Hospital Physicians’ Stethoscopes: Bacterial Contamination After a Simple Cleaning Protocol

BACKGROUND

Stethoscope surfaces become contaminated with bacteria due to inconsistent cleaning practices,​ as​​ ​​​​cleaning frequency and practical clean​s​ing approaches are not well-established.

METHODS

We investigated bacterial contamination of stethoscopes at baseline, after simple cleaning, and after examining one patient. We surveyed 30 hospital providers on stethoscope cleaning practices and then measured bacterial contamination of stethoscope diaphragm surfaces before cleaning, after cleaning with alcohol-based hand sanitizer, and after use in examining one patient.

RESULTS

Only 20% of providers reported cleaning stethoscopes regularly. Before cleaning, 50% of stethoscopes were contaminated with bacteria, compared with 0% after cleaning (p<0.001) and 36.7% after examining one patient (p=0.002). Among providers who reported not cleaning stethoscopes regularly, 58% had bacterial-contaminated stethoscopes compared with 17% who did report cleaning regularly (p=0.068).

CONCLUSIONS

Hospital providers' stethoscopes had a high probability of bacterial contamination at baseline and after examining one patient. We recommend decontamination with alcohol-based hand sanitizer immediately before each patient examination.

Here's the rub: A case of constrictive pericarditis in an adult with cystic fibrosis

We present a rare coexistence of constrictive pericarditis in a patient with cystic fibrosis. Careful attention to cardiac friction rub auscultated on initial examination prompted echocardiography revealing constrictive pericarditis further confirmed by cardiac magnetic resonance imaging that allowed for dedicated treatment in addition to management of his concurrent respiratory infection.

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Only the third reported case of constrictive pericarditis in a patient with cystic fibrosis.

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Symptoms of severe cystic fibrosis and constrictive pericarditis are similar.

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Cardiac knocks or friction rubs should raise suspicion for a pericardial process.

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Annulus paradoxus and reversus are echo hallmarks for constrictive pericarditis.

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Management of constrictive pericarditis requires dedicated treatment and monitoring.

Clinical Case-Conference Blogs: Integrating Clinical Librarians to Enhance Resident Education and Enforce ACGME Competencies

Resident conferences are primary educational endeavors for trainees and faculty alike. We describe the development of collaborative clinician-librarian educational blogs within the Internal Medicine (2009), Pediatrics (2012), and General Surgery (2018) residency programs. Clinical librarians attended resident conferences and generated evidence-based blog posts based on learning topics and clinical questions encountered during the conferences. In the decade since introduction of the blogs, this partnership has resulted in over 2000 blog posts and generated over 1800 individual views per month. The development of a clinical librarian-managed blog serves as a relevant resource for promoting evidence-based practices within a case-based learning curriculum, engages interdisciplinary collaboration through existing resources, and is generalizable across various clinical practice disciplines and trainees.

Practical Evidence-Based Medicine at the Student-to-Physician Transition: Effectiveness of an Undergraduate Medical Education Capstone Course

INTRODUCTION

Medical information is expanding at exponential rates. Practicing physicians must acquire skills to efficiently navigate large bodies of evidence to answer clinical questions daily. How best to prepare medical students to meet this challenge remains unknown. The authors sought to design, implement, and assess a pragmatic evidence-based medicine (EBM) course engaging students at the transition from undergraduate to graduate medical education.

MATERIALS AND METHODS

An elective course was offered during the required 1-month Capstone medical school curriculum. Participants included one hundred sixty-eight graduating fourth-year medical students at Emory University School of Medicine who completed the course from 2012 to 2018. Through interactive didactics, small groups, and independent work, students actively employed various electronic tools to navigate medical literature and engaged in structured critical appraisal of guidelines and meta-analyses to answer clinical questions.

RESULTS

Assessment data was available for 161 of the 168 participants (95.8%). Pre- and post-assessments demonstrated students' significant improvement in perceived and demonstrated EBM knowledge and skills (p < 0.001), consistent across gender and specialty subgroups.

DISCUSSION

The Capstone EBM course empowered graduating medical students to comfortably navigate electronic medical resources and accurately appraise summary literature. The objective improvement in knowledge, the perceived improvement in skill, and the subjective comments support this curricular approach to effectively prepare graduating students for pragmatic practice-based learning as resident physicians.

Reorganizing a hospital ward as an accountable care unit

Traditional hospital wards are not specifically designed as effective clinical microsystems. The feasibility and sustainability of doing so are unclear, as are the possible outcomes. To reorganize a traditional hospital ward with the traits of an effective clinical microsystem, we designed it to have 4 specific features: (1) unit-based teams, (2) structured interdisciplinary bedside rounds, (3) unit-level performance reporting, and (4) unit-level nurse and physician coleadership. We called this type of unit an accountable care unit (ACU). In this narrative article, we describe our experience implementing each feature of the ACU. Our aim was to introduce a progressive approach to hospital care and training.

Evaluating Simulation-Based ACLS Education on Patient Outcomes: A Randomized, Controlled Pilot Study

BACKGROUND

Simulation training is widely accepted as an effective teaching tool, especially for dealing with high-risk situations.

OBJECTIVE

We assessed whether standardized, simulation-based advanced cardiac life support (ACLS) training improved performance in managing simulated and actual cardiac arrests.

METHODS

A total of 103 second- and third-year internal medicine residents were randomized to 2 groups. The first group underwent conventional ACLS training. The second group underwent two 2 1/2-hour sessions of standardized simulation ACLS teaching. The groups were assessed by evaluators blinded to their assignment during in-hospital monthly mock codes and actual inpatient code sheets at 3 large academic hospitals. Primary outcomes were time to initiation of cardiopulmonary resuscitation, time to administration of first epinephrine/vasopressin, time to delivery of first defibrillation, and adherence to American Heart Association guidelines.

RESULTS

There were no differences in primary outcomes among the study arms and hospital sites. During 21 mock codes, the most common error was misidentification of the initial rhythm (67% [6 of 9] and 58% [7 of 12] control and simulation arms, respectively, P  =  .70). There were no differences in primary outcome among groups in 147 actual inpatient codes.

CONCLUSIONS

This blinded, randomized study found no effect on primary outcomes. A notable finding was the percentage of internal medicine residents who misidentified cardiac arrest rhythms.

Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models

BACKGROUND

A shortage of critical care specialists or intensivists, coupled with expanding United States critical care needs, mandates identification of alternate qualified physicians for intensive care unit (ICU) staffing.

OBJECTIVE

To compare mortality and length of stay (LOS) of medical ICU patients cared for by a hospitalist or an intensivist-led team.

DESIGN

Prospective observational study.

SETTING

Urban academic community hospital affiliated with a major regional academic university.

PATIENTS

Consecutive medical patients admitted to a hospitalist ICU team (n = 828) with selective intensivist consultation or an intensivist-led ICU teaching team (n = 528).

MEASUREMENTS

Endpoints were ICU and in-hospital mortality and LOS, adjusted for patient differences with logistic and linear regression models and propensity scores.

RESULTS

The odds ratio adjusted for disease severity for in-hospital mortality was 0.8 (95% confidence interval [CI]: 0.49, 1.18; P = 0.23) and ICU mortality was 0.8 (95% CI: 0.51, 1.32; P = 0.41), referent to the hospitalist team. The adjusted LOS was similar between teams (hospital LOS difference 0.9 days, P = 0.98; ICU LOS difference 0.3 days, P = 0.32). Mechanically ventilated patients with intermediate illness severity had lower hospital LOS (10.6 vs 17.8 days, P < 0.001) and ICU LOS (7.2 vs 10.6 days, P = 0.02), and a trend towards decreased in-hospital mortality (15.6% vs 27.5%, P = 0.10) in the intensivist-led group.

CONCLUSIONS

The adjusted mortality and LOS demonstrated no statistically significant difference between hospitalist and intensivist-led ICU models. Mechanically ventilated patients with intermediate illness severity showed improved LOS and a trend towards improved mortality when cared for by an intensivist-led ICU teaching team.

Hospitalist handoffs: a systematic review and task force recommendations

BACKGROUND

Handoffs are ubiquitous to Hospital Medicine and are considered a vulnerable time for patient safety.

PURPOSE

To develop recommendations for hospitalist handoffs during shift change and service change.

DATA SOURCES

PubMed (through January 2007), Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network, white papers, and hand search of article bibliographies.

STUDY SELECTION

Controlled studies evaluating interventions to improve in-hospital handoffs (n = 10).

DATA EXTRACTION

Studies were abstracted for design, setting, target, outcomes (including patient-level, staff-level, or system-level outcomes), and relevance to hospitalists.

DATA SYNTHESIS

Although there were no studies of hospitalist handoffs, the existing literature from related disciplines and expert opinion support the use of a verbal handoff supplemented with written documentation in a structured format or technology solution. Technology solutions were associated with a reduction in preventable adverse events, improved satisfaction with handoff quality, and improved provider identification. Nursing studies demonstrate that supplementing verbal exchange with a written medium leads to improved retention of information. White papers characterized effective verbal exchange, as focusing on ill patients and actions required, with time for questions and minimal interruptions. In addition, content should be updated daily to ensure communication of the latest clinical information. Using this literature, recommendations for hospitalist handoffs are presented with corresponding levels of evidence. Recommendations were reviewed by hospitalists at the Society of Hospital Medicine (SHM) Annual Meeting and by an interdisciplinary team of expert consultants and were endorsed by the SHM governing board.

CONCLUSIONS

The systematic review and resulting recommendations provide hospitalists a starting point from which to improve in-hospital handoffs.

Spreading the word, not the infection: reaching hospitalists about the prevention of antimicrobial resistance

BACKGROUND

To reach and engage hospitalists in the prevention of antimicrobial resistance, the Society of Hospital Medicine and the Centers for Disease Control and Prevention developed and conducted a quality improvement workshop based on the Centers for Disease Control and Prevention's Campaign to Prevent Antimicrobial Resistance in Healthcare Settings.

METHODS

We aimed to examine motivating factors, perceived barriers, and cues to action for hospitalists to learn about and engage in the prevention of antimicrobial resistance and to determine whether a workshop can facilitate the implementation of a quality improvement project. Using the Health Belief Model as a theoretical framework, we interviewed hospitalists who attended (attendees) and did not attend (nonattendees) the workshop. Data were qualitatively coded and analyzed.

RESULTS

Nine attendees and 10 nonattendees participated in interviews. Motivating factors for attending the workshop included an interest in the topic of quality improvement and antimicrobial resistance prevention, the promotion of the workshop by institutions and colleagues, the opportunity to network with colleagues, and the qualifications of the presenter. Barriers to involvement in quality improvement efforts and the prevention of antimicrobial resistance for both attendees and nonattendees included perceived lack of time, other institutional priorities, and lack of administrative and institutional support. Attendees and nonattendees also identified perceived effective and preferred methods for receiving information about antimicrobial resistance, such as workshops and presentations, e-mail, institutional involvement, and the Internet. Overall, attendees thought that the workshop could be effective in facilitating the implementation of a quality improvement project.

CONCLUSION

By considering factors that influence behavioral change, interventions, such as the Society of Hospital Medicine workshop, have the ability to reach and engage clinicians such as hospitalists in quality improvement efforts to prevent antimicrobial resistance and improve adherence to infection control strategies. Furthermore, this study demonstrated that the Health Belief Model can provide an applicable framework for examining factors that influence clinician behavior.

Impact of Society of Hospital Medicine workshops on hospitalists' knowledge and perceptions of health care-associated infections and antimicrobial resistance

BACKGROUND

Health care-associated infections and antimicrobial resistance threaten the safety of hospitalized patients. New prevention strategies are necessary to address these problems. In response, the Society of Hospital Medicine (SHM) in collaboration with the Centers for Disease Control and Prevention developed and conducted workshops to educate hospitalists about conducting quality improvement programs to address antimicrobial resistance and health care-associated infections in hospitalized patients.

METHODS

SHM collected and analyzed data from pretests and posttests administered to physicians who attended SHM workshops in 2005 in 1 of 3 major cities: Denver, Colorado; Boston, Massachusetts; or Portland, Oregon.

RESULTS

A total of 69 SHM members attended the workshops, and 50 completed both a pretest and a posttest. Scores on the knowledge-based questions increased significantly from pretest to posttest (x = 48% vs. 63%, P < .0001); however, perceptions of the problem of antimicrobial resistance did not change. Most participants (85%) rated the quality of the workshop as "very good" or "excellent" and rated the workshop sessions as "useful" (x = 3.9 on a 5.0 scale).

CONCLUSIONS

Hospitalists who attended the SHM workshop increased their knowledge of health care-associated infections, antimicrobial resistance, and quality improvement programs related to these issues. Similar workshops should be considered in efforts to prevent health care-associated infections and antimicrobial resistance.

Use of handheld computers in medical education. A systematic review

BACKGROUND

Over the past decade, handheld computers (or personal digital assistants [PDAs]) have become a popular tool among medical trainees and physicians. Few comprehensive reviews of PDA use in medicine have been published.

OBJECTIVE

We systematically reviewed the literature to (1) describe medical trainees' use of PDAs for education or patient care, (2) catalog popular software applications, and (3) evaluate the impact of PDA use on patient care.

DATA SOURCES

MEDLINE (1993 to 2004), medical education-related conference proceedings, and hand search of article bibliographies.

REVIEW METHODS

We identified articles and abstracts that described the use of PDAs in medical education by trainees or educators. Reports presenting a qualitative or quantitative evaluation were included.

RESULTS

Sixty-seven studies met inclusion criteria. Approximately 60% to 70% of medical students and residents use PDAs for educational purposes or patient care. Satisfaction was generally high and correlated with the level of handheld computer experience. Most of the studies included described PDA use for patient tracking and documentation. By contrast, trainees rated medical textbooks, medication references, and medical calculators as the most useful applications. Only 1 randomized trial with educational outcomes was found, demonstrating improved learning and application of evidence-based medicine with use of PDA-based decision support software. No articles reported the impact of PDA use on patient outcomes.

CONCLUSION

Most medical trainees find handhelds useful in their medical education and patient care. Further studies are needed to evaluate how PDAs impact learning and clinical outcomes.

Core competencies in hospital medicine: development and methodology

BACKGROUND

The hospitalist model of inpatient care has been rapidly expanding over the last decade, with significant growth related to the quality and efficiency of care provision. This growth and development have stimulated a need to better define and characterize the field of hospital medicine. Training and developing curricula specific to hospital medicine are the next step in the evolution of the field.

METHODS

The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, introduces the expectations of hospitalists and provides an initial structural framework to guide medical educators in developing curricula that incorporate these competencies into the training and evaluation of students, clinicians-in-training, and practicing hospitalists. This article outlines the process that was undertaken to develop the Core Competencies, which included formation of a task force and editorial board, development of a topic list, the solicitation for and writing of chapters, and the execution of multiple reviews by the editorial board and both internal and external reviewers.

RESULTS

This process culminated in the Core Competencies document, which is divided into three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in each section delineate the core knowledge, skills, and attitudes necessary for effective inpatient practice while also incorporating a systems organization and improvement approach to care coordination and optimization.

CONCLUSIONS

These competencies should be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve inpatient training practices.

How to use The Core Competencies in Hospital Medicine: a framework for curriculum development

BACKGROUND

The seminal article that coined the term hospitalist, published in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital. Since that time the role of the hospitalist has evolved, and hospitalists are being called upon to demonstrate that they actually improve quality of care and the education of the next generation of physicians. A companion article in this issue describes in detail the rationale for the development of the Core Competencies document and the methods by which it was created.

METHODS

Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development. The cases illustrate 1) a specific problem and the need for improvement; 2) a needs assessment of the targeted learners (hospitalists and clinicians in training); 3) goals and specific measurable objectives; 4) educational strategies using the competencies to provide structure and guidance; 5) implementation (applying competencies to a variety of training opportunities and curricula); 6) evaluation and feedback; and 7) remaining questions and the need for additional research.

RESULTS

This article illustrates how to utilize The Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

CONCLUSIONS

Medical educators should compare their learning objectives to the Core Competencies to ensure that their trainees have achieved competency to practice hospital medicine and improve the hospital setting.

Core competencies in hospital medicine: development and methodology

BACKGROUND

The hospitalist model of inpatient care has been rapidly expanding over the last decade, with significant growth related to the quality and efficiency of care provision. This growth and development have stimulated a need to better define and characterize the field of hospital medicine. Training and developing curricula specific to hospital medicine are the next step in the evolution of the field.

METHODS

The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, introduces the expectations of hospitalists and provides an initial structural framework to guide medical educators in developing curricula that incorporate these competencies into the training and evaluation of students, clinicians-in-training, and practicing hospitalists. This article outlines the process that was undertaken to develop the Core Competencies, which included formation of a task force and editorial board, development of a topic list, the solicitation for and writing of chapters, and the execution of multiple reviews by the editorial board and both internal and external reviewers.

RESULTS

This process culminated in the Core Competencies document, which is divided into three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in each section delineate the core knowledge, skills, and attitudes necessary for effective inpatient practice while also incorporating a systems organization and improvement approach to care coordination and optimization.

CONCLUSIONS

These competencies should be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve inpatient training practices.

How to use the core competencies in hospital medicine: a framework for curriculum development

BACKGROUND

The seminal article that coined the term hospitalist, published in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital. Since that time the role of the hospitalist has evolved, and hospitalists are being called upon to demonstrate that they actually improve quality of care and the education of the next generation of physicians. A companion article in this issue describes in detail the rationale for the development of the Core Competencies document and the methods by which it was created.

METHODS

Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development. The cases illustrate 1) a specific problem and the need for improvement; 2) a needs assessment of the targeted learners (hospitalists and clinicians in training); 3) goals and specific measurable objectives; 4) educational strategies using the competencies to provide structure and guidance; 5) implementation (applying competencies to a variety of training opportunities and curricula); 6) evaluation and feedback; and 7) remaining questions and the need for additional research.

RESULTS

This article illustrates how to utilize The Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

CONCLUSIONS

Medical educators should compare their learning objectives to the Core Competencies to ensure that their trainees have achieved competency to practice hospital medicine and improve the hospital setting.

Effects of race on lipid-lowering management in hospitalized patients with coronary heart disease

The objective of this study was to determine the association between patient characteristics, specifically race, and the appropriate management of lipid-reducing therapy in patients with coronary heart disease (CHD) discharged from the hospital. Two hundred fifty-eight consecutive patients with diagnoses suggestive of CHD were identified in a large, inner-city university teaching hospital serving a predominantly indigent African American population. The outcome measure, suboptimal lipid management, evaluated the intensification of lipid-reducing therapy when indicated using the National Cholesterol Education Program guidelines for the low-density lipoprotein cholesterol goal. The overall rate of suboptimal lipid management was 48%. Black patients with CHD were significantly more likely to have suboptimal lipid management than nonblack patients by the time of hospital discharge (52.3% vs 16.7%, p = 0.021). The disparity in the clinical management of black patients with CHD may help explain the differential in health outcomes seen between black and white patients.

Hospitalists as teachers

OBJECTIVE

To compare evaluations of teaching effectiveness among hospitalist, general medicine, and subspecialist attendings on general medicine wards.

DESIGN

Cross-sectional.

SETTING

A large, inner-city, public teaching hospital.

PARTICIPANTS

A total of 423 medical students and house staff evaluating 63 attending physicians.

MEASUREMENTS AND MAIN RESULTS

We measured teaching effectiveness with the McGill Clinical Tutor Evaluation (CTE), a validated 25-item survey, and reviewed additional written comments. The response rate was 81%. On a 150-point composite measure, hospitalists' mean score (134.5 [95% confidence interval (CI), 130.2 to 138.8]) exceeded that of subspecialists (126.3 [95% CI, 120.4 to 132.1]), P =.03. General medicine attendings (135.0 [95% CI, 131.2 to 138.8]) were also rated higher than subspecialists, P =.01. Physicians who graduated from medical school in the 1990s received higher scores (136.0 [95% CI, 133.0 to 139.1]) than did more distant graduates (129.1 [95% CI, 125.1 to 133.1]), P =.006. These trends persisted after adjusting for covariates, but only year of graduation remained statistically significant, P =.05. Qualitative analysis of written remarks revealed that trainees valued faculty who were enthusiastic teachers, practiced evidence-based medicine, were involved in patient care, and developed a good rapport with patients and other team members. These characteristics were most often noted for hospitalist and general medicine attendings.

CONCLUSIONS

On general medicine wards, medical students and residents considered hospitalists and general medicine attendings to be more effective teachers than subspecialists. This effect may be related to the preferred faculty members exhibiting specific characteristics and behaviors highly valued by trainees, such as enthusiasm for teaching and use of evidence-based medicine.