Optimizing Transitions of Care and Enhancing Surgical Education on Acute Care Surgery: A Multi-Institutional Survey Study

OBJECTIVE

Critically ill and injured patients are routinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Environment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty-specific handoff format in order to optimize patient care and enhance surgical education on the ACS service.

DESIGN

A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, supervised handoffs by trauma attendings, and surgical education. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs.

SETTING

Ten American College of Surgeons-verified Level 1 adult trauma centers.

PARTICIPANTS

All general surgery residents and trauma/acute/surgical critical care fellows were surveyed.

RESULTS

The study task was completed by 147 postgraduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees utilized the open-ended response field to highlight specific best practices of their home institutions.

CONCLUSIONS

Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance surgical knowledge. As TC continue to be a focus of certifying bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education.

Use of a Continuous Glucose Monitoring System in High Risk Hospitalized Non-critically ill Patients with Diabetes after Cardiac Surgery and during their Transition of Care from the Intensive Care Unit during Covid-19-A Pilot Study

OBJECTIVE

Continuous glucose monitoring (CGM) has demonstrated benefits in managing inpatient diabetes. We initiated this single-arm pilot feasibility study during the COVID-19 pandemic in 11 patients to determine the feasibility and accuracy of real-time CGM in cardiac surgery patients with diabetes after their transition of care from the intensive care unit(ICU).

METHODS

Clarke Error Grid(CEG) analysis was used to compare CGM and point-of-care(POC) measurements. Mean absolute relative difference(MARD) of the paired measurements was calculated to assess the accuracy of the CGM for glucose measurements during the first 24 hours on CGM, the remainder of time on the CGM as well as for different chronic kidney disease(CKD) strata.

RESULTS

Overall MARD between POC and CGM measurements was 14.80%. MARD for patients without CKD IV and V with eGFR < 20 ml/min/1.73m² was 12.13%. Overall, 97% of the CGM values were within the no-risk zone of the CEG analysis. For the first 24 hours, a sensitivity analysis of the overall MARD for all subjects and for those with eGFR > 20 ml/min/1.73m² was 15.42% (+/- 14.44) and 12.80% (+/- 7.85) respectively. Beyond the first 24 hours, overall MARD for all subjects and for those with eGFR > 20 ml/min/1.73m² was 14.54% (+/- 13.21) and 11.86% (+/- 7.64) respectively.

CONCLUSIONS

CGM has great promise to optimize inpatient diabetes management in the noncritical care setting and after the transition of care from the ICU with high clinical reliability, and accuracy. More studies are needed to further assess CGM in patients with advanced CKD.

Interdisciplinary Education Apartment Simulation (IDEAS) Project: An Interdisciplinary Simulation for Transitional Home Care

INTRODUCTION

Home-based care (HBC) is a valuable tool to provide care to rural, medically underserved populations. By mitigating geographic and transportation barriers for vulnerable populations, HBC is a promising modality of health care delivery. Interprofessional education has become an integral part in undergraduate and professional curricula; however, applications of team-based training in HBC are often missing from curricula. When included, instruction in HBC often utilizes didactic instruction or laboratory experiences, which are discipline-specific and lack a focus on integration of team-based care.

METHODS

We implemented a standardized patient (SP) simulation of a posthospital discharge home visit using a team of learners from nursing, physical therapy (PT), occupational therapy (OT), dentistry, pharmacy, and medicine in a simulated home environment. Pre- and postsimulation competencies of interprofessional care were measured using the 20-item Interprofessional Collaborative Competency Attainment Survey (ICCAS).

RESULTS

Throughout the academic years of August 2018 - August 2020, 68 students from nursing, PT, OT, pharmacy, medicine, and dentistry completed a simulated home visit with an SP discharged from a hospital. For all 20 perceived abilities on the ICCAS, learners showed a statistically significant increase in postsurvey measurement. A modest to large (.31 ≤ r ≤ .94) effect size was observed in the majority of responses.

DISCUSSION

This SP simulation described a novel, interdisciplinary approach to incorporating HBC into interprofessional curricula.

Transit Care Hub pharmacist: improving patient flow within the hospital

Background The Transit Care Hub (TCH) is an inpatient ward traditionally used as a waiting area for patients who require transport to return home. In July 2018, a six-month pilot of a TCH pharmacist was funded to improve the flow of patients through the hospital. Setting Major Australian teaching hospital. Objective(s) To determine the effect that the TCH pharmacist had on patient flow within the hospital and on the time saved for other clinical pharmacists, as well as estimating cost savings. Methods A service delivery framework for the TCH pharmacist was developed and tested. This involved a proactive approach to patient discharge with ward-based staff. Data were collected from July to November 2018, 20 weeks prior to and 20 weeks after the commencement of the pilot. Main outcome measure Measurements included the number of best possible medication histories (BPMHs) completed during admission, improvements in arrival time to TCH from inpatient wards and cost savings. Results During the pilot study period (20 weeks), 791 patients were discharged by the TCH pharmacist, arriving an average of 70 minutes earlier than other patients discharging through TCH. There was a 16% increase in patients discharging through TCH which released ward beds. The TCH pharmacist increased the number of BPMHs on day of admission by 14%. There was an estimated annual saving of AU$252,008 for the hospital. Conclusions The TCH pharmacist service enhanced patient flow by coordinating earlier discharges, increasing the timely completion of BPMHs, and saving ward pharmacist time. Significant cost savings supported a permanently funded position.

Pharmacist-Led Discharge Medication Counseling and its Corresponding Impact on Medication Adherence and Hospital Readmission Rates

Objectives: Pharmacists have been shown to reduce hospital readmission rates and improve adherence rates by providing discharge medication counseling and offering services such as a bedside delivery program.¹ Hospitals are now penalized by Medicare if patients are readmitted within 30 days of discharge, so implementation of these programs have the potential to be financially significant as well.² The primary endpoint of this study is to evaluate the impact of a pharmacist discharge medication counseling bedside delivery program on medication adherence rates within a six-week period following discharge. The secondary endpoint focuses on hospital readmission rates. The objective of this study is to increase collaboration between community pharmacies and hospitals in order to improve the quality of patient care. Methods: This study was designed as intervention versus control, whereas the intervention patients were those who received counseling from a pharmacist or pharmacist intern and control patients were those who did not within the same time period. Collected patient data (n=81) included patients’ demographic data and all disease states, genders, and insurance coverage were encompassed by the included patients. Medication adherence was measured at follow-up intervals utilizing the proportion of days covered (PDC) equation, where a score of at least 80% is required for optimal therapeutic efficacy. Informed consent was obtained from all participants regarding a follow-up telephone call or retrieval of medication records through the pharmacy electronic medication records system and hospital electronic medical records system. Approximately 10-15-minute counseling sessions were performed at the time of discharge. Follow-up phone calls were conducted for the intervention group at four-weeks and six-weeks post-discharge to discuss medication adherence and side effects experienced. Results: There was a total of 81 patients enrolled in this study. There were 27 patients in the intervention group and 54 patients in the control group. The pharmacist-led discharge counseling sessions made a statistically significant difference in medication adherence rates (p<0.001) as calculated using PDC, showing adherence rates of 84.4% in the intervention group and 62.8% in the control group. The pharmacist-led discharge counseling sessions made a statistically significant difference in hospital readmission rates (p=0.022), with a 24% readmission rate in the control group and a 3% readmission rate in the intervention group. Conclusion: Pharmacist involvement in a bedside delivery program helps to improve medication adherence in patients being discharged from a hospital. A PDC of at least 80% is required for optimal therapeutic efficacy in most classes of chronic medications, and only the intervention arm reached this threshold.³ The findings also show a statistically significant reduction in hospital readmission rates for patients receiving a pharmacist-led discharge counseling session.

Medication Reconciliation: An Educational Module

INTRODUCTION

Patients often transition between health care settings, such as office to hospital, hospital to nursing facility, or hospital to home. When a patient is admitted, it is imperative that clinicians review prior medication lists along with new orders to reconcile any discrepancies. This process should occur in a standardized manner to reduce medication errors leading to adverse events and patient harm.

METHODS

We developed this program as an instructional method via PowerPoint to teach the importance of accurate medication reconciliation. We implemented the program in multiple grand rounds settings with students, trainees, and attending physicians in internal medicine and surgery. Approximately 150 learners attended the sessions. We assessed learners with pre/post self-efficacy assessment (74 completed precourse surveys, 39 completed posttest surveys, and 49 participated in the audience response during the course) and multiple-choice knowledge questions.

RESULTS

The results of the postcourse knowledge assessment demonstrated improvement in every question we tested, with two of the improvements reaching statistical significance. We found that 30% of attendees were not at all confident or only somewhat confident in conducting an appropriate medication reconciliation on admission to the hospital. Additionally, 82% of respondents reported that the presentation was likely or extremely likely to improve their medication reconciliation efforts.

DISCUSSION

Our educational program was successful in improving learners' knowledge in every question we tested; however, only two of the improvements were statistically significant. Our program is an organized and effective tool for teaching effective and reliable medication reconciliation.

Assessing Quality of Pharmacist-Led Education for Patients with COPD Using the Lung Information Needs Questionnaire: A Pilot Study

BACKGROUND

Transitioning a patient from the hospital to home is an area of vulnerability for patients with Chronic Obstructive Pulmonary Disease (COPD). Patients with COPD frequently readmit as they often do not understand their disease state, medications or when to seek medical attention.

OBJECTIVES

The objective of this study is to determine the impact that pharmacist-led education has on a patient's understanding of their disease state by assessing the results of the Lung Information Needs Questionnaire (LINQ).

METHODS

This study uses a quasi-experimental design to formally assess pharmacist-led education provided to patients with COPD using the LINQ. The LINQ was used to assess knowledge of the disease state and medications before and after receiving education on disease state management, smoking cessation and proper medication use.

RESULTS

A total of 17 patients completed the LINQ. The survey results showed a statistically significant improvement in patient understanding in 4 of the 6 targeted areas.

CONCLUSION

Results from the formal assessment using the LINQ suggest that pharmacist-lead education for COPD patients is beneficial and reliable. This study presents a continued need for patient education and research in this high-risk patient population.

Twelve Tips for Preparing a Surgical Discharge Summary: Enabling a Safe Discharge

This article was migrated. The article was marked as recommended. The surgical discharge summary allows the perioperative care team to summarize a recent hospitalization and relay important information to a variety of invested parties including other healthcare providers, outpatient caregivers, and the surgical patient. The inpatient care team can promote a smooth transition of care and empower outpatient providers and the patient to foster a confident progression through recovery. We describe twelve tips for a streamlined, successful discharge summary geared towards the surgical intern. A successful surgical discharge summary begins with patient and caregiver collaboration, communication and teamwork, and culminates with concise documentation. These tips reflect a review of the current literature and rely on the clinical expertise of an interdisciplinary surgical team. Our aim is to empower surgical educators and trainees to understand the complexity of discharge planning, and to improve the efficiency with which it can be completed and the quality of the discharge process at their training hospitals.

Rehab Concepts and Discharge Dispositions: Workshop for Medical Students

Introduction

Safe transitions of care are an essential component of safety and quality for the patient community. It is imperative that providers choose appropriate discharge settings to reduce avoidable hospital readmissions. Additionally, providers must also ensure that the multifaceted needs of each patient are met with every discharge recommendation. There is often a lack of formal instruction in medical school on the various discharge dispositions, indications for rehab, and clinical indications for each setting. This is problematic for new interns who are tasked with entering discharge orders and relaying critical information between lead physicians and the interprofessional team.

Methods

A 60-minute workshop with both didactic and experiential components provided medical students with opportunities to gain an overview of discharge dispositions while also exercising critical thinking using case examples. The workshop was part of a 2-week Transition to Residency course at a single institution.

Results

Twenty-two fourth-year medical students participated in the workshop. Following the workshop, 100% of the participants stated that they had learned something new and that they intended to use the content in practice as interns. Subjective responses indicated that workshop content ought to be incorporated earlier in medical training.

Discussion

These results suggest that a 60-minute workshop including didactic instruction as well as experiential and inquiry-based learning can impact medical student knowledge and intent for practice change in regard to providing safe transitions of care for the patient community.

Medication Reconciliation in the Hospital: An Interactive Case-Based Session for Internal Medicine Residents

Introduction

Medication reconciliation is a complex process of creating and maintaining the most accurate medication list for a patient to help guide therapy. Done incorrectly, the process of medication reconciliation can lead to medical error and result in adverse events for patients. Medication reconciliation on inpatient medicine service is often done by internal medicine residents. However, published reports of educational interventions for residents are limited.

Methods

We created a 1-hour session that was experiential, case based, and targeted to the level of a first-year resident. In total, 31 internal medicine residents completed the curriculum, which involved either a 1-hour classroom group activity or an individual virtual activity. The curriculum was evaluated using standard forms with qualitative feedback regarding learner satisfaction, pre- and postsession confidence survey, and pre- and postsession patient chart audits.

Results

Qualitative feedback demonstrated residents' positive experiences. There was no significant change in residents' confidence in portions of the medication reconciliation process. One month following the educational intervention, 100% of inpatient charts audited for review of the medication list were accurate, as compared to 67%-83% accuracy prior to the session.

Discussion

This novel case-based medication reconciliation teaching session, targeted at learners in an internal medicine residency, can easily be implemented at other institutions using the institution-specific electronic health record. The session was well received by residents, and we observed improved accuracy in the medication reconciliation process done by residents.

I-PASS Mentored Implementation Handoff Curriculum: Implementation Guide and Resources

Introduction

Communication failures during shift-to-shift handoffs of patient care have been identified as a leading cause of adverse events in health care institutions. The I-PASS Handoff Program is a comprehensive handoff program that has been shown to decrease rates of medical errors and adverse events. As part of the spread and adaptation of this program, a comprehensive implementation guide was created to assist individuals in the implementation process.

Methods

The I-PASS Mentored Implementation Guide grew out of materials created for the original I-PASS Study, Society of Hospital Medicine (SHM) mentored implementation programs, and the experience of members of the I-PASS Study Group. The guide provides a comprehensive framework of all elements required to implement the large-scale I-PASS Handoff Program and contains detailed information on generating institutional support, training activities, a campaign, measuring impact, and sustaining the program.

Results

Thirty-two sites across North America utilized the guide as part of the SHM program. The guide served as a main reference for 477 hours of mentoring phone calls between site leads and their mentors. Postprogram surveys from wave 2 sites revealed that 85% (N = 34) of respondents felt the quality of the guide was very good/excellent. Site leads noted that they referenced the guide most often during the early part of the program and that they referenced the sections on the curriculum and handoff observations most often.

Discussion

The I-PASS Mentored Implementation Guide is an essential resource for those looking to implement the large-scale I-PASS Handoff Program at their institution.

Transitions of Care: Improving the Quality of Discharge Summaries Completed By Internal Medicine Residents

INTRODUCTION

Discharge summaries are now the accepted means of communication in transition from inpatient to ambulatory care. However, there is often no formal residency education on this critical document, leading to discordance in discharge summaries written by internal medicine residents. There is little in the literature focusing on teaching how to effectively create a discharge summary using an electronic health record (EHR).

METHODS

A 1-hour workshop was designed to teach components of the discharge summary and how to utilize this document to safely transition patients from the inpatient to the ambulatory setting. One or two faculty facilitators led the workshop with approximately 20 resident learners. A 50-point rubric was created to assess effectiveness of discharge summaries pre- and postworkshop.

RESULTS

The workshop was well received by residents and median scores on the rubric improved from 39 to 45 (p < .001) postworkshop.

DISCUSSION

We found that by teaching the concepts using examples of discharge summaries written by our residents, and then creating a standardized EHR template, residents wrote more effective discharge summaries with increased focus on the transition to the ambulatory provider. These materials can be applied to other programs and levels of learners to improve discharge summary quality. This serves to provide a resource to those at other institutions looking to create a more formalized didactic session on discharge summaries with a particular focus on transitioning care to the ambulatory provider.

Discharging Mrs. Fox: A Team-Based Interprofessional Collaborative Standardized Patient Encounter

INTRODUCTION

In 2003, the Institute of Medicine recommended that interprofessional education be incorporated into the training programs of health care professionals. However, many logistical challenges hinder formal interprofessional learning in health care profession programs.

METHODS

This resource is a 3-hour interprofessional small-group session designed for health professions student teams to engage in a standardized patient encounter, each team member contributing a profession-specific perspective to create a collaborative care plan across five discharge decisions. The activity includes a simulated standardized patient encounter and debrief session wherein students discuss the role of bias and communication and create a collaborative care plan.

RESULTS

Following the activity, participants were surveyed about the value of the educational experience. Over 12 months, 106 students (81 medicine, nine nursing, 16 pharmacy) participated in the interprofessional activity. Eighty-four students responded to the postevent survey (79% response rate). Students were confident that the experience helped them integrate profession-specific knowledge, create a shared care plan, and understand how interprofessional collaboration contributes to quality care. The debriefing session and interprofessional interaction were an integral component of the experience.

DISCUSSION

This resource is a feasible interprofessional small-group activity that has been implemented without excessive faculty time or institutional resources. It is adaptable to institutional needs, local resources, level of trainee, and professions. The session provides interprofessional students the opportunity to engage with one another and with the patient in a collaborative decision-making activity focused around a critical transition of care.

Cardiovascular Admissions, Readmissions, and Transitions of Care

Hospital 30-day readmissions have become a major priority for hospitals. Hospitals face penalties for excessive readmissions for acute myocardial infarction (AMI) and heart failure (HF). Thus, it is important for hospitals to understand the transitions of care that occur for both of these conditions, and what tools are available to guide the processes involved. A multi-disciplinary team including Emergency Medical Service providers, Emergency Medicine providers, cardiologists, hospitalists, pharmacists, nurses, case managers, and outpatient physicians can all be involved in the process of safely transitioning a patient between care settings. Small-scale studies in the geriatric population have shown improved transitions of care and decreased readmissions with these care teams. The emergency department is a key transition point for patients with AMI and HF, yet it is rarely identified and utilized as such in transitions of care interventions. Future research and implementation projects will need to refine and expand the role of the emergency department in the process.