A patient safety and transitions of care curriculum for third-year medical students

Transitions curriculum impact on students and care

BACKGROUND

Transitions of patient care from the inpatient to outpatient setting is a high-risk time often resulting in medical errors and adverse events. Transitions of care programmes have been demonstrated to reduce negative outcomes. Several professional societies have highlighted care transitions as a central pillar of patient care and therefore a crucial aspect of health professional education; however, little data exist on medical student education in this area.

APPROACH

The Transitions of Care Curriculum was developed and delivered to all Harvard Medical School Core I Internal Medicine Clerkship students at Beth Israel Deaconess Medical Center, Boston, MA between January 2017 and March 2019, where 12-14 students participated each quarter and included didactic teaching followed by experiential learning. Student data were collected via postclerkship survey. Patient data were collected via chart review. Student self-reported comfort level with transitions in care skills and medical errors were analysed.

EVALUATION

All student measures related to comfort with transitions in care skills demonstrated statistically significant improvement after curriculum participation(p < 0.001). Of the patients with a completed postdischarge note, students identified ≥1 postdischarge related issue in 33 of 70 patients, with multiple issues identified in many of these patients. Seventy-six total issues were identified.

IMPLICATIONS

The Transitions of Care Curriculum demonstrated promising student and patient outcomes, suggesting that students can successfully learn and advance clinical skills while having a positive impact on a highly needed and important aspect of patient care by reducing postdischarge errors and adverse events.

How health literacy is taught and evaluated in dentistry, medicine, nursing, law, pharmacy, public health, and social work: a narrative review

BACKGROUND

This narrative review examined the published peer-reviewed literature on how health literacy is taught and evaluated in seven health professional and adjacent disciplines: dentistry, medicine, nursing, law, pharmacy, public health, and social work. The study objectives were to assess how students are educated about health literacy and how their health literacy education and skills are evaluated.

METHODS

Study selection followed guidelines outlined in PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). We searched PubMed, CINAHL, SocINDEX (EBSCOhost), Lexis Advance and Public Health (ProQuest) for English-language publications of health literacy education studies across seven disciplines at U.S.-based institutions. Inclusion criteria included: 1) methods describing a primary health literacy educational intervention, 2) professional education in one or more of the seven disciplines, 3) educational institutions in the United States, and 4) articles published in peer-reviewed journals between 2000 and 2020.

RESULTS

The searches yielded 44 articles. Health literacy education is evident in six of the seven studied disciplines, and varies widely in the quality, quantity, timing and mode of education and evaluation. Despite the presence of health literacy accreditation requirements, none of the seven disciplines has developed and implemented a standard, rigorous health literacy education program for students.

CONCLUSIONS

Graduating institutions and professional accreditation organizations that set the standards for education must lead the way by implementing upstream changes in health literacy professional education. Teaching health literacy to students in health professions is one strategy to help close gaps in patient/client professional communication for graduates and those they serve.

Patient safety topics, especially the second victim phenomenon, are neglected in undergraduate medical and nursing curricula in Europe: an online observational study

This study aims to assess the inclusion of second victims and other patient safety issues in the curricula of undergraduate medical and nursing degrees in the countries participating in the European Researchers' Network Working on Second Victims (The ERSNT Consortium, COST Action 19,113). A review of medical and nursing school curricula in 206 universities was carried out, using their websites to search for subjects addressing "patient safety", "quality of care", "risk management", "safe practices", "interprofessional communication", "adverse events", and "second victims". There was substantial variability in the extent of training for patient safety. Forty-four out of 88 nursing schools and 74 of 118 medical schools did not include any of the patient safety topics studied. The most frequent in both nursing and medicine was "interprofessional communication", followed by "quality of care" and basic aspects on "patient safety". The second victim phenomenon was present in only one curriculum of the total sample. Our study showed that patient safety, especially the second victim phenomenon, is still neglected in medical and nursing curricula in European universities, although positive initiatives were also found. Given the frequency with which adverse events occur in health centres and the need to prepare students to deal with them adequately, additional efforts are needed to introduce patient safety elements into medical and nursing education.

Effectiveness of a Comprehensive Health Literacy Consultation Skills Training for Undergraduate Medical Students: A Randomized Controlled Trial

Comprehensible communication by itself is not sufficient to overcome health literacy related problems. Future doctors need a larger scope of capacities in order to strengthen a patient’s autonomy, participation, and self-management abilities. To date, such comprehensive training-interventions are rarely embedded in curricula, nor systematically evaluated. We assessed whether comprehensive training increased these health literacy competencies, in a randomized controlled trial (RCT), with a waiting list condition. Participants were international undergraduate medical students of a Dutch medical faculty (intervention: 39; control: 40). The 11-h-training-intervention encompassed a health literacy lecture and five interactive small-group sessions to practise gathering information and providing comprehensible information, shared decision-making, and enabling of self-management using role-play and videotaped conversations. We assessed self-reported competencies (knowledge and awareness of health literacy, attitude, self-efficacy, and ability to use patient-centred communication techniques) at baseline, after a five and ten-week follow-up. We compared students’ competencies using multi-level analysis, adjusted for baseline. As validation, we evaluated demonstrated skills in videotaped consultations for a subsample. The group of students who received the training intervention reported significantly greater health literacy competencies, which persisted up to five weeks afterwards. Increase was greatest for providing comprehensible information (B: 1.50; 95% confidence interval, CI 1.15 to 1.84), shared decision-making (B: 1.08; 95% CI 0.60 to 1.55), and self-management (B: 1.21; 95% CI 0.61 to 1.80). Effects regarding demonstrated skills confirmed self-rated competency improvement. This training enhanced a larger scope of health literacy competences and was well received by medical students. Implementation and further evaluation of this training in education and clinical practice can support sustainable health literacy capacity building of future doctors and contribute to better patient empowerment and outcomes of consultations.

Medical students' reflections of a posthospital discharge patient visit

Transitions of care is an important part of patient safety that is not often taught in medical schools. As part of a curriculum for patient safety and transitions of care, third-year medical students followed patients they cared for during their inpatient rotations on a posthospital discharge visit. Students answered reflection questions on these visits, which were reviewed at a group debriefing session. The written reflections and oral debriefings were analyzed qualitatively to identify what medical students were able to learn from a posthospital discharge visit. Of the students who visited patients, 265 participated in the debriefing sessions, and their responses were grouped into 7 domains and 33 themes. Students commented most often on the importance of family and caregivers who provided support for the patient after hospitalization. They identified problems specific to the discharge process and factors that helped or hindered transitions, noted new experiences visiting postacute care facilities, and also developed solutions to improve transitions. Postdischarge visits combined with brief reflection writing and debriefing allowed students to better understand difficulties that can be faced in care transitions.

Developing and pilot testing a comprehensive health literacy communication training for health professionals in three European countries

OBJECTIVE

Skills to address different health literacy problems are lacking among health professionals. We sought to develop and pilot test a comprehensive health literacy communication training for various health professionals in Ireland, Italy and the Netherlands.

METHODS

Thirty health professionals participated in the study. A literature review focused on evidence-informed training-components. Focus group discussions (FGDs) explored perspectives from seventeen professionals on a prototype-program, and feedback from thirteen professionals following pilot-training. Pre-post questionnaires assessed self-rated health literacy communication skills.

RESULTS

The literature review yielded five training-components to address functional, interactive and critical health literacy: health literacy education, gathering and providing information, shared decision-making, enabling self-management, and supporting behaviour change. In FGDs, professionals endorsed the prototype-program and reported that the pilot-training increased knowledge and patient-centred communication skills in addressing health literacy, as shown by self-rated pre-post questionnaires.

CONCLUSION

A comprehensive training for health professionals in three European countries enhances perceived skills to address functional, interactive and critical health literacy.

PRACTICE IMPLICATIONS

This training has potential for wider application in education and practice in Europe.

Individual versus interprofessional team performance in formulating care transition plans: A randomised study of trainees from five professional groups

Health professions trainees' performance in teams is rarely evaluated, but increasingly important as the healthcare delivery systems in which they will practice move towards team-based care. Effective management of care transitions is an important aspect of interprofessional teamwork. This mixed-methods study used a crossover design to randomise health professions trainees to work as individuals and as teams to formulate written care transition plans. Experienced external raters assessed the quality of the written care transition plans as well as both the quality of team process and overall team performance. Written care transition plan quality did not vary between individuals and teams (21.8 vs. 24.4, respectively, p = 0.42). The quality of team process did not correlate with the quality of the team-generated written care transition plans (r = -0.172, p = 0.659). However, there was a significant correlation between the quality of team process and overall team performance (r = 0.692, p = 0.039). Teams with highly engaged recorders, performing an internal team debrief, had higher-quality care transition plans. These results suggest that high-quality interprofessional care transition plans may require advance instruction as well as teamwork in finalising the plan.

Low Health Literacy Is Associated with Increased Transitional Care Needs in Hospitalized Patients

OBJECTIVE

To examine the association of health literacy with the number and type of transitional care needs (TCN) among patients being discharged to home.

DESIGN, SETTING, PARTICIPANTS

A cross-sectional analysis of patients admitted to an academic medical center.

MEASUREMENTS

Nurses administered the Brief Health Literacy Screen and documented TCNs along 10 domains: caregiver support, transportation, healthcare utilization, high-risk medical comorbidities, medication management, medical devices, functional status, mental health comorbidities, communication, and financial resources.

RESULTS

Among the 384 patients analyzed, 113 (29%) had inadequate health literacy. Patients with inadequate health literacy had needs in more TCN domains (mean = 5.29 vs 4.36; P < 0 .001). In unadjusted analysis, patients with inadequate health literacy were significantly more likely to have TCNs in 7 out of the 10 domains. In multivariate analyses, inadequate health literacy remained significantly associated with inadequate caregiver support (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.37-4.99) and transportation barriers (OR, 1.69; 95% CI, 1.04-2.76).

CONCLUSIONS

Among hospitalized patients, inadequate health literacy is prevalent and independently associated with other needs that place patients at a higher risk of adverse outcomes, such as hospital readmission. Screening for inadequate health literacy and associated needs may enable hospitals to address these barriers and improve postdischarge outcomes.

Medication safety curriculum: enhancing skills and changing behaviors

BACKGROUND

Adverse drug reactions are a leading cause of death in the United States. Safe and effective management of complex medication regimens is a skill for which recent medical school graduates may be unprepared when they transition to residency. We wished to assess the impact of a medication safety curriculum on student competency when evaluating medication therapeutic appropriateness as well as evaluate students' ability to transfer curricular material to management of patients in clinical settings.

METHODS

To prepare 3rd and 4th year medical students to critically evaluate medication safety and appropriateness, we developed a medication reconciliation/optimization curriculum and embedded it within a Patient-Centered Medical Home longitudinal elective. This curriculum is comprised of a medication reconciliation workshop, in-class and individual case-based assignments, and authentic patient encounters in which medication management skills are practiced and refined. Pre- and post-course competency and skills with medication reconciliation/optimization are evaluated by assessing student ability to identify and resolve medication-related problems (MRPs) in case-based assignments using paired difference tests. A group of students who had wished to enroll in the elective but whose schedule did not permit it, served as a comparison group.

RESULTS

Students completing the curriculum (n = 45) identified 75 % more MRPs in case assignments compared to baseline. No changes from baseline were apparent in the comparison group. Enrolled students were able to transfer their skills to the care of authentic patients; these students identified an average of 2.5 MRPs per patient from a panel of individuals that had recently transitioned from hospital to home. Moreover, patient questionnaires (before and several months following the medication encounters with assigned students) indicated that patients felt more knowledgeable about several medication parameters as a result of the student-led medication encounter. Patients also indicated that students helped them overcome barriers to medication adherence (e.g. cost, transportation, side effects).

CONCLUSIONS

Novice learners may have difficulty transitioning from knowledge of basic pharmacology facts to application of that information in clinical practice. Our curriculum appears to bridge that gap in ways that may positively impact patient care.

Advancing Medication Safety: Establishing a National Action Plan for Adverse Drug Event Prevention

BACKGROUND

Adverse drug events (ADEs) are important contributors to preventable morbidity and mortality, comprising one third of all hospital adverse events. In response to growing evidence detailing the high prevalence of ADEs, particularly among vulnerable older adults, Congress requested that the Secretary of the Department of Health and Human Services (HHS) convene a Federal Interagency Steering Committee to establish a National Action Plan to focus on ADE prevention. In August 2014, the Office of Disease Prevention and Health Promotion released the final version of the National Action Plan for Adverse Drug Event Prevention. The Action Plan directly supports the goals of the HHS Strategic Plan and the Patient Protection and Affordable Care Act by providing guidance on tracking and preventing ADEs, as well as describing evidence-based tools and resources to enhance medication safety. ADE ACTION PLAN CONTENT: The Federal Interagency Steering Committee focused the Action Plan on ADEs that are clinically significant, account for the greatest number of measurable harms as identified by using existing surveillance tools, and are largely preventable. As such, the decision was made to target three medication classes: anticoagulants, diabetes agents (insulin and oral hypoglycemic agents), and opioids. The Action Plan is organized around four key areas: surveillance; evidence-based prevention; payment, policy incentives, and oversight; and research opportunities to advance medication safety.

CONCLUSION

One measure of the ADE Action Plan's success will be the wider dissemination of information and educational resources to providers and patients (or consumers) regarding the risks associated with medications. Future Action Plan iterations are likely to consider other high-priority medication classes and update the recommendations.