Effect of case-based training for medical residents on inpatient glycemia

Who Needs Diabetes Education? A Qualitative Analysis of Emerging Adults With Type 1 Diabetes

BACKGROUND

The purpose of this study is to explore the diabetes self-management education (DSME) needs of emerging adults with type 1 diabetes mellitus (T1DM) because addressing these needs may facilitate optimal glycemic management during this challenging transitional period.

METHODS

A hybrid qualitative design was utilized. Emerging adults and parents of emerging adults were recruited from endocrinology and primary care clinics and through a Utah-specific T1DM online community. Interviews were conducted to asses needs to achieve target A1C. Data were interpreted thematically.

RESULTS

Emerging adults with T1DM (N = 33) and parents of emerging adults with T1DM (N = 17) were interviewed. Three main themes emerged: (1) mixed desire for personal DSME; (2) I don't need the education, others do; and (3) health care provider (HCP) attributes that make a difference. Associated subthemes were reported.

CONCLUSIONS

Emerging adults reported that further education for themselves was not needed, although newly diagnosed individuals would benefit from increased training in diabetes management. Although many emerging adults had a supportive social network, they endorsed the need for greater public education to avoid diabetes misinformation. Emerging adults felt more connected with HCPs that had diabetes-specific training (ie, endocrinologist) or those who personally live with T1DM.

Modeling Ketogenesis for Use in Pediatric Diabetes Simulation

BACKGROUND

Simulation is being increasingly integrated into medical education. Diabetes simulation is well-received by trainees and has demonstrated improved clinical results, including reduced adult inpatient hyperglycemia. However, no pediatric-specific diabetes simulation programs exist for use in medical education. None of the existing diabetes models incorporate ketones as an input or an output, which is essential for use in teaching pediatric diabetes management.

METHODS

We created a pediatric diabetes simulation incorporating both blood sugar and urine ketones as output. Ketone output is implemented as a state variable but is obfuscated to simulate hospital experience. Blood sugar output is similar to other models and incorporates the current blood sugar, insulin on board (IOB) and carbohydrates on board (COB), and insulin and carbohydrate sensitivities. The program calculates all IOB and COB every 15 minutes based on user input and provides written summary feedback at the end of the simulation about inaccurate dosing and timing.

RESULTS

The simulation realistically incorporated both blood glucose and urine ketones in clinically valid and actionable formats. After completing this simulation, 16/17 pediatric residents indicated that they wanted more simulated diabetes cases integrated into their curriculum.

CONCLUSION

Implementing simulation into pediatric diabetes education was feasible and well-received. More work is needed to further study the role of simulation in pediatric diabetes education when used adjunctively or in lieu of lectures when time or resources are limited.

Development, Implementation, and Evaluation of a Physician-Targeted Inpatient Glycemic Management Curriculum

OBJECTIVE

Diabetes is prevalent among hospitalized patients and there are multiple challenges to attaining glycemic control in the hospital setting. We sought to develop an inpatient glycemic management curriculum with stakeholder input and to evaluate the effectiveness of this educational program on glycemic control in hospitalized patients.

METHODS

Using the Six-Step Approach of Kern to Curriculum Development for Medical Education, we developed and implemented an educational curriculum for inpatient glycemic management targeted to internal medicine residents and hospitalists. We surveyed physicians (n = 73) and conducted focus group sessions (n = 18 physicians) to solicit input regarding educational deficits and desired format of the educational intervention. Based on feedback from the surveys and focus groups, we developed educational goals and objectives and a case-based curriculum, which was delivered over a 1-year period via in-person teaching sessions by 2 experienced diabetes physicians at 3 hospitals. Rates of hypoglycemia and hyperglycemia were evaluated among at-risk patient days using an interrupted time-series design.

RESULTS

We developed a mnemonic-based (SIGNAL) curriculum consisting of 10 modules, which covers key concepts of inpatient glycemic management and provides an approach to daily glycemic management: S = steroids, I = insulin, G = glucose, N = nutritional status, A = added dextrose, and L = labs. Following implementation of the curriculum, there was no difference in the rates of hyperglycemia in insulin-treated patients following the intervention; however, there was an increase in the rates of hypoglycemia defined as blood glucose (BG) ⩽ 70 mg/dL (5.6% vs 3.0%, P < .001) and clinically significant hypoglycemia defined as BG < 54 mg/dL (1.9% vs 0.8%, P = .01). There was poor penetration of the curriculum, with 60%, 20%, and 90% of the learning modules being delivered at the three participating hospitals, respectively.

CONCLUSIONS

In this pilot study, a physician-targeted educational curriculum was not associated with improved glycemic control. Adapting the intervention to increase penetration and integrating the curriculum into existing clinical decision support tools may improve the effectiveness of the educational program on glycemic outcomes.

Human Rabies Postexposure Prophylaxis Knowledge and Retention Among Health Professionals by Using an Online Continuing Education Module: Arizona, 2012 to 2015

Rabies postexposure prophylaxis (PEP) is administered for rabies prevention after a human exposure to a potentially rabid animal, such as a bite. Previous studies have reported that rabies PEP is often inappropriately administered. Health professional education was proposed as one potential solution to address inappropriate PEP use. We assessed baseline knowledge, knowledge gain, and knowledge retention among health professionals in Arizona of rabies epidemiology and appropriate PEP administration. Maricopa County Department of Public Health created an online rabies PEP continuing education module and measured knowledge before and after module completion using a 10-question test. The same test was administered three times (pretest, posttest, and retention test at ≥3 months). To assess knowledge gain and retention, we compared median scores using nonparametric methods. A total of 302 respondents completed the pretest (median score, 60%) and posttest (median score, 90%; p < .001); 98 respondents completed all three tests with median scores 60% (pretest), 90% (posttest, p < .01), and 80% (retention test and compared with pretest, p < .01). Sixty-nine (70%) respondents improved their pretest to retention test score by a mean of 2.4 points out of a total 10 points (median: 2 points; range: -5 to 7 points). Only 48% of pretest respondents correctly answered that PEP should not be administered immediately to anyone bitten by a healthy dog. However, 81% and 70% answered correctly on the posttest (p < .0001) and retention test (p = .002), respectively. Respondents demonstrated rabies epidemiology and PEP knowledge gain and ≥3-month knowledge retention after completing the online continuing education module.

Common Models Used for Inpatient Diabetes Management

PURPOSE OF REVIEW

Diabetes affects about a third of all hospitalized patients and up to 50% of inpatients go on to experience hyperglycemia. Despite strong evidence supporting the importance of adequate glycemic control, as well detailed guidelines from major national organizations, many patients continue to have hypo- and hyperglycemia during their hospital stay. While this may be partially related to provider and patient-specific factors, system-based barriers continue to pose a major obstacle. Therefore, there is a need to go beyond merely discussing specific insulin protocols and provide guidance for effective models of care in the acute glycemic management of hospitalized patients.

RECENT FINDINGS

To date, there is limited data evaluating the various models of care for inpatient diabetes management in terms of efficacy or cost, and there is no summary on this topic guiding physicians and hospital administrators. In this paper, four common models of inpatient diabetes care will be presented including those models led by the following: an endocrinologist(s), mid-level provider(s), pharmacist(s), and a virtual glucose management team. The authors will outline the intrinsic benefits as well as limitations of each model of care as well as cite supporting evidence, when available. Discussion pertaining to how a given model of care shapes and formulates a particular organization's structured glucose management program (GMP) will be examined. Furthermore, the authors describe how the model of care chosen by an institution serves as the foundation for the creation of a GMP. Finally, the authors examine the critical factors needed for GMP success within an institution and outline the nature of hospital administrative support and accompanying reporting structure, the function of a multidisciplinary diabetes steering committee, and the role of the medical director.

Improving paediatric residents' knowledge and perspectives regarding the insulin pump using a novel educational workshop

OBJECTIVES

As a pilot study, we aimed to investigate the knowledge and perceptions of categorical paediatric residents (RES) at our institution regarding insulin pumps (IPs) and the impact following a targeted workshop.

METHODS

All RES at our institution in attendance at a routine noon conference participated in a workshop, completing an anonymous survey before and right after the intervention to evaluate knowledge, attitudes and self-reported comfort regarding IPs. The workshop consisted of a didactic lecture followed by an insulin pump (IP) device demonstration of three commonly available brands. Knowledge score (KS) was calculated for each RES based on the total correct responses. Attitudes were assessed via 5-point Likert scale. Frequencies, t-test and McNemar tests were used to analyse data.

RESULTS

Thirty four completed surveys were analysed out of 49 RES (69.3%) who attended the workshop. Among them, there were 19 first-year, 8 second-year and 7 third-year residents. Following the intervention, KS increased significantly (p<0.001) with progression in residents' attitudes. Overall, more RES reported being comfortable with handling the IP, including looking up and changing the settings (p<0.001).

CONCLUSION

There is scope for improvement in the knowledge and perceptions of RES regarding IPs. Educational interventions like ours are needed to familiarise our future physicians with IPs to allow hospitals to provide their systematic and safe inpatient use.

Can a single interactive seminar durably improve knowledge and confidence of hospital diabetes management?

BACKGROUND

Safe and effective diabetes management in the hospital is challenging. Inadequate knowledge has been identified by trainees as a key barrier. In this study we assess both the short-term and long-term impact of an interactive seminar on medical student knowledge and comfort with hospital diabetes management.

METHODS

An interactive seminar covering hospital diabetes management and utilizing an audience response system was added to the third-year medical student curriculum. Students were given a multiple choice assessment immediately before and after the seminar to assess their comprehension of the material. Students were also asked to rate their confidence on this topic. Approximately 6 months later, students were given the same assessment to determine if the improvements in hospital diabetes knowledge and confidence were durable over time. Students from the preceding medical school class, who did not have a hospital diabetes seminar as a part of their curriculum, were used as a control.

RESULTS

Fifty-three students participated in the short-term assessment immediately before and after the seminar. The mean score (maximum 15) was 7.7 +/- 2.7 (51%) on the pre-test and 11.4 +/- 1.8 (76%) on the post-test (p < 0.01). 75 students who attended the seminar completed the same set of questions 6 months later with mean score of 9.2 ± 2.3 (61%). The control group of 100 students who did not attend seminar had a mean score of 8.8 ± 2.5 (58%). The difference in scores between the students 6-months after the seminar and the control group was not significantly different (p = 0.30).

CONCLUSIONS

Despite initial short-term gains, a single seminar on hospital diabetes management did not durably improve trainee knowledge or confidence. Addition of repeated and focused interactions during clinical rotations or other sustained methods of exposure need to be evaluated.

PERSPECTIVES ON LEARNING AND CLINICAL PRACTICE IMPROVEMENT FOR DIABETES IN THE HOSPITAL: A REVIEW OF EDUCATIONAL INTERVENTIONS FOR PROVIDERS

OBJECTIVE

The management of inpatient hyperglycemia and diabetes requires expertise among many health-care providers. There is limited evidence about how education for healthcare providers can result in optimization of clinical outcomes. The purpose of this critical review of the literature is to examine methods and outcomes related to educational interventions regarding the management of diabetes and dysglycemia in the hospital setting. This report provides recommendations to advance learning, curricular planning, and clinical practice.

METHODS

We conducted a literature search through PubMed Medical for terms related to concepts of glycemic management in the hospital and medical education and training. This search yielded 1,493 articles published between 2003 and 2016.

RESULTS

The selection process resulted in 16 original articles encompassing 1,123 learners from various disciplines. We categorized findings corresponding to learning outcomes and patient care outcomes.

CONCLUSION

Based on the analysis, we propose the following perspectives, leveraging learning and clinical practice that can advance the care of patients with diabetes and/or dysglycemia in the hospital. These include: (1) application of knowledge related to inpatient glycemic management can be improved with active, situated, and participatory interactions of learners in the workplace; (2) instruction about inpatient glycemic management needs to reach a larger population of learners; (3) management of dysglycemia in the hospital may benefit from the integration of clinical decision support strategies; and (4) education should be adopted as a formal component of hospitals' quality planning, aiming to integrate clinical practice guidelines and to optimize diabetes care in hospitals.

Impact of the Diabetes Inpatient Care and Education (DICE) project and the DICE Care Pathway on patient outcomes and trainee doctor's knowledge and confidence

AIM

To evaluate the impact of the Diabetes Inpatient Care and Education project and a comprehensive diabetes care pathway, the Diabetes Inpatient Care and Education Care Pathway, on patient outcomes and on the knowledge and confidence of trainee doctors.

METHODS

The effect on patient outcomes was evaluated by comparing the National Diabetes Inpatient Audit data before (2012) and after (2013) implementing the Diabetes Inpatient Care and Education project. The impact on trainee doctors was evaluated using the Modified Kirkpatrick model. Just before the project began and again 3 months later, trainee doctors were surveyed to assess their knowledge and confidence in inpatient diabetes care.

RESULTS

Patient harm was found to have been reduced significantly when National Diabetes Inpatient Audit data for 2012 and 2013 were compared. Severe hypoglycaemia decreased from 15.4 to 9.7%, medication errors from 56.9 to 21.1% and insulin errors from 31 to 7%. Across the 96 trainee doctors surveyed, the mean (sd) knowledge and confidence scores increased significantly (P < 0.001 for both) from 57.1 (16.8) and 61.8 (14.9) to 68.4 (13.3) and 74.3 (11.7), respectively.

CONCLUSION

The Diabetes Inpatient Care and Education project and the Diabetes Inpatient Care and Education Care Pathway improved patient outcomes and the knowledge and confidence of trainee doctors in this hospital. The impact of a similar project in other hospitals needs to be evaluated.

Improvement in inpatient glycemic care: pathways to quality

The management of inpatient hyperglycemia is a focus of quality improvement projects across many hospital systems while remaining a point of controversy among clinicians. The association of inpatient hyperglycemia with suboptimal hospital outcomes is accepted by clinical care teams; however, the clear benefits of targeting hyperglycemia as a mechanism to improve hospital outcomes remain contentious. Glycemic management is also frequently confused with efforts aimed at intensive glucose control, further adding to the confusion. Nonetheless, several regulatory agencies assign quality rankings based on attaining specified glycemic targets for selected groups of patients (Surgical Care Improvement Project (SCIP) measures). The current paper reviews the data supporting the benefits associated with inpatient glycemic control projects, the components of a successful glycemic control intervention, and utilization of the electronic medical record in implementing an inpatient glycemic control project.

Resident physicians using modern practices for excellent documentation and care in heart failure (PUMPED CHF)

The most common indication for readmission among Medicare patients is congestive heart failure (CHF). Prior studies underscore the use of residents to bolster hospital-wide programs and reduce CHF readmissions. The authors assessed the effectiveness of a novel online training program designed to improve resident documentation and knowledge related to CHF. The findings suggest that despite a significant increase in knowledge scores following the online educational course, there was only a slight increase in documentation scores. Additional teaching modalities need to be identified to foster resident education and create sustained behavior change.

Effect of online diabetes training for hospitalists on inpatient glycaemia

AIM

An online diabetes course for medical residents led to lower patient blood glucose, but also increased hypoglycaemia despite improved trainee confidence and knowledge. Based on these findings, we determined whether an optimized educational intervention delivered to hospitalists (corresponding to an Acute Physician or Specialist in Acute Hospital Medicine in the UK) improved inpatient glycaemia without concomitant hypoglycaemia.

METHODS

All 22 hospitalists at an academic medical centre were asked to participate in an online curriculum on the management of inpatient dysglycaemia in autumn 2009 and a refresher course in spring 2010.

RESULTS

All hospitalists completed the initial intervention. Median event blood glucose decreased from 9.3 mmol/l (168 mg/dl) pre-intervention to 7.8 mmol/l (141 mg/dl) post-intervention and 8.5 mmol/l (153 mg/dl) post-refresher (P < 0.001 for both). Hospitalizations categorized as hyperglycaemia decreased from 83.3 to 55.6% (P = 0.014), with a trend towards euglycaemia (10-28.9%, P = 0.08) and no change in hypoglycaemia. Hyperglycaemic patient-days decreased from 72.0 to 57.3% (P = 0.004), with greater target glycaemia (27.3-39.4%, P = 0.016) and no change in hypoglycaemia.

CONCLUSIONS

An optimized online educational intervention delivered to hospitalists yielded significant improvements in inpatient glycaemia without increased hypoglycaemia.

A learner-centered diabetes management curriculum: reducing resident errors on an inpatient diabetes pathway

OBJECTIVE

Diabetes errors, particularly insulin administration errors, can lead to complications and death in the pediatric inpatient setting. Despite a lecture-format curriculum on diabetes management at our children's hospital, resident diabetes-related errors persisted. We hypothesized that a multifaceted, learner-centered diabetes curriculum would help reduce pathway errors.

RESEARCH DESIGN AND METHODS

The 8-week curricular intervention consisted of 1) an online tutorial addressing residents' baseline diabetes management knowledge, 2) an interactive diabetes pathway discussion, 3) a learner-initiated diabetes question and answer session, and 4) a case presentation featuring embedded pathway errors for residents to recognize, resolve, and prevent. Errors in the 9 months before the intervention, as identified through an incident reporting system, were compared with those in the 10 months afterward, with errors classified as relating to insulin, communication, intravenous fluids, nutrition, and discharge delay.

RESULTS

Before the curricular intervention, resident errors occurred in 28 patients (19.4% of 144 diabetes admissions) over 9 months. After the intervention, resident errors occurred in 11 patients (6.6% of 166 diabetes admissions) over 10 months, representing a statistically significant (P = 0.0007) decrease in patients with errors from before intervention to after intervention. Throughout the study, the errors were distributed into the categories as follows: insulin, 43.8%; communication, 39.6%; intravenous fluids, 14.6%; nutrition, 0%; and discharge delay, 2.1%.

CONCLUSIONS

An interactive learner-centered diabetes curriculum for pediatric residents can be effective in reducing inpatient diabetes errors in a tertiary children's hospital. This educational model promoting proactive learning has implications for decreasing errors across other medical disciplines.

Durability of the effect of online diabetes training for medical residents on knowledge, confidence, and inpatient glycemia

BACKGROUND

Inpatient dysglycemia is associated with increased morbidity, mortality and cost. Medical education must not only address knowledge gaps, but also improve clinical care.

METHODS

  All 129 medicine residents at a large academic medical center were offered a case-based online curriculum on the management of inpatient dysglycemia in the fall of 2009. First-year residents took a 3-h course with 10 modules. Second and third-year residents, who had been educated the prior year, underwent abbreviated training. All residents were offered a 20-min refresher course in the spring of 2009. We assessed resident knowledge, resident confidence, and patient glycemia on two teaching wards before and after the initial intervention, as well as after the refresher course.

RESULTS

  A total of 117 residents (91%) completed the initial training; 299 analyzed admissions generated 11, 089 blood glucose values and 4799 event blood glucose values. Admissions with target glycemia increased from 19.4% to 33.0% (P = 0.035) by the end of the curriculum. There was a strong downward trend in hyperglycemia from 22.4% to 11.3% (P = 0.055) without increased hypoglycemia. Confidence and knowledge increased significantly among first-time and repeat participants. Residents rated the intervention as highly relevant to their practice and technologically well implemented.

CONCLUSION

  Optimization of an online curriculum covering the management of inpatient glycemia over the course of 2 years led to significantly more admissions in the target glycemia range. Given its scalability, modularity and applicability, this web-based educational intervention may become the standard curriculum for the management of inpatient glycemia.

Improving the management of diabetes in hospitalized patients: the results of a computer-based house staff training program

BACKGROUND

Poorly controlled diabetes in hospitalized patients is associated with poor clinical outcomes. We hypothesized that computer-based diabetes training could improve house staff knowledge and comfort for the management of diabetes in a large tertiary-care hospital.

METHODS

We implemented a computer-based training program on inpatient diabetes for internal medicine house staff at the Brigham and Women's Hospital (Boston, MA) in September 2009. House staff were required to complete the program and answer a set of questions, before and after the program, to evaluate their level of comfort and knowledge of inpatient diabetes. Chart reviews of all non-critically ill patients with diabetes managed by house staff in August 2009 (before the program) and December 2009 (after the program) were performed. Chart reviews were also performed for August 2008 and December 2008 to compare house staff management practices when the computer-based educational program was not available.

RESULTS

A significant increase in comfort levels and knowledge in the management of inpatient diabetes was seen among house staff at all levels of training (P<0.02), but the increase was smaller for senior house staff compared with junior house staff. Nonsignificant trends suggesting increased use of basal-bolus insulin (P=0.06) and decreased use of sliding-scale insulin (P=0.10) were seen following the educational intervention in 2009, whereas no such change was seen in 2008 (P>0.90). Overall, house staff evaluated the training program as "very relevant" and the technology interface as "good."

CONCLUSIONS

A computer-based diabetes training program can improve the comfort and knowledge of house staff and potentially improve their insulin administration practices at large academic centers.

Basal-bolus insulin protocols enter the computer age

Diabetes affects approximately one quarter of all hospitalized patients. Poor inpatient glycemic control has been associated with increased risk for multiple adverse events including surgical site infections, prolonged hospital length of stay, and mortality. Inpatient glycemic control protocols based on physiologic basal-bolus insulin regimens have been shown to improve glycemia and clinical outcomes and are recommended by the American Diabetes Association, the American Association of Clinical Endocrinologists, and the Society of Hospital Medicine for inpatient glycemic management of noncritically ill patients. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act will catalyze widespread computerized medication order entry implementation over the next few years. Here, we focus on the noncritical care setting and review the background on inpatient glycemic management as it pertains to computerized order entry, the translation and efficacy of computerizing glycemic control protocols, and the barriers to computerizing glycemic protocols.