Self-reported Changes In Practice Research Articles

Using the Project ECHO Model to Increase Pediatric Primary Care Provider Confidence to Independently Treat Adolescent Depression.

The model for the Extension for Community Healthcare Outcomes (Project ECHO®) was used to extend specialist support to the pediatric medical home for the treatment of adolescent depression by taking a comprehensive, disease-specific approach. Child and adolescent psychiatrists constructed a course to train community pediatric primary care providers (PCPs) to screen patients for depression, initiate evidence-based interventions, and provide ongoing management. Participants were assessed for changes in clinical knowledge and self-efficacy. Secondary measures included self-reported practice change and emergency department (ED) mental health referrals 12months pre- and post-course completion. Sixteen out of 18 participants in cohort 1 and 21 out of 23 participants in cohort 2 completed the pre- and post-assessments. Clinical knowledge and self-efficacy showed statistically significant improvement pre- and post-course completion. ED mental health referrals from participant PCPs decreased by 34% (cohort 1) and 17% (cohort 2) after course completion. These findings indicate that utilizing the Project ECHO format to provide subspecialist support and education on the treatment of depression can improve pediatric PCPs' clinical knowledge and confidence in their ability to independently treat depression. Secondary measures suggest that this can translate into practice change and improved treatment access with decreased ED referrals for mental health assessments by participant PCPs. Future directions include more robust outcomes measurement and developing more courses with an in-depth approach to a single or similar cluster of mental health diagnoses such as anxiety disorders.

Advancing CAR T-Cell Care in Relapsed/Refractory Multiple Myeloma: Insights from a Collaborative Quality Improvement Initiative

Background Multiple myeloma (MM) is most often diagnosed in late stages where the risk of relapse or progression is highest. Treatment of patients with relapsed disease refractory to many available treatment options poses a substantial clinical challenge for providers. Recently approved chimeric antigen receptor (CAR) T-cell therapies have proven efficacious in highly relapsed/refractory MM. Despite CAR T-cell therapy's efficacy, many challenges and barriers to optimal treatment exist in the integration, communication, and care collaboration between centers related to CAR T-cell therapy for MM patients. To improve quality care related to T-cell therapy treatment in MM, we conducted a quality initiative (QI) study focused on evidence-based integration of CAR T-cell therapy, communication, and care coordination between community oncology clinics and regional CAR T-cell therapy performing centers. Methods Building on the design of our prior QI programs (Hussein ASCO 2020), this initiative includes baseline (n = 93) and follow-up provider surveys, and small-group, team-based audit-feedback (AF) sessions. Survey questions were designed to assess knowledge, confidence, and experiences using CAR T-cell therapy in MM treatment. Care teams from each clinic, along with a CAR T-cell expert from the regional center and nationally renowned expert CAR T-cell physician, participated in audit and feedback sessions to (a) assess system-specific practice gaps identified via the provider surveys, (b) prioritize areas for improvement, and (c) develop action plans for addressing root causes. Additional surveys completed before and after the AF sessions will measure changes in participants’ beliefs and confidence in care delivery. Results Provider Surveys: Providers top reported challenges encountered with CAR T-cell therapy include identifying patients eligible for treatment with CAR T-cell therapy (63%), transferring the patient to a CAR T-cell center for infusion (24%), gaining approval from the insurance company for CAR T-cell therapy (23%) and managing the patient post-CAR T-cell therapy (22%). When asked about the level of communication and collaboration between centers, most providers rated very good/excellent (49%) versus good (29%) and poor/fair (22%). Barriers to very good/excellent communication are insufficient sharing of patient information including test results, premedication documents and details of CAR T-cell therapy administration (30%) followed by lack of expertise in CAR T-cell therapy administration among infusion faculty/clinic staff and lack of time for our clinic's staff to communicate with infusion facility staff (figure 1). HCPs reported vastly different frequencies of referring eligible patients for treatment with CAR T-cell therapy, with a combined 36% often or always referring eligible patients and 34% rarely/never initiating a referral. Small Group A/F Sessions: HCPs participating in the small group A/F sessions also reported identifying patients eligible for treatment with CAR T-cell therapy as the biggest challenge regarding treatment with CAR T-cell therapy. Very high/high confidence in identifying eligible patients for CAR T-cell therapy treatment reported by providers increased from 37% to 72%. HCPs also noted increases in their confidence in managing adverse/late effects of CAR T-cell therapy in patients with MM (38% to 63% very high/high confidence). Conclusions Through this QI initiative, clinical teams created and implemented action plans to close gaps in identifying eligible patients, coordinating CAR T-cell therapy referral and approval, and providing counseling and obtaining consent among hematology/oncology team members. Following the initiative, meaningful confidence gains were observed in identifying eligible patients for CAR T-cell therapy and managing adverse/late effects of treatment. Follow-up surveys will assess self-reported practice changes stemming from the action plans. These data underscore clinical practice gaps that can be addressed in future initiatives to support safe, effective, and evidence-based integration of CAR T-cell therapies into MM care to optimize patient outcomes. Study Sponsor Statement The study reported in this abstract was funded by independent educational grants from Bristol Myers Squibb, who had no role in the study design, execution, analysis, or reporting. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Learning Through Listening: A Scoping Review of Podcast Use in Medical Education.

To improve understanding of podcast use in medical education by examining current research on descriptive attributes and educational outcomes, highlighting implications of the current evidence base for educational practices, and identifying research gaps to guide future investigation. The authors conducted a scoping review, searching PubMed and Embase databases in June-July 2020 for English-language studies of audio-only medical education podcast use in undergraduate, graduate, and continuing medical education. The authors excluded studies without original data or with nonphysician data that could not be separated from physician data. From included studies, the authors extracted data regarding descriptive outcomes (e.g., podcast use, content areas, structure) and educational outcomes (classified using Kirkpatrick's 4 levels of evaluation). Of 491 unique articles, 62 met inclusion criteria. Descriptive outcomes were reported in 44 studies. Analysis of these studies revealed podcast use has increased over time, podcasts are a top resource for resident education, and podcasts are being incorporated into formal medical curricula. Educational outcomes were reported in 38 studies. The 29 studies that assessed learner reaction and attitudes to podcasts (Kirkpatrick level 1) showed learners value podcasts for their portability, efficiency, and combined educational and entertainment value. The 10 studies that assessed knowledge retention (Kirkpatrick level 2) showed podcasts to be noninferior to traditional teaching methods. The 11 studies that assessed behavior change (Kirkpatrick level 3) showed improved documentation skills in medical students and self-reported practice change in residents and practicing physicians after listening to podcasts. None of the studies reported system change or patient outcomes (Kirkpatrick level 4). Future research should focus on the optimal structure of podcasts for learning, higher-level outcomes of podcasts, and the implementation of podcasts into formal curricula. Podcasts may prove to be essential tools for disseminating and implementing the most current, evidence-based practices.

A Statewide Collaboration to Deliver and Evaluate a Pediatric Critical Care Simulation Curriculum for Emergency Medical Services.

ObjectiveCare of the critically ill child is a rare but stressful event for emergency medical services (EMS) providers. Simulation training can improve resuscitation care and prehospital outcomes but limited access to experts, simulation equipment, and cost have limited adoption by EMS systems. Our objective was to form a statewide collaboration to develop, deliver, and evaluate a pediatric critical care simulation curriculum for EMS providers.MethodsWe describe a statewide collaboration between five academic centers to develop a simulation curriculum and deliver it to EMS providers. Cases were developed by the collaborating PEM faculty, reviewed by EMS regional directors, and based on previously published EMS curricula, a statewide needs assessment, and updated state EMS protocols. The simulation curriculum was comprised of 3 scenarios requiring recognition and acute management of critically ill infants and children. The curriculum was implemented through 5 separate education sessions, led by a faculty lead at each site, over a 6 month time period. We evaluated curriculum effectiveness with a prospective, interventional, single-arm educational study using pre-post assessment design to assess the impact on EMS provider knowledge and confidence. To assess the intervention effect on knowledge scores while accounting for nested data, we estimated a mixed effects generalized regression model with random effects for region and participant. We assessed for knowledge retention and self-reported practice change at 6 months post-curriculum. Qualitative analysis of participants' written responses immediately following the curriculum and at 6 month follow-up was performed using the framework method.ResultsOverall, 78 emergency medical technicians (EMTs) and 109 paramedics participated in the curriculum over five separate sessions. Most participants were male (69%) and paramedics (58%). One third had over 15 years of clinical experience. In the regression analysis, mean pediatric knowledge scores increased by 9.8% (95% CI: 7.2%, 12.4%). Most (93% [95% CI: 87.2%, 96.5%]) participants reported improved confidence caring for pediatric patients. Though follow-up responses were limited, participants who completed follow up surveys reported they had used skills acquired during the curriculum in clinical practice.ConclusionThrough statewide collaboration, we delivered a pediatric critical care simulation curriculum for EMS providers that impacted participant knowledge and confidence caring for pediatric patients. Follow-up data suggest that knowledge and skills obtained as part of the curriculum was translated into practice. This strategy could be used in future efforts to integrate simulation into EMS practice.

Educational innovation to integrate cancer survivorship in primary care: course evaluation and learner outcomes.

To evaluate the outcomes of an online cancer survivorship course designed to influence practice change in primary care clinicians through asynchronous education that incorporates emotionally sensitive patient stories and practical resources to prepare clinicians to care for cancer survivors. The Health After Cancer: Cancer Survivorship for Primary Care continuing medical education (CME) course launched in April 2020. Learners who earned CME credit for the course (n=288) completed a survey that assessed satisfaction, engagement, and intent to change practice. A follow-up survey was completed by a subset of learners (n=47) and evaluated impact on clinical practice. Metrics representing learners' interaction with the course were collected automatically. Quantitative survey data and learner metrics were analyzed descriptively, and qualitative survey data were coded to generate latent themes relevant to learning outcomes. The course reached a global audience of learners from the USA and 40 countries. Each patient case had slight drop-offs in viewership over video play time. Learners reported high satisfaction and relevance to practice. Three latent themes were generated from the qualitative data: improve patient communication, utilize course materials, enhance collaboration with multidisciplinary team. The course achieved its purpose of educating learners through an asynchronous format that showcased the value of using patient-centered stories to close a knowledge gap related to cancer survivorship care. Learners self-reported changes in practice; however, further assessment needs to be conducted to measure long-term impact to clinical practice. Educational approaches that prepare generalists and specialists to care for cancer survivors are essential to optimize health outcomes for cancer survivors. Ongoing efforts are needed to increase use of these resources throughout medical training and within the primary care community.

Measuring and Improving Evidence-Based Patient Care Using a Web-Based Gamified Approach in Primary Care (QualityIQ): Randomized Controlled Trial.

BackgroundUnwarranted variability in clinical practice is a challenging problem in practice today, leading to poor outcomes for patients and low-value care for providers, payers, and patients.ObjectiveIn this study, we introduced a novel tool, QualityIQ, and determined the extent to which it helps primary care physicians to align care decisions with the latest best practices included in the Merit-Based Incentive Payment System (MIPS).MethodsWe developed the fully automated QualityIQ patient simulation platform with real-time evidence-based feedback and gamified peer benchmarking. Each case included workup, diagnosis, and management questions with explicit evidence-based scoring criteria. We recruited practicing primary care physicians across the United States into the study via the web and conducted a cross-sectional study of clinical decisions among a national sample of primary care physicians, randomized to continuing medical education (CME) and non-CME study arms. Physicians “cared” for 8 weekly cases that covered typical primary care scenarios. We measured participation rates, changes in quality scores (including MIPS scores), self-reported practice change, and physician satisfaction with the tool. The primary outcomes for this study were evidence-based care scores within each case, adherence to MIPS measures, and variation in clinical decision-making among the primary care providers caring for the same patient.ResultsWe found strong, scalable engagement with the tool, with 75% of participants (61 non-CME and 59 CME) completing at least 6 of 8 total cases. We saw significant improvement in evidence-based clinical decisions across multiple conditions, such as diabetes (+8.3%, P<.001) and osteoarthritis (+7.6%, P=.003) and with MIPS-related quality measures, such as diabetes eye examinations (+22%, P<.001), depression screening (+11%, P<.001), and asthma medications (+33%, P<.001). Although the CME availability did not increase enrollment in the study, participants who were offered CME credits were more likely to complete at least 6 of the 8 cases.ConclusionsAlthough CME availability did not prove to be important, the short, clinically detailed case simulations with real-time feedback and gamified peer benchmarking did lead to significant improvements in evidence-based care decisions among all practicing physicians.Trial RegistrationClinicalTrials.gov NCT03800901; https://clinicaltrials.gov/ct2/show/NCT03800901

Promoting a Shared Medication Adherence Practice: A Call to Action

Medication nonadherence exists among most patients and leads to increased morbidity, medical costs, and unnecessary hospitalizations. This study trained primary care staff at an urban Federally Qualified Health Center to address medication nonadherence. It included a single educational workshop that described medication nonadherence, demonstrated validated assessment tools to formulate evidence-based interventions, and incorporated motivational interviewing techniques. Evaluations conducted at pre-post training and at 4 weeks showed an increase in staff knowledge (29%), self-confidence (46%), and self-reported practice change (77%). Our findings suggest this training resulted in practice change through increased patient engagement, shared decision making, and strengthening patient-provider trust.

Predicting Clinical Practice Change: An Evaluation of Trainings on Sexually Transmitted Disease Knowledge, Diagnosis, and Treatment.

Sexually transmitted disease clinical training for working professionals requires substantial time and resources. Understanding the predictors of change in worksite practices and barriers to change will allow educators, learners, and clinical leadership to aid in ensuring learned practices are implemented and barriers are addressed. Data for this analysis come from the first standardized national evaluation of a Centers for Disease Control and Prevention-funded clinical prevention training network, including precourse registration and responses to immediate postcourse (1-3 days) and 90-day postcourse evaluations from 187 courses. Univariate statistics describe the trainees and their workplace. Bivariate statistics describe their intention to change and actual change stratified by functional role and employment setting. Logistic regression identified predictors of self-reported changes in practice. The strongest predictors for practice change included an intention to change and attendance at a training lasting 4 hours or more. Functional role was a weaker predictor of change in practice; employment setting did not predict change. More than half of the trainees (65.9%; n = 912) stated their intention to make a change in their practice immediately after training. At 90 days after a course, 62.4% (n = 863) reported making a practice change. Trainees that took courses lasting 4 hours or more reported making a change more often (70%) compared with trainees from shorter courses (53%). We also report on trainees' barriers to practice change. Results suggest that longer trainings may result in more practice change than shorter trainings, recruitment of trainees should focus on those more likely to make a change in their practice, and future trainings should focus on organizational capacity building and assessing change at the organizational level.

Practice change intentions after academic detailing align with subsequent opioid prescribing

ObjectiveSelf-reported behavior change is used to evaluate the effectiveness of educational outreach interventions delivered to clinicians, such as academic detailing (AD). However, self-reported changes in behavior are often not corroborated with data on actual behavior change. To assess alignment between self-reported practice change intentions and actual opioid prescribing behavior among primary care clinicians after an AD intervention. MethodsWe used a difference-in-differences approach to compare pre-post changes in opioid prescribing using data from the Illinois Prescription Monitoring Program. An opioid-focused AD intervention was delivered to primary care clinicians from a large health system in the Chicago metropolitan area from June 2018 to August 2018. Immediately after the AD intervention, clinicians were administered a single-item self-reported practice change measure. Clinicians were categorized into 2 groups on the basis of their responses: (1) intention to change and (2) no-to-moderate intention to change. Outcomes were mean total opioid prescriptions and high-dose opioid prescriptions (≥ 90 morphine milligram equivalents) per clinician per month. Repeated measures linear regression models were used to compare changes in opioid prescribing outcomes between the 2 groups in the 6 months before and after the AD intervention. ResultsA total of 149 clinicians were included for analysis. An intention to change was reported by 72 clinicians and no-to-moderate intention to change was reported by 77 clinicians. In the 6 months after the AD intervention, there were 1.48 (95% CI −2.48 to −0.47) fewer total opioid prescriptions and 0.50 (−0.69 to −0.31) fewer high-dose opioid prescriptions per clinician per month in the intention to change group than in the no-to-moderate intention to change group. ConclusionThis study showed considerable alignment between self-reported practice change intentions and actual changes in opioid prescribing behavior. Future opioid-focused educational outreach interventions should consider using standardized single-item practice change measures as an immediate indicator of future behavior change.

End-of-Life Care in Acute Hospitals: Practice Change Reported by Health Professionals Following Online Education.

Providing quality care for those dying in hospital is challenging for health professionals who receive little training in this. “End of Life Essentials” (EOLE) was developed to address gaps in health professionals’ knowledge, skills and confidence in end-of-life care via the provision of online learning modules and practice resources. This study aimed to determine whether respondents could describe clinical practice change as a result of module completion. Deidentified data were collected between October and November 2018 from learners registered for the online learning modules. Both quantitative and qualitative data were extracted and analysed. The survey design and conduct were reviewed, and ethical approval was obtained. Although the response rate was very low, results from n = 122 learners show improvements in knowledge, skills, awareness and confidence as a result of the undertaking of the learning modules. Two thirds self-reported practice changes (71%, n = 59) following the education, with “communication” cited most commonly (n = 19). The findings suggest that the EOLE education modules can help to improve end-of-life care by increasing health professionals’ awareness of good practice as well as their knowledge, skills and confidence. Online learning has also been reinforced as an appropriate forum for end-of-life education. Following education, implementing what has been learned occurs more easily at a personal level rather than at a team and organisational level. Barriers to and enablers of clinical practice change in hospital are described, including the fact that the organisation may not be responsive to changes or have the relevant resources to support change.

Primary Care Physicians in the Merit-Based Incentive Payment System (MIPS): a Qualitative Investigation of Participants' Experiences, Self-Reported Practice Changes, and Suggestions for Program Administrators.

While both administrators of pay-for-performance programs and practicing physicians strive to improve healthcare quality, they sometimes disagree on the best approach. The Medicare Access and CHIP Reauthorization Act of 2015 mandated the creation of the Merit-Based Incentive Payment System (MIPS), a program that incentivizes more than 700,000physician participants to report on four domains of care, including healthcare quality. While MIPS performance scores were recently released, little is known about how primary care physicians (PCPs) and their practices are being affected by the program and what actions they are taking in response to MIPS. To (1) describe PCP perspectives and self-reported practice changes related to quality measurement under MIPS and (2) disseminate PCP suggestions for improving the program. Qualitative study employing semi-structured interviews. Twenty PCPs trained in internal medicine or family medicine who were expected to report under MIPS for calendar year 2017 were interviewed between October 2017 and June 2018. Eight PCPs self-reported to be knowledgeable about MIPS. Seven PCPs worked in small practices. Most PCPs identified advantages of quality measurement under MIPS, including the creation of practice-level systems for quality improvement. However, they also cited disadvantages, including administrative burdens and fears that practices serving vulnerable patients could be penalized. Many participants reported using technology or altering staffing to help with data collection and performance improvement. A few participants were considering selling small practices or joining larger ones to avoid administrative tasks. Suggestions for improving MIPS included simplifying the program to reduce administrative burdens, protecting practices serving vulnerable populations, and improving communication between program administrators and PCPs. MIPS is succeeding in nudging PCPs to develop quality measurement and improvement systems, but PCPs are concerned that administrative burdens are leading to the diversion of clinical resources away from patient-centered care and negatively impacting patient and clinician satisfaction. Program administrators should improve communication with participants and consider simplifying the program to make it less burdensome. Future work should be done to investigate how technical assistance programs can target PCPs that serve vulnerable patient populations and are having difficulty adapting to MIPS.

Clinician-reported changes in octreotide prescribing for malignant bowel obstruction as a result of an adequately powered phase III study: A transnational, online survey

Background: Translating research evidence into clinical practice often has a long lag time. Aim: To determine the impact of a phase III randomised controlled trial on palliative care clinicians’ self-reported practice change. Design: Online survey about use of octreotide in managing inoperable malignant bowel obstruction due to cancer or its treatments distributed in November 2016, 2 years after the first publication of the study in a peer-reviewed journal. Demographic, self-reported practice and the reasons underpinning this were collected. Responses were aggregated to ‘practice modified’ or ‘practice not modified’. A multinomial regression model explored predictors of practice change. Setting: Members of the Australian New Zealand Society of Palliative Medicine. Results: Response rate was 20.8% (106/509): 55.6% were aged >50 years, 56.5% were female and 77% had previously prescribed octreotide for this clinical indication. Out of 106 respondents, 52 (49.1%) indicated modified practice (60.9% of those who had previously prescribed octreotide in this setting). In those who reported practice change, most frequently octreotide was now used when other therapies failed; for not changing practice, ‘more confirmatory evidence was needed’ was most often cited. In the regression model, older age (clinician age = 50–59 years; relative risk = 0.147; 95% confidence interval = 0.024–0.918; p = 0.04) and having practices with lower proportions of people treated with octreotide (0%–20%; relative risk = 0.039; 95% confidence interval = 0.002–0.768; p = 0.033) predicted greater self-reported practice change. Conclusion: Clinician-reported change in practice in the survey is seen in the majority of respondents. This suggests that there is a cohort of ‘early adopters’ within palliative care practice as new evidence becomes available.

An evaluation of the fall prevention practice of community-based occupational therapists working in primary care

Introduction Occupational therapy in primary care settings in Australia is developing. This study aimed to examine current practice in preventing falls among older people living in the community prior to attending a home safety workshop; explore the outcomes of the workshop on fall prevention practice; and investigate self-reported changes in practice 3 months after the workshop. Method The 3-hour workshop was focused on evidence-based home safety interventions and was offered to occupational therapists providing community-based services in the Sydney North Primary Health Network area. Knowledge surveys were used immediately pre and post workshop, and practice surveys were collected data at baseline and at 3-month follow-up. Results Three workshops were run in 2015–2016, with a total of 40 occupational therapists. At follow-up, a positive impact on confidence and knowledge was reported. Less impact was observed on identifying and reducing an older person’s fall risk, and on fall prevention services provided and referrals received. Changes in practice were reported by 48% ( n = 16) of the 33 participants who returned surveys at 3 months. Conclusion These findings provide support for the benefit of professional development workshops to improve confidence and knowledge, but challenges remain in facilitating change in fall prevention service delivery. Further study on screening for fall risk and collaboration between community service providers in the primary care context is recommended.

Development of a Sleep Telementorship Program for Rural Department of Veterans Affairs Primary Care Providers: Sleep Veterans Affairs Extension for Community Healthcare Outcomes.

Primary care providers (PCPs) frequently encounter sleep complaints, especially in regions with limited specialty care access. The U.S. Department of Veterans Affairs Extension for Community Healthcare Outcomes (VA-ECHO) program (based on Project ECHO) has successfully provided rural PCP education in subspecialty areas, including hepatitis C. We describe the feasibility of an ECHO program for sleep medicine. ECHO creates a virtual learning community through video-teleconferencing, combining didactics with individualized clinical case review. We invited multidisciplinary providers to attend up to 10 stand-alone, 1-hour sessions. Invitees completed a needs assessment, which guided curriculum development. After program completion, we examined participant characteristics and self-reported changes in practice and comfort with managing sleep complaints. We surveyed participation barriers among invitees with low/no attendance. Of the 39 program participants, 38% worked in rural healthcare. Participants included nurse practitioners (26%), registered nurses (21%), and physicians (15%). Seventeen (44%) completed the summative program evaluation. Respondents anticipated practice change from the program, especially in patient education about sleep disorders (93% of respondents). Respondents reported improved comfort managing sleep complaints, especially sleep-disordered breathing, insomnia, and sleep in post-traumatic stress disorder (80% of respondents each). A follow-up survey of program invitees who attended zero to two sessions reported scheduling conflicts (62%) and lack of protected time (52%) as major participation barriers. Participants in a pilot sleep medicine VA-ECHO program report practice change and increased comfort managing common sleep complaints. Future work is needed to identify objective measures of return on investment and address participation barriers.

Improving Residents' Safe Opioid Prescribing for Chronic Pain Using an Objective Structured Clinical Examination.

Internal medicine residents care for a sizable number of patients with chronic pain. Programs need educational strategies to promote safe opioid prescribing. To describe a safe opioid prescribing education program utilizing an objective structured clinical examination (OSCE) and report the resulting impact on residents' knowledge, confidence, and self-reported practices. Using a quasi-experimental design, 39 internal medicine residents from an urban academic medical center were assigned to 1 of 4 groups: 1-hour lecture only, lecture followed by immediate OSCE, lecture followed by 4-month delayed OSCE, and control. Safe opioid prescribing knowledge, confidence, and self-reported practices were assessed at baseline and at 8 months. At 8 months, knowledge, confidence, and self-reported practices improved in the control and in all 3 intervention groups. The immediate OSCE group had the greatest improvements in combined confidence scores within group (0.74, P = .01) compared to controls (0.52, P = .05), using a 5-point scale. This group also had the greatest improvement in self-reported practice changes (1.04, P = .04), while other groups showed nonsignificant improvements-delayed OSCE (0.43, P = .44), lecture only (0.66, P = .24), and control (0.43, P = .19). Safe opioid prescribing education that includes a lecture immediately followed by an OSCE had an impact on residents' confidence and self-reported practices greater than those for delayed OSCE or lecture only groups. There was no difference in knowledge improvement among the groups. Lecture followed by an OSCE was highly regarded by residents, but required additional resources.

The impact of the Rasouli decision: a Survey of Canadian intensivists

IntroductionIn a landmark 2013 decision, the Supreme Court of Canada (SCC) ruled that the withdrawal of life support in certain circumstances is a treatment requiring patient or substitute decision maker...

Evaluating an online training module on protecting children from secondhand smoke exposure: impact on knowledge, confidence and self-reported practice of health and social care professionals

BackgroundHealthcare professionals report that a lack of training is the primary barrier to raising the issue of secondhand smoke (SHS). An open access online training module was therefore developed for those working with smoking families to deliver effective very brief advice on SHS. The current study aimed to evaluate the following: (1) does knowledge increase as a result of participating in the online training module, and (2) does the module impact on participant confidence and self-reported practice relating to SHS.MethodsThose accessing the module were invited to participate in an evaluation to assess participants’ knowledge about, and confidence in, delivering very brief advice on SHS. Change in knowledge was assessed via ten multiple choice questions and confidence was assessed by Likert scale responses to three statements. Data were collected across three time points: pre-training, post-training and after 3 months. Data were also collected at 3 months post module completion on self-reported changes in practice and key learning points.ResultsData at all three time points were available for 178 participants (~1 % of those who visited the module homepage over a 2 year period). Knowledge and confidence to deliver effective very brief advice for SHS significantly increased between the pre- and post-training assessments and was maintained at 3 months. Eighty-four percent self-reported that they perceived taking part in the training had led to positive changes in their clinical practice.ConclusionsThere is potential for this module to be embedded within training programmes across health and social care professions, which may help to increase the knowledge and confidence of health and social care professionals to deliver very brief advice for SHS to smoking families. Future research needs to explore whether the smoking families who receive very brief advice for SHS are motivated to make changes to their home smoking behaviours and whether roll-out of this intervention would be cost-effective.

215 A Novel Clinical Protocol for Placement and Management of Indwelling Urinary Catheters in Older Adults in the Emergency Department: Implementation and Impact Assessment

Indwelling urinary catheters (IUCs) are placed frequently in older adults (age ≥65) in the emergency department (ED) and carry significant risks. As highlighted by the Choosing Wisely campaign, this is an intervention that should be considered judiciously. To implement and assess the impact of a novel clinical protocol to assist ED providers with appropriate indications for placement, reassessment, and removal of IUCs in older adults in the ED. We developed a comprehensive, evidence-based clinical protocol and implemented it at a large, urban, academic medical center with over 67,000 adult patient visits annually. We introduced the protocol to multiple EM providers, including attendings, residents, mid-levels, and nurses with a 20-minute scripted slide presentation. Pocket cards were distributed and the protocol was displayed in the ED. Written surveys were administered before the intervention, immediately after, and at 6-months to assess providers’ baseline knowledge, attitudes, and practices, as well as the protocol’s long-term impact. Surveys included asking providers for IUC management decisions for 25 unique clinical scenarios. To objectively assess the clinical impact of the protocol, we retrospectively compared rates of IUC placement in this ED in patients aged ≥65 in the 6 months before (January 1, 2013 to June 30, 2013) and 6 months after (September 1, 2013 to February 28, 2014) implementation of the protocol. Of the 125 EM providers participating in the implementation phase of this study, 112 (90%) completed 6-month follow-up. Immediately after protocol introduction, 98% of the participants reported that the intervention made them more comfortable with the appropriate indications for IUC placement; 87% reported anticipating that this intervention would reduce rates of IUC use and increase patient safety. At 6-month follow-up, 80% felt that the protocol had changed their practice and 38% reported frequently referencing the protocol. In the clinical vignettes, ED providers correctly identified the appropriate approach for IUC placement in 33% of cases pre-intervention compared to 54% immediately post-intervention and 44% at 6 months (P<.001). Four thousand nine hundred sixty-seven (61%) of the 8,147 older adults evaluated in the ED during the 6 months prior to implementation were admitted. Of those admitted, 935 (18.8%) received an IUC in the ED. In the 6 months after implementation, 4,781 (59%) of the 8,119 older adults evaluated in the ED were admitted, with 731 (15.3%) having received an IUC in the ED. This represents a relative risk reduction of 18.6% (P<.001) for ED use of IUCs in this population. Introduction of this comprehensive, evidence-based clinical protocol has been well received by ED providers. It has led to sustained self-reported practice change and significant reduction in overall IUC placement in older adults in our ED who were admitted to the hospital. Our next steps include evaluating whether this reduction has concomitantly increased the proportion of IUCs placed in the ED for appropriate indications, and to assess whether it has led to fewer catheter-associated urinary tract infections during hospital admission and improved patient-centered outcomes.

Experiences from an interprofessional student-assisted chronic disease clinic

Faced with significant health and workforce challenges in the region, the Central Queensland Health Service District (CQHSD) commenced a student-assisted clinical service. The Capricornia Allied Health Partnership (CAHP) is an interprofessional clinical placement program in which pre-entry students from exercise physiology, nutrition and dietetics, occupational therapy, pharmacy, podiatry and social work are embedded in a collaborative chronic disease service delivery model. The model coordinates multiple student clinical placements to: address service delivery gaps for previously underserved people with chronic disease in need of early intervention and management; provide an attractive clinical placement opportunity for students that will potentially lead to future recruitment success, and demonstrate leadership in developing future health workforce trainees to attain appropriate levels of interprofessional capacity. The CAHP clinic commenced student placements and client services in February 2010. This report provides early evaluative information regarding student experiences included self-reported changes in practice.

Characteristics of an educational publication sourced from deaths investigated by the Coroner that is reported to have promoted practice change

The purpose of this study was to investigate the characteristics of the Residential Aged Care Coronial Communiqué that have promoted previously reported professional practice change, and to explore the circumstances of these changes. This was an exploratory, qualitative study for which data was collected through semi-structured interview of 15 subscribers to the Residential Aged Care Coronial Communiqué. The Residential Aged Care Coronial Communiqué was reported to promote self-reported practice change though the inclusion of case studies, by being associated with the Coroner, and by providing evidence to justify change. The combination of existing concerns about risk and staff awareness, in conjunction with reading the Residential Aged Care Coronial Communiqué was also reported to promote practice change, as was having the support of senior staff and the authority to implement change. The combination of narrative case studies in the context of an educational publication associated with the Coroner's Office has been reported to provided evidence and incentive to promote professional practice change in an aged care setting. However the relative influence of the Residential Aged Care Coronial Communiqué, and other background circumstance and facilitating factors on practice change cannot be determined from this study.