reduce the rate of 30-day hospital readmissions in older patients with heart failure (HF) are reported. A retrospective chart review was performed to identify patients 60 years of age or older who were admitted to an academic medical center with a primary diagnosis of HF during the period March 2013-June 2014 and received standard postdischarge follow-up care provided by physicians, nurses, and case managers. The rate of 30-day readmissions in that historical control group was compared with the readmission rate in a group of older patients with HF who were admitted to the hospital during a 15-month intervention period (July 2014-October 2015); in addition to usual postdischarge care, these patients received medication reconciliation and counseling from a team of pharmacists, pharmacy residents, and pharmacy students. Twelve of 97 patients in the intervention group (12%) and 20 of 80 patients in the control group (25%) were readmitted to the hospital within 30 days of discharge (p = 0.03); 11 patients in the control group (55%) and 7 patients in the intervention group (58%) had HF-related readmissions (p = 0.85). In a population of older patients with HF, the rate of 30-day all-cause readmissions in a group of patients targeted for a pharmacy team-led postdischarge intervention was significantly lower than the all-cause readmission rate in a historical control group.

Rapid Response: To Scan or Not to Scan? The Utility of Noncontrast CT Head for Altered Mental Status.

The aims of the study were the following: (1) to determine how often computed tomography (CT) scans of the head are obtained on rapid responses called for altered mental status (AMS), (2) to determine whether CT imaging of the head is required during all rapid responses called for AMS, (3) to determine which patients would benefit from CT scans of the head in this setting, (4) to note whether an adequate neurologic exam was documented, (5) to determine the cost of CT scans that did not change management, and (6) to examine the role of medications leading to AMS. The study was a retrospective chart review at Abington Jefferson Hospital. Data collected included the age, sex, time of rapid response, clinical condition of the patient, whether an arterial blood gas and blood glucose were done, and whether a neurological exam was documented in the resident's rapid response team note. The patien's medications were also reviewed. Computed tomography scan findings as well as changes made in a patient's care as a result of the scan were recorded. Any findings that did not lead to a change in management were considered a "negative" scan. Overall, 610 rapid responses were activated from January to August 2016. One hundred four (17.04%) of the total rapid responses were for AMS and 83 (79.8%) of these patients underwent noncontrast CT scan of the head. The mean (SD) age of the patients was 74.7 (13.6) years. A total of 56.6% were female. The most frequent clinical conditions documented at the time of rapid responses were noted as confused (33.7%, 28/83), either lethargic or unconscious (32.5%, 27/83), and concern for stroke (21.7%, 18/83). A total of 96.4% (80/83) of the CT scans done were negative for any acute changes. The three patients with positive scans (3/83) had a change in management as a result of the scans. If patients with symptoms concerning for stroke and unconscious patients are excluded, the total number of remaining patients is 56. Of these, zero patients had a positive scan. A total of 64.7% of the rapid response teams were activated either in the afternoon (31.3%) or at night (33.7%). A total of 33.7% had a complete neurological exam documented. A total of 66.2% were either incomplete (34.9%) or absent (31.3%). Sixty percent of the patients who had a CT head for AMS also had a blood sugar checked at bedside. Thirty-eight percent had an arterial blood gas. More than half the patients were taking one or more sedating medications (45/83, 57.8%). Most patients were not on anticoagulants (79.5%). The findings of this study suggest that CT scan of the head is useful in older patients, patients with symptoms concerning for stroke, or cases of sudden onset of impaired consciousness. Noncontrast CT scans of the head are not useful for other presentations of AMS.

Crisis Management Simulation: Establishing a Dual Neurosurgery and Anesthesia Training Experience.

Simulation training has been shown to be an effective teaching tool. Learner management of an intraoperative crisis such as a major cerebrovascular bleed requires effective teamwork, communication, and implementation of key skill sets at appropriate time points. This study establishes a first of a kind simulation experience in a neurosurgery/anesthesia resident (learners) team working together to manage an intraoperative crisis. Using a cadaveric cavernous carotid injury perfusion model, 7 neurosurgery and 6 anesthesia learners, were trained on appropriate vascular injury management using an endonasal endoscopic technique. Learners were evaluated on communication skills, crisis management algorithms, and implementation of appropriate skill sets at the right time. A preanatomic and postanatomic examination and postsimulation survey was administered to neurosurgery learners. Anesthesia learners provided posttraining evaluation through a tailored realism and teaching survey. Neurosurgery learners' anatomic examination score improved from presimulation (33.89%) to postsimulation (86.11%). No significant difference between learner specialties was observed for situation awareness, decision making, communications and teamwork, or leadership evaluations. Learners reported the simulation realistic, beneficial, and highly instructive. Realistic, first of kind, clinical simulation scenarios were presented to a neurosurgery/anesthesia resident team who worked together to manage an intraoperative crisis. Learners were effectively trained on crisis management, the importance of communication, and how to develop algorithms for future implementation in difficult scenarios. Learners were highly satisfied with the simulation training experience and requested that it be integrated more consistently into their residency training programs.

Analgesia Post Abdominal Surgery: Intravenous vs. Continuous Thoracic Epidural Pain Management

Introduction/Background: This study evaluates the effects of continuous thoracic epidural analgesia (TEA) vs. intravenous pain control methods on the narcotics requirement for common laparoscopic abdominal surgeries. The introduction of new guidelines at Tampa General Hospital for the year 2017 afforded the opportunity for a sequential case series analysis of these two methods of pain management. Methods: A sequential case-series on patients undergoing laparoscopic or robot assisted abdominal surgery was performed. Patients were recruited upon request of surgeons using the same nurses and resident support team. Data were obtained from retrospective chart review following local IRB approval and evaluated for the effects of intravenous analgesia compared to continuous T9-10 epidural analgesia. Primary outcomes were intraoperative, 24 h and post-24 h opioid use in morphine milligram equivalents (MME). Length of hospital stay and VAS pain scores were also collected. Results: There was no significant difference in terms of age, gender, and BMI between groups. When compared patients who received epidural reported significantly lower pain scores in the first 24 h after surgery (p<0.05) and for the remainder of their hospital stay (p<0.05). Significant decreases in narcotic requirement was noted in the PACU (p<0.001), the first 24 h after surgery (p<0.001), and aggregate use per day (p<0.01). Conclusions: Continuous thoracic epidural analgesia is a viable alternative to intravenous pain control for patients undergoing common laparoscopic surgeries. Further research is required to determine the risks and benefits of TEA for laparoscopic colorectal surgery.

Resident assessment facilitation team: collaborative support for activated learning

Because healthcare knowledge, practices and systems change so rapidly, physicians-in-training need to develop skills related to lifelong learning. The adult learning paradigm defines the effective professional learner as autonomous and activated. A part of the residency’s p4 (Preparing the Personal Physician for Practice) redesign, the RAFT (Resident Assessment Facilitation Team) process was designed to encourage residents’ adoption of activated learning behaviors by incorporating their participation in team-based educational planning and assessment of competence. This study examined interaction within the RAFT meetings to guage residents’ adoption of activated learning behaviors over time. In this study, transcripts of RAFT meetings from a single cohort of residents during the first and third years of training were analyzed using a grounded theory approach. Teams of at least two analysts per transcript engaged in two rounds of descriptive coding and three levels of axial coding to examine interaction during the RAFT meetings and identify how that interaction was related to residents’ activated learning. Four categories of interaction were identified: advising, managing the process of the meeting, expressing and managing emotion, and demonstrating reflective practice and mindfulness. Across those categories, 36 sub-types of messages indicated both similarities and differences between first- and third-year residents. Specifically, third-year residents took a more active leadership role in meetings; faculty team members were more likely to hand over responsibility for problem solving to thirdyear residents. Integrating residents into the RAFT advising and assessment process provides a context for residents to practice and exhibit activated learning behaviors.

거주자 및 상인 집단의 도시재생사업 만족도에 관한 연구 : 서울시 도시재생활성화지역 13곳을 대상으로

The purpose of this research is to suggest an implication of policy to improve the satisfaction of residents and merchants who are the main participants in the Seoul Urban Regeneration Project. This research compares and analyzes the factors that influence the resident and merchant satisfaction in the Seoul Urban Regeneration Activation Regions by multiple regression analysis. The results are as follows: The factors affecting the resident groups achievements include the role of the urban regeneration support center, the support and role of the local government, and improvement of the residential environment. The factors affecting the merchant group include the support and part of the local government, residential environment improvement, the participatory local event, and the community involvement in the project. The following factors are required to enhance the resident and merchant satisfaction. First, the support and services from administrative districts must be boosted, and improvement in the residential environment must be prioritized. Then, we need to discriminate as to whether there is a need for involvement between community residents and the merchant group. For the resident team, indirect participation around the urban regeneration support center is suitable. If the merchant group is impacted by the district project, more direct participation and reflection on the group’s opinions are required for higher efficiency. This research proposal is significant, as it examines strategies to improve the primary participants’satisfaction with the ongoing project.

ROSC rates and live discharge rates after cardiopulmonary resuscitation by different CPR teams - a retrospective cohort study

BackgroundPrevious studies have reported that the quality of cardiopulmonary resuscitation (CPR) is closely associated with patient outcomes. The aim of this study was to compare patient CPR outcomes across resident, emergency medicine, and rapid response teams.MethodsThe records of patients who underwent CPR at the Seoul National University Bundang Hospital from January 1, 2013 to December 31, 2016 were analyzed retrospectively. Return of spontaneous circulation, 10- and 30-day survival, and live discharge after return of spontaneous circulation were compared across patients treated by the three CPR teams.ResultsOf the 1145 CPR cases, 444 (39%) were conducted by the resident team, 431 (38%) by the rapid response team, and 270 (23%) by the emergency medicine team. The adjusted odds ratios for the return of spontaneous circulation and subsequent 10-day survival among patients who received CPR from the resident team compared to the rapid response team were 0.59 (P = 0.001) and 0.71 (P = 0.037), respectively. There were no significant differences in the 30-day survival and rate of live discharge between patients who received CPR from the rapid response and resident teams; likewise, no significant differences were observed between patients who received CPR from the emergency medicine and rapid response teams.ConclusionsPatients receiving CPR from the rapid response team may have higher 10-day survival and return of spontaneous circulation rates than those who receive CPR from the resident team. However, our results are limited by the differences in approach, time of CPR, and room settings between teams.

The Rise of Hospitalists: An Opportunity for Clinical Ethics

Translating ethical theories into clinical practice presents a perennial challenge to educators. While many suggestions have been put forth to bridge the theory-practice gap, none have sufficiently remedied the problem. We believe the ascendance of hospital medicine, as a dominant new force in medical education and patient care, presents a unique opportunity that could redefine the way clinical ethics is taught. The field of hospital medicine in the United States is comprised of more than 50,000 hospitalists-specialists in inpatient medicine-representing the fastest growing subspecialty in the history of medicine, and its members have emerged as a dominant new force around which medical education and patient care pivot. This evolution in medical education presents a unique opportunity for the clinical ethics community. Through their proximity to patients and trainees, hospitalists have the potential to teach medical ethics in real time on the wards, but most hospitalists have not received formal training in clinical ethics. We believe it is time to strengthen the ties between hospital medicine and medical ethics, and in this article we outline how clinical ethicists might collaborate with hospitalists to identify routine issues that do not rise to the level of an "ethics consult," but nonetheless require an intellectual grounding in normative reasoning. We use a clinical vignette to explore how this approach might enhance and broaden the scope of medical education that occurs in the inpatient setting: A patient with an intra-abdominal abscess is admitted to the academic hospitalist teaching service for drainage of the fluid, hemodynamic support, and antimicrobial therapy. During the initial encounter with the hospitalist and his team of medical students and residents, the patient reports night sweats and asks if this symptom could be due to the abscess. How should the hospitalist approach this question?

The Effectiveness of a Novel Simulation Training Program for Resident Rapid Response Team Leaders

The Effectiveness of a Novel Simulation Training Program for Resident Rapid Response Team Leaders

Multidisciplinary interventions and continuous quality improvement to reduce unplanned extubation in adult intensive care units

We conduct a retrospective study of patients with unplanned extubation (UE) in adult intensive care units (ICU) at a medical center. In 2001, a multidisciplinary team of intensivists, senior residents, nurses, and respiratory therapists was established at Chi Mei Medical Center. The improvement interventions, implemented between 2001 and 2015, were organized around 8 key areas: standardizing procedures, improving communication skills, revising sedation and weaning protocols, changing strategies for restraints, establishing a task force for identifying and managing high-risk patients, using new quality-improvement models as breakthrough series and team resource management, using the strategy of accountability without assigning blame, and changing a new method to secure endotracheal tube. We measured the outcome as the annual event and the rate of UE. During this 15-year period, there were 1404 episodes of UE, with 44,015 episodes of mechanical ventilation (MV) (319,158 ventilator-days). The overall rate of UE was 3.19/100 ventilated patients (4.40/1000 ventilator-days). In 2001, there were 188 episodes of UE and the rate of UE was 6.82/100 ventilated patients or 9.0/1000 ventilator-days. After this continue quality improvement project had been implemented, the annual number of episodes of UE declined to 27, and the rate fell to 0.95/100 ventilated patients or 1.36/1000 ventilator-days in 2015. Overall, the trend analysis showed the change was significant with P < .0001. In conclusion, UE in adult ICU can be continuously and effectively reduced using multidisciplinary and sequential quality improvement interventions.

Scheduling internal medicine resident rotations to ensure fairness and facilitate continuity of care.

Completing a residency program is a requirement for medical students before they can practice medicine independently. Residency programs in internal medicine must undergo a series of supervised rotations in elective, inpatient, and ambulatory units. Typically, a team of chief residents is charged to develop a yearly rotational schedule. This process is complex, as it needs to consider academic, managerial, regulatory, and legal restrictions while also facilitating the provision of patient care, ensuring a diverse educational experience, balancing the workload, and improving resident satisfaction. This study proposes (1) a multi-stage multi-objective optimization approach for generating yearlong weekly resident rotation schedules and (2) the use of Analytical Hierarchy Process (AHP) to compare schedules across multiple criteria to select those that are more equitable and hence to facilitate their adoption and implementation. Furthermore, the proposed approach allows the scheduling of periodic clinic rotation schemes that are commonly used to facilitate continuity of care, such as "4+1" or the "8+2" policies. In the "4+1" policy residents rotate for four consecutive weeks in different units prior to return for a week to a predetermined clinical post. Similarly, in the "8+2" policy, residents rotate eight weeks across multiple units before doing a two week rotation at a predetermined clinic.