Effects of increased overnight supervision on resident education, decision-making, and autonomy

Patient Surgical Outcomes When Surgery Residents Are the Primary Surgeon by Intensity of Surgical Attending Supervision in Veterans Affairs Medical Centers

Objective

Using health records from the Department of Veterans Affairs (VA), the largest healthcare training platform in the United States, we estimated independent associations between the intensity of attending supervision of surgical residents and 30-day postoperation patient outcomes.

Background

Academic leaders do not agree on the level of autonomy from supervision to grant surgery residents to best prepare them to enter independent practice without risking patient outcomes.

Methods

Secondary data came from a national, systematic 1:8 sample of n = 862,425 teaching encounters where residents were listed as primary surgeon at 122 VA medical centers from July 1, 2004, through September 30, 2019. Independent associations between whether attendings had scrubbed or not scrubbed on patient 30-day all-cause mortality, complications, and 30-day readmission were estimated using generalized linear-mixed models. Estimates were tested for any residual confounding biases, robustness to different regression models, stability over time, and validated using moderator and secondary factors analyses.

Results

After accounting for potential confounding factors, residents supervised by scrubbed attendings in 733,997 nonemergency surgery encounters had fewer deaths within 30 days of the operation by 14.2% [0.3%, 29.9%], fewer case complications by 7.9% [2.0%, 14.0%], and fewer readmissions by 17.5% [11.2%, 24.2%] than had attendings not scrubbed. Over the 15 study years, scrubbed surgery attendings may have averted an estimated 13,700 deaths, 43,600 cases with complications, and 73,800 readmissions.

Conclusions

VA policies on attending surgeon supervision have protected patient safety while allowing residents in selected teaching encounters to have limited autonomy from supervision.

Trainee Autonomy and Supervision in the Modern Clinical Learning Environment: A Mixed-Methods Study of Faculty and Trainee Perspectives

Background

Balancing autonomy and supervision during medical residency is important for trainee development while ensuring patient safety. In the modern clinical learning environment, tension exists when this balance is skewed. This study aimed to understand the current and ideal states of autonomy and supervision, then describe the factors that contribute to imbalance from both trainee and attending perspectives.

Methods

A mixed-methods design included surveys and focus groups of trainees and attendings at three institutionally affiliated hospitals between May 2019-June 2020. Survey responses were compared using chi-square tests or Fisher's exact tests. Open-ended survey and focus group questions were analyzed using thematic analysis.

Results

Surveys were sent to 182 trainees and 208 attendings; 76 trainees (42%) and 101 attendings (49%) completed the survey. Fourteen trainees (8%) and 32 attendings (32%) participated in focus groups. Trainees perceived the current culture to be significantly more autonomous than attendings; both groups described an "ideal" culture as more autonomous than the current state. Focus group analysis revealed five core contributors to the balance of autonomy and supervision: attending-, trainee-, patient-, interpersonal-, and institutional-related factors. These factors were found to be dynamic and interactive with each other. Additionally, we identified a cultural shift in how the modern inpatient environment is impacted by increased hospitalist attending supervision and emphasis on patient safety and health system improvement initiatives.

Conclusions

Trainees and attendings agree that the clinical learning environment should favor resident autonomy and that the current environment does not achieve the ideal balance. There are several factors contributing to autonomy and supervision, including attending-, resident-, patient-, interpersonal-, and institutional-related. These factors are complex, multifaceted, and dynamic. Cultural shifts towards supervision by primarily hospitalist attendings and increased attending accountability for patient safety and systems improvement outcomes further impacts trainee autonomy.

Guiding Fellows to Independent Practice: Current Trends in Pediatric Emergency Medicine Fellow Supervision

BACKGROUND

Recent studies highlight the importance of physician readiness to practice beyond graduate training. The Accreditation Council for Graduate Medical Education mandates that pediatric emergency medicine (PEM) fellows be prepared for independent practice by allowing "progressive responsibility for patient care." Prior unpublished surveys of program directors (PDs) indicate variability in approaches to provide opportunities for more independent practice during fellowship training.

OBJECTIVES

The aims of the study were to describe practices within PEM fellowship programs allowing fellows to work without direct supervision and to identify any barriers to independent practice in training.

DESIGN/METHODS

An anonymous electronic survey of PEM fellowship PDs was performed. Survey items were developed using an iterative modified Delphi process and pilot tested. Close-ended survey responses and demographic variables were summarized with descriptive statistics. Responses to open-ended survey items were reviewed and categorized by theme.

RESULTS

Seventy two of 84 PDs (88%) responded to the survey; however, not all surveys were completed. Of the 68 responses to whether fellows could work without direct supervision (as defined by the Accreditation Council for Graduate Medical Education) during some part of their training, 31 (45.6%) reported that fellows did have this opportunity. In most programs, clinical independence was conditional on specific measures including the number of clinical hours completed, milestone achievement, and approval by the clinical competency committee. Reported barriers to fellow practice without direct oversight included both regulatory and economic constraints.

CONCLUSIONS

Current training practices that provide PEM fellows with conditional clinical independence are variable. Future work should aim to determine best practices of entrustment, identify ideal transition points, and mitigate barriers to graduated responsibility.

Use of Chart-Stimulated Recall to Explore Uncertainty in Medical Decision-Making Among Senior Internal Medicine Residents

BACKGROUND

Uncertainty is common and impacts both patients and clinicians. The approach to uncertainty in medical trainees may be distinct from that of practicing clinicians and has important implications for medical education.

OBJECTIVE

Describe trainee approach to uncertainty with the use of chart-stimulated recall (CSR)-based interviews, as well as the utility of such interviews in promoting reflection about decision-making among senior internal medicine (IM) residents.

DESIGN

Qualitative analysis of CSR-based interviews with IM residents.

PARTICIPANTS

Senior IM residents rotating on inpatient night float at the University of Pittsburgh Medical Center from February to September 2019.

INTERVENTION

Each participant completed one, 20-min CSR session based on a self-selected case in which there was uncertainty in decision-making. Interviews explored the sources of, approaches to, and feelings about uncertainty.

APPROACH

Two independent coders developed a codebook and independently coded all transcripts. Transcripts were then analyzed using thematic analysis.

KEY RESULTS

The perceived acuity of the patient presentation was the main driver of the approach to and stress related to uncertainty. Perceived level of responsibility in resolving uncertainty during the overnight shift also varied among individual participants. Attending expression of uncertainty provided comfort to residents and alleviated stress related to uncertainty. Residents felt comfortable discussing their uncertainty and felt that the opportunity to think aloud during the exercise was valuable.

CONCLUSIONS

Our study demonstrated a novel approach to the exploration of uncertainty in medical decision-making, with the use of CSR. Variations in resident perceived level of responsibility in resolving uncertainty during the overnight shift suggest a need for curriculum development in approach to uncertainty during night shifts. Though residents often experienced stress related to uncertainty, attending expression of uncertainty was an important mitigator of that stress, emphasizing the important role that the trainee-attending interaction plays in the diagnostic process.

A Prospective Trial of an In-house Overnight Fellow Rotation in the Intensive Care Unit

Background

Although previous studies in academic intensive care units (ICUs) have found no improvement in patient care outcomes with in-house overnight attending physician coverage compared with home call coverage, the effect of in-house supervision on trainee education and well-being is less clear. In addition, no studies have examined the effect of in-house coverage by fellow physicians overnight.

Objective

What is the impact of an in-house overnight critical care fellow on resident, fellow, and attending perception of patient safety, house staff education, and house staff well-being?

Methods

A prospective trial alternating 2-week periods of in-house overnight critical care fellow coverage with 2-week periods of home call coverage was performed in our tertiary medical ICU. Residents, fellows, and attendings were surveyed to evaluate perceptions of the night fellows' impact on patient care, communication, supervision, educational experience, autonomy, well-being, and job satisfaction.

Results

Over the 6-month study period, surveys were sent to 83 residents, 22 fellows, and 23 attendings, with completion by 56 (67%), 22 (100%), and 16 (70%), respectively. Overall, 89% of residents, 68% of fellows, and 81% of attendings reported perceived improvements in patient care with an in-house fellow. The in-house fellow was also associated with improved well-being in 79% of residents and 73% of fellows, and 82% of residents felt that it positively impacted education.

Conclusion

As compared with the traditional home call system, an in-house night critical care fellow can improve the perception of patient care, trainee well-being, and education in a tertiary ICU at an academic hospital.

Autonomy and developing physicians: Reimagining supervision using self-determination theory

In this article, we address the question, 'What is the role of autonomy in physician development?' Medical education is a developmental process, and autonomy plays a motivational role in physician development. Calls for increased supervision of residents have raised concerns that the resulting decreased autonomy might interfere with resident development, leading the authors to explore the relationship between supervision and autonomy. The medical education literature posits a simple inverse relationship between supervision and autonomy. Within competency frameworks, autonomy is operationalised as independence and viewed as the end goal of training. Alternatively, there is emerging empirical literature describing autonomy and supervision as dynamic and developmental constructs and point towards more complex relationship between supervision and autonomy. Self-determination theory (SDT) presents a framework for understanding this dynamic relationship and the role of autonomy in physician development. Within SDT, autonomy is a fundamental psychological need, associated with motivation for learning, self-regulation and an internal locus of control. Supporting learner autonomy can afford learners the opportunity to internalise the values and norms of the profession, leading to an integrated regulation of their behaviours and actions. Conceptualising autonomy through the lens of SDT provides an avenue for education interventions and future research on supervision and autonomy. Educators can integrate supervision and autonomy support in the clinical setting, seeking to motivate learner development by balancing optimal challenge and support and integrating autonomy support with 'hands-on' approaches to supervision. SDT also provides a theoretical framework relevant to current discussions regarding feedback conversations and coaching in medical education. Lastly, conceptualising autonomy using SDT opens new avenues for investigation, exploring the complex relationship between supervision and autonomy and developing efforts to integrate autonomy support with clinical supervision.

Flying Solo: Effectiveness of Attendingless Family-Centered Rounds on Improving Resident Autonomy

BACKGROUND AND OBJECTIVES

The Accreditation Council for Graduate Medical Education requires that residents demonstrate increasing autonomy during their training. Although residents report a better educational environment with hospitalists present during family-centered rounds (FCRs), there is a concern that attending presence may reduce resident autonomy. We aim to determine the effect of FCRs without an attending during rounds on senior residents' sense of autonomy.

METHODS

We conducted a multicenter, retrospective, preintervention-postintervention study at 5 children's hospitals to evaluate the effect of rounding without an attending on senior residents' self-efficacy, using a questionnaire developed by using Bandura's principles of self-efficacy and Accreditation Council for Graduate Medical Education milestones. Questions addressed skills of diagnosis and/or management, communication, teaching, and team management. We compared preintervention and postintervention results using paired t tests and Wilcoxon rank tests. One-way analysis of variance tests were used to compare means among >2 groups.

RESULTS

116 (82% response rate) of 142 eligible senior residents completed the questionnaire, which yielded a high reliability (α = 0.80) with a 1-factor score. The average composite score of self-efficacy significantly improved after intervention compared with the preintervention score (66.71 ± 6.95 vs 60.91 ± 6.82; P < .001). Additional analyses revealed meaningful improvement of each individual item postintervention. The highest gain was reported in directing bedside teaching (71.8% vs 42.5%; P < .001) and answering learner questions on rounds (70.7% vs 47.0%; P < .001).

CONCLUSIONS

Conducting FCRs without an attending increases resident reported self-efficacy regarding core elements of patient care and team leadership. In future studies, researchers should examine the impact of rounding without the attending on other stakeholders, such as students, interns, patients and/or families.

Barriers to Accessing Nighttime Supervisors: a National Survey of Internal Medicine Residents

BACKGROUND

Single-center studies have reported residents experience barriers to accessing supervising physicians overnight, but no national dataset has described barriers perceived by residents or the association between supervision models and perceived barriers.

OBJECTIVE

To explore residents' perception of barriers to accessing overnight supervision.

DESIGN

Questions about overnight supervision and barriers to accessing it were included on the American College of Physicians Internal Medicine In-Training Examination® (IM-ITE®) Resident Survey in Fall 2017.

PARTICIPANTS

All US-based internal medicine residents who completed the 2017 IM-ITE®. Responses from 20,744 residents (84%) were analyzed.

MAIN MEASURES

For our main outcome, we calculated percentages of responses for eight barriers and tested for association with the presence or absence of nocturnists. For our secondary outcome, we categorized free-text responses enumerating barriers from all residents into the five Systems Engineering Initiative for Patient Safety (SEIPS) categories to elucidate future areas for study or intervention.

KEY RESULTS

Internal medicine residents working in hospitals without nocturnists more commonly reported having at least one barrier to accessing a supervising physician "always" or "most of the time" (5075/9842, 51.6%) compared to residents in hospitals with nocturnists (3074/10,902, 28.2%, p < 0.001). Among residents in hospitals without nocturnists, the most frequently reported barrier to accessing attending supervision was attendings not being present in the hospital (30.4% "always" or "most of the time"); residents in hospitals with nocturnists most frequently reported desire to make their own decisions as a barrier to contacting attendings (15.7% "always" or "most of the time"). Free-text responses from residents with and without nocturnists most commonly revealed organization (47%) barriers to accessing supervision; 28% cited person barriers, and 23% cited tools/technology barriers.

CONCLUSIONS

Presence of nocturnists is associated with fewer reported barriers to contacting supervising physicians overnight. Organizational culture, work schedules, desire for independence, interpersonal interactions, and technology may present important barriers.

Life on Call: Perspectives of Junior and Senior Internal Medicine Residents

PURPOSE

Models of daytime and nighttime on-call responsibilities for residents vary across internal medicine training programs, but there are few data regarding residents' perceptions of their on-call experiences. The authors sought to understand what residents perceive as the benefits and detriments of 24-hour, in-house call, a perspective instrumental to informing change.

METHOD

The authors conducted in-depth individual interviews and focus groups between December 2018 and March 2019 with 17 internal medicine residents from postgraduate years 1, 2, and 3 at the University of Toronto about their on-call experiences. Using constructivist grounded theory, the authors developed a framework to understand the residents' perceived benefits and drawbacks of 24-hour in-house call.

RESULTS

Residents' experiences on call were grouped into 7 themes regarding negative and positive aspects of call. Participants reported multidimensional fatigue related to call, including decision fatigue, emotional fragility and lability, and loss of empathy, and also reported that call adversely affected their personal lives. Residents expressed conflicting opinions as to whether prolonged duty hours affected patient outcomes. In contrast, residents also expressed benefits to call, including that overnight call led to increased autonomy and decision-making skills and provided preparation for future careers as independent internists. They described developing camaraderie and a sense of belonging to a team with coresidents overnight. Lastly, residents described occupying different roles during regular duty hours and while on call-daytime roles revolved around follow-up of previously admitted patients and administrative tasks, while overnight duties centered on initial workup and medical stabilization of referred patients.

CONCLUSIONS

Understanding the nuanced phenomenon of being on call from the perspective of those who live through it is a critical step in creating evidence-based educational policies. New call models should emphasize resident autonomy and decision making and should include a consideration of residents' perceived differences between daytime and on-call roles.

Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study

BACKGROUND

Nocturnists (overnight hospitalists) are commonly implemented in US teaching hospitals to adhere to per-resident patient caps and improve care but are rare in Canada, where patient caps and duty hours are comparatively flexible. Our objective was to assess the impact of a newly implemented nocturnist program on perceived quality of care, code status documentation and patient outcomes.

METHODS

Nocturnists were phased in between June 2018 and December 2019 at Toronto General Hospital, a large academic teaching hospital in Toronto, Ontario. We performed a quality-improvement study comparing rates of code status entry into the electronic health record at admission, in-hospital mortality, the 30-day readmission rate and hospital length of stay for patients with cancer admitted by nocturnists and by residents. Surveys were administered in June 2019 to general internal medicine faculty and residents to assess their perceptions of the impact of the nocturnist program.

RESULTS

From July 2018 to June 2019, 30 nocturnists were on duty for 241/364 nights (66.5%), reducing the mean maximum overnight per-resident patient census from 40 (standard deviation [SD] 4) to 25 (SD 5) (p < 0.001). The rate of admission code status entry was 35.3% among patients admitted by residents (n = 133) and 54.9% among those admitted by nocturnists (n = 339) (p < 0.001). The mortality rate was 10.5% among patients admitted by residents and 5.6% among those admitted by nocturnists (p = 0.06), the 30-day readmission rate was 8.3% and 5.9%, respectively (p = 0.4), and the mean acute length of stay was 7.2 (SD 7.0) days and 6.4 (SD 7.8) days, respectively (p = 0.3). Surveys were completed by 15/24 faculty (response rate 62%), who perceived improvements in patient safety, efficiency and trainee education; however, only 30/102 residents (response rate 29.4%) completed the survey.

INTERPRETATION

Although implementation of a nocturnist program did not affect patient outcomes, it reduced residents' overnight patient census, and improved faculty perceptions of quality of care and education, as well as documentation of code status. Our results support nocturnist implementation in Canadian teaching hospitals.

Low performance of internal medicine senior residents in in-service examinations

We observed an unprecedented and consistent low performance of senior residents as compared with juniors in monthly examinations. This compelled us to evaluate systematically and compare the scores of senior residents with their junior colleagues. This retrospective observational study was conducted in April 2020 among internal medicine residents. Residents in first and second year of their training were labelled as junior residents. Residents in third or fourth year of their training were labelled as senior residents. Comparison of mean scores of each resident level was done separately both for monthly formative multiple-choice questions tests, and summative yearly end of term examinations. We discussed the possible reasons as well. There were 67 residents in year 2018 and 69 in 2019. There is no significant difference between scores of monthly examinations of years 2018 and 2019 among residents of each level. Rather, in March and December 2018, junior residents perform better than senior residents with p values of 0.01 and 0.04, respectively. In February and September 2019, senior residents performed better than junior residents with p value of 0.02. Similarly, there is no significant difference in scores of residents of each level in end-of-term examinations of years 2018 and 2019 with p values 0.18 and 0.25, respectively. Performance of senior residents in our residency programme in in-service examinations is relatively low as compared with their junior colleagues. There is a need to evaluate reasons for this relatively low performance of senior residents.

Midnight Report: A Novel Faculty-Guided Night Curriculum to Enhance Resident Nighttime Education

OBJECTIVES

A large discrepancy exists in resident educational activities between daytime and nighttime medical rotations. The Accreditation Council for Graduate Medical Education duty-hour regulations led to the increased adoption of the dedicated nighttime rotation called night float. Nighttime education has largely been negatively perceived by night float medical residents. Although there have been attempts to improve nighttime education, none of the initiatives included faculty-guided structured night curriculum. Our objective was to improve resident experience with and perception of nighttime education by implementing a structured, faculty-guided, nighttime educational curriculum.

METHODS

This was an assessment of an educational initiative at a single academic medical center, Virginia Commonwealth University Health System. The internal medicine residency program implemented a teaching nocturnist program in 2013 and a novel faculty-guided nighttime teaching curriculum in 2016 called midnight report. We then evaluated resident experience with and perception of nighttime education at our institution using anonymous free-response surveys for the academic year July 2016-June 2017.

RESULTS

Of the 142 eligible residents, 95 (67%) responded to the survey. The majority of the residents (54%-77%) positively perceived their experience of the nighttime educational environment during their night float rotation after implementation of the teaching nocturnist program and midnight report.

CONCLUSIONS

Compared with the published literature reporting negative perceptions of the nighttime educational environment by residents at different academic centers, our results showed that the majority of our residents positively perceived the impact of our new faculty-guided nighttime educational curriculum.

Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing

OBJECTIVES

To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital intensivist staffing compared with a standard daytime intensivist model.

DESIGN

Prospective observational study.

SETTING

Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime intensivist staffing.

PATIENTS

Twenty faculty and 13 fellows assigned to rotations in the medical ICU during 2012.

INTERVENTIONS

As part of the parent study, there was weekly randomization of staffing model, stratified by 2-week faculty rotation. During the standard staffing model, there were in-hospital residents, with a fellow and faculty member available at nighttime by phone. In the intervention, there were in-hospital residents with an in-hospital nighttime intensivist. Fellows and faculty completed diaries detailing their sleep, work, and well-being; wore actigraphs; and performed psychomotor vigilance testing daily.

MEASUREMENTS AND MAIN RESULTS

Daily sleep time (mean hours [SD]) was increased for fellows and faculty in the intervention versus control (6.7 [0.3] vs 6.0 [0.2]; p < 0.001 and 6.7 [0.1] vs 6.4 [0.2]; p < 0.001, respectively). In-hospital work duration did not differ between the models for fellows or faculty. Total hours of work done at home was different for both fellows and faculty (0.1 [< 0.1] intervention vs 1.0 [0.1] control; p < 0.001 and 0.2 [< 0.1] intervention vs 0.6 [0.1] control; p < 0.001, respectively). Psychomotor vigilance testing did not demonstrate any differences. Measures of well-being including physical exhaustion and alertness were improved in faculty and fellows in the intervention staffing model.

CONCLUSIONS

Although no differences were measured in patient outcomes between the two staffing models, in-hospital nighttime intensivist staffing was associated with small increases in total sleep duration for faculty and fellows, reductions in total work hours for fellows only, and improvements in subjective well-being for both groups. Staffing models should consider how work duration, sleep, and well-being may impact burnout and sustainability.

A Systematic Review of the Use of Google Glass in Graduate Medical Education

BACKGROUND

Graduate medical education (GME) has emphasized the assessment of trainee competencies and milestones; however, sufficient in-person assessment is often constrained. Using mobile hands-free devices, such as Google Glass (GG) for telemedicine, allows for remote supervision, education, and assessment of residents.

OBJECTIVE

We reviewed available literature on the use of GG in GME in the clinical learning environment, its use for resident supervision and education, and its clinical utility and technical limitations.

METHODS

We conducted a systematic review in accordance with 2009 PRISMA guidelines. Applicable studies were identified through a review of PubMed, MEDLINE, and Web of Science databases for articles published from January 2013 to August 2018. Two reviewers independently screened titles, abstracts, and full-text articles that reported using GG in GME and assessed the quality of the studies. A systematic review of these studies appraised the literature for descriptions of its utility in GME.

RESULTS

Following our search and review process, 37 studies were included. The majority evaluated GG in surgical specialties (n = 23) for the purpose of surgical/procedural skills training or supervision. GG was predominantly used for video teleconferencing, and photo and video capture. Highlighted positive aspects of GG use included point-of-view broadcasting and capacity for 2-way communication. Most studies cited drawbacks that included suboptimal battery life and HIPAA concerns.

CONCLUSIONS

GG shows some promise as a device capable of enhancing GME. Studies evaluating GG in GME are limited by small sample sizes and few quantitative data. Overall experience with use of GG in GME is generally positive.

Educational roles as a continuum of mentoring's role in medicine - a systematic review and thematic analysis of educational studies from 2000 to 2018

BACKGROUND

Recent studies have gone to great lengths to differentiate mentoring from teaching, tutoring, role modelling, coaching and supervision in efforts to better understand mentoring processes. This review seeks to evaluate the notion that teaching, tutoring, role modelling, coaching and supervision may in fact all be part of the mentoring process. To evaluate this theory, this review scrutinizes current literature on teaching, tutoring, role modelling, coaching and supervision to evaluate their commonalities with prevailing concepts of novice mentoring.

METHODS

A three staged approach is adopted to evaluate this premise. Stage one involves four systematic reviews on one-to-one learning interactions in teaching, tutoring, role modelling, coaching and supervision within Internal Medicine, published between 1st January 2000 and 31st December 2018. Braun and Clarke's (2006) approach to thematic analysis was used to identify key elements within these approaches and facilitate comparisons between them. Stage two provides an updated view of one-to-one mentoring between a senior physician and a medical student or junior doctor to contextualise the discussion. Stage three infuses mentoring into the findings delineated in stage one.

RESULTS

Seventeen thousand four hundred ninety-nine citations were reviewed, 235 full-text articles were reviewed, and 104 articles were thematically analysed. Four themes were identified - characteristics, processes, nature of relationship, and problems faced in each of the four educational roles.

CONCLUSIONS

Role modelling, teaching and tutoring, coaching and supervision lie within a mentoring spectrum of increasingly structured interactions, assisted by assessments, feedback and personalised support that culminate with a mentoring approach. Still requiring validation, these findings necessitate a reconceptualization of mentoring and changes to mentor training programs and how mentoring is assessed and supported.

By the Light of Day: Quality, Safety, and Education During the Overnight Admission Handoff

Background

Current duty hour restrictions have led to increased patient handoffs as well as increased use of faculty in the nocturnist role. Nocturnists typically supervise residents and perform direct patient care leading to a diversity of provider experience level during morning handoffs. In this study, we explored how the presence of nocturnists impacts perceptions patient safety, quality, and educational value of morning care transitions.

Methods

We performed a cross-sectional survey examining the housestaff and attending perceptions of the morning sign-out of overnight admissions from both night float residents and nocturnists in July of 2016. Survey responses were Likert-style format, querying respondents’ level of agreement (1-5, strongly disagree to strongly agree) with statements. 108 providers responded (41% response rate)

Results

Relative to attendings, residents reported feeling like they had less time to ask questions (4.0 vs. 5.0, p < 0.001) and felt less comfortable asking questions of the nocturnist during handoff (4.0 vs. 5.0, p < 0.001). Residents were also less comfortable than attendings in changing a nocturnist’s plan of care (4.0 vs. 5.0, p < 0.001). Housestaff reported that receiving signout from the overnight resident was more likely to improve their confidence managing similar conditions (4.0 vs. 3.0, p < 0.001).

Conclusion

The benefits of nocturnist supervision may come at an educational cost as trainees feel less comfortable asking questions or changing the plan of care. With increasingly prevalent night float systems and nocturnist providers, academic programs have to negotiate the balancing safe and high-quality patient care with creating positive learning environments and clear expectations.

Shining a Light on Overnight Education: Hospitalist and Resident Impressions of the Current State, Barriers, and Methods for Improvement

INTRODUCTION

Restrictions on resident work hours and increased requirements for resident supervision have led to night float rotations overseen by overnight hospitalists (nocturnists). The educational value of night float rotations for residents has traditionally been low and studies have yet to elucidate the optimal role of nocturnists in resident education.

METHODS

We performed a cross-sectional survey of all residents within our training program and attending hospitalists in the department of medicine at our three teaching medical centers. Questions sought to investigate the current state of overnight education within an internal medicine residency program, understand barriers to overnight education, and define best practices for nighttime teaching.

RESULTS

Both attending and resident physicians reported low satisfaction with the current state of overnight education, while simultaneously expressing high levels of interest in performing and receiving dedicated nighttime teaching. Attending and resident physicians identified similar barriers to overnight teaching (clinical work, time coordination, provider fatigue) and agreed on the ideal format for overnight didactics (case-based, chalk-talk, 20-minute duration between 10 pm to 2 am).

CONCLUSION

Our study identifies a desire by both faculty and trainees for increased overnight teaching and offers a simple initial framework for programs to improve overnight housestaff education utilizing nocturnist providers.

Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education: A Randomized Clinical Trial

IMPORTANCE

While the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient safety.

OBJECTIVE

To determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program.

INTERVENTIONS

Twenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order.

MAIN OUTCOMES AND MEASURES

The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings.

RESULTS

Of the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04).

CONCLUSIONS AND RELEVANCE

Increased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03318198.

The evolution of graduate medical education over the past decade: Building a new pediatric residency program in an era of innovation

AIM

In 2011, Johns Hopkins Medicine integrated with All Children's Hospital in St. Petersburg Florida to create an academic campus nearly 1000 miles from Baltimore. In 2014, the newly named Johns Hopkins All Children's Hospital established a new pediatric residency program. At that time, the Association for Graduate Medical Education had not accredited a new pediatric program in the USA in over 10 years.

METHODS

A unique set of circumstances provided an opportunity for program developers to build the residency under newly identified core tenets to create a number of innovative features targeted to address the many calls for change in graduate medical education.

RESULTS

This paper focuses on three of those innovations and demonstrates how they address the many challenges introduced by the changing landscape of graduate medical education.

CONCLUSION

Although a full evaluation of our program is only possible after many years, this article presents the core tenets which guided curricular development and discusses our experiences thus far. We provide lessons learned for programs considering similar innovations.

Collaborative Comanagement Between Neurohospitalists and Internal Medicine Hospitalists Decreases Provider Costs and Enhances Satisfaction With Neurology Care at an Academic Medical Center

Background and Purpose

The majority of academic medical centers are moving to a neurohospitalist model of care for hospital neurology coverage. Potential benefits over a more traditional academic model of patient care include greater expertise in acute neurologic disease, increased efficiency, and improved availability to patients, providers, and learners. Despite these perceived advantages, switching to a neurohospitalist model can come at substantial financial cost, so finding ways to maximize the positive impact of a limited number of neurohospitalists is very important to the future health of academic neurology departments. Over the past 7 years, we have implemented a model for inpatient neurological care based on an intimate collaborative relationship between the neurology and hospital medicine services at our main academic hospital. Our goal was to optimize the value of care by decreasing cost while improving quality.

Methods

Cost and revenue associated with professional services was evaluated on a yearly basis. As part of ongoing quality improvement efforts, yearly surveys were administered to referring providers during the transition to a collaborative care model in which NHs and medicine hospitalists comanage neurology inpatients.

Results

Net operating loss was dramatically decreased upon transition to the new care model. Concomitantly, there was a robust positive impact on perception of overall quality, timeliness, and communication skills of neurology services.

Conclusions

Collaborative comanagement is an effective strategy to improve overall satisfaction with neurology services at a tertiary academic medical center while maintaining financial viability.

Intermediate care to intensive care triage: A quality improvement project to reduce mortality

PURPOSE

Medical patients whose care needs exceed what is feasible on a general ward, but who do not clearly require critical care, may be admitted to an intermediate care unit (IMCU). Some IMCU patients deteriorate and require medical intensive care unit (MICU) admission. In 2012, staff in the Johns Hopkins IMCU expressed concern that patient acuity and the threshold for MICU admission were too high. Further, shared triage decision-making between residents and supervising physicians did not consistently occur.

METHODS

To improve our triage process, we used a 4Es quality improvement framework (engage, educate, execute, evaluate) to (1) educate residents and fellows regarding principles of triage and (2) facilitate real-time communication between MICU residents conducting triage and supervising physicians.

RESULTS

Among patients transferred from the IMCU to the MICU during baseline (n=83;July-December 2012) and intervention phases (n=94;July-December 2013), unadjusted mortality decreased from 34% to 21% (p=0.06). After adjusting for severity of illness, admitting diagnosis, and bed availability, the odds of death were lower during the intervention vs. baseline phase (OR 0.33; 95%CI 0.11-0.98).

CONCLUSIONS

Using a structured quality improvement process targeting triage education and increased resident/supervisor communication, we demonstrated reduced mortality among patients transferred from the IMCU to the MICU.

Supervision and autonomy of ophthalmology residents in the outpatient Clinic in the United States: a survey of ACGME-accredited programs

BACKGROUND

The development and demonstration of incremental trainee autonomy is required by the ACGME. However, there is scant published research concerning autonomy of ophthalmology residents in the outpatient clinic setting. This study explored the landscape of resident ophthalmology outpatient clinics in the United States.

METHODS

A link to an online survey using the QualtricsTM platform was emailed to the program directors of all 115 ACGME-accredited ophthalmology programs in the United States. Survey questions explored whether resident training programs hosted a continuity clinic where residents would see their own patients, and if so, the degree of faculty supervision provided therein. Metrics such as size of the resident program, number of faculty and clinic setting were also recorded. Correlations between the degree of faculty supervision and other metrics were explored.

RESULTS

The response rate was 94%; 69% of respondents indicated that their trainees hosted continuity clinics. Of those programs, 30% required a faculty member to see each patient treated by a resident, while 42% expected the faculty member to at least discuss (if not see) each patient. All programs expected some degree of faculty interaction based upon circumstances such as the level of training of the resident or complexity of the clinical situation. 67% of programs that tracked the contribution of the clinic to resident surgical caseloads reported that these clinics provided more than half of the resident surgical volumes. More ¾ of resident clinics were located in urban settings. The degree of faculty supervision did not correlate to any of the other metrics evaluated.

CONCLUSIONS

The majority of ophthalmology resident training programs in the United States host a continuity clinic located in an urban environment where residents follow their own patients. Furthermore, most of these clinics require supervising faculty to review both the patients seen and the medical documentation created by the resident encounters. The different degrees of faculty supervision outlined by this survey might provide a useful guide presuming they can be correlated with validated metrics of educational quality. Finally, this study could provide an adjunctive resource to current international efforts to standardize ophthalmic residency education.

A novel use of the discrete templated notes within an electronic health record software to monitor resident supervision

Objective

Monitoring the supervision of residents can be a challenging task. We describe our experience with the implementation of a templated note system for documenting procedures with the aim of enabling automated, discrete, and standardized capture of documentation of supervision of residents performing floor-based procedures, with minimal extra effort from the residents.

Materials and methods

Procedural note templates were designed using the standard existing template within a commercial electronic health record software. Templates for common procedures were created such that residents could document every procedure performed outside of the formal procedural areas. Automated reports were generated and letters were sent to noncompliers.

Results

A total of 27 045 inpatient non-formal procedural area procedures were recorded from August 2012 to June 2014. Compliance with NoteWriter template usage averaged 86% in the first year and increased to 94.6% in the second year ( P  = .0055).

Initially, only 12.5% of residents documented supervision of any form. By the end of the first year, this was above 80%, with the gains maintained into the second year and beyond. Direct supervision was documented to have occurred where required in 62.8% in the first year and increased to 99.8% in the second year ( P  = .0001) after the addition of hard stops. Notification of attendings prior to procedures was documented 100% of the time by September 2013. Letters sent to errant residents decreased from 3.6 to 0.83 per 100 residents per week.

Conclusion

The templated procedure note system with hard stops and integrated reporting can successfully be used to improve monitoring of resident supervision. This has potential impact on resident education and patient safety.

The Resident-Run Minor Surgery Clinic: A Pilot Study to Safely Increase Operative Autonomy

OBJECTIVE

General surgery training has evolved to align with changes in work hour restrictions, supervision regulations, and reimbursement practices. This has culminated in a lack of operative autonomy, leaving residents feeling inadequately prepared to perform surgery independently when beginning fellowship or practice. A resident-run minor surgery clinic increases junior resident autonomy, but its effects on patient outcomes have not been formally established. This pilot study evaluated the safety of implementing a resident-run minor surgery clinic within a university-based general surgery training program.

DESIGN

Single institution case-control pilot study of a resident-run minor surgery clinic from 9/2014 to 6/2015. Rotating third-year residents staffed the clinic once weekly. Residents performed operations independently in their own procedure room. A supervising attending surgeon staffed each case prior to residents performing the procedure and viewed the surgical site before wound closure. Postprocedure patient complications and admissions to the hospital because of a complication were analyzed and compared with an attending control cohort.

SETTING

Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program.

PARTICIPANTS

Ten third-year general surgery residents.

RESULTS

Overall, 341 patients underwent a total of 399 procedures (110 in the resident clinic vs. 289 in the attending clinic). Minor surgeries included soft tissue mass excision (n = 275), abscess incision and drainage (n = 66), skin lesion excision (n = 37), skin tag removal (n = 15), and lymph node excision (n = 6). There was no significant difference in the overall rate of patients developing a postprocedure complication within 30 days (3.6% resident vs. 2.8% attending; p = 0.65); which persisted on multivariate analysis. Similar findings were observed for the rate of hospital admission resulting from a complication. Resident evaluations overwhelmingly supported the rotation, citing increased operative autonomy as the greatest strength.

CONCLUSIONS

Implementation of a resident-run minor surgery clinic is a safe and effective method to increase trainee operative autonomy. The rotation is well suited for mid-level residents, as it provides an opportunity for realistic self-evaluation and focused learning that may enhance their operative experience during senior level rotations.

Factors Associated with Inpatient Thoracentesis Procedure Quality at University Hospitals

BACKGROUND

Physicians increasingly refer thoracentesis procedures to interventional radiology (IR) rather than performing them at the bedside. Factors associated with thoracentesis procedures at university hospitals were studied to determine clinical outcomes by provider specialty.

METHODS

An administrative database review was performed of patients who underwent an inpatient thoracentesis procedure in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through September 2013. The incidence of iatrogenic pneumothorax, mean total hospital costs, and mean length of stay (LOS) were compared by clinical specialty.

RESULTS

There were 113,860 admissions with 132,472 thoracentesis procedures performed on 99,509 patients at 234 UHC hospitals. IR performed 43,783 (33%) thoracentesis procedures; medicine, 22,243 (17%); and pulmonary, 26,887 (20%). The incidence of iatrogenic pneumothorax was 2.8% for IR, 2.9% for medicine, and 3.1% for pulmonary. Medicine and pulmonary had equivalent risk of iatrogenic pneumothorax compared to IR after controlling for clinical covariates. Admissions with medicine and pulmonary procedures were associated with significantly lower costs compared to IR admissions (p < 0.001) after controlling for clinical covariates. Admissions with IR procedures had a mean LOS of 14.1 days; medicine, 13.2 days; and pulmonary, 15.9 days. Admissions with medicine and pulmonary procedures were associated with fewer hospital days when compared to IR in the controlled model (p < 0.001).

CONCLUSION

Admissions with medicine and pulmonary bedside thoracentesis procedures are as safe and less costly than IR procedures. Shifting IR thoracentesis procedures to the bedside might be a potential way to reduce hospital costs while still ensuring high-quality patient care, provided that portable ultrasound is used.

Associations between attending physician workload, teaching effectiveness, and patient safety

BACKGROUND

Prior studies suggest that high workload among attending physicians may be associated with reduced teaching effectiveness and poor patient outcomes, but these relationships have not been investigated using objective measures of workload and safety.

OBJECTIVE

To examine associations between attending workload, teaching effectiveness, and patient safety, hypothesizing that higher workload would be associated with lower teaching effectiveness and negative patient outcomes.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a retrospective study of 69,386 teaching evaluation items submitted by 543 internal medicine residents for 107 attending physicians who supervised inpatient teaching services from July 2, 2005 to July 1, 2011.

MEASUREMENTS

Attending workload measures included hospital service census, patient length of stay, daily admissions, daily discharges, and concurrent outpatient duties. Teaching effectiveness was measured using residents' evaluations of attendings. Patient outcomes considered were applicable patient safety indicators (PSIs), intensive care unit transfers, cardiopulmonary resuscitation/rapid response team calls, and patient deaths. Mixed linear models and generalized linear regression models were used for statistical analysis.

RESULTS

Workload measures of midnight census and daily discharges were associated with lower teaching evaluation scores (both β = -0.026, P < 0.0001). The number of daily admissions was associated with higher teaching scores (β = 0.021, P = 0.001) and increased PSIs (odds ratio = 1.81, P = 0.0001).

CONCLUSION

Several measures of attending physician workload were associated with slightly lower teaching effectiveness, and patient safety may be compromised when teams are managing new admissions. Ongoing efforts by residency programs to optimize the learning environment should include strategies to manage the workload of supervising attendings.

Impact of an Overnight Internal Medicine Academic Hospitalist Program on Patient Outcomes

BACKGROUND

Many academic hospitals have implemented overnight hospitalists to supervise house staff and improve outcomes, but few studies have described the impact of this role.

OBJECTIVE

To investigate the effect of an overnight academic hospitalist program on patient-level outcomes. Secondary objectives were to describe the program's revenue generation and work tasks.

DESIGN

Retrospective interrupted time-series analysis of patients admitted to the medicine service before and after implementation of the program.

PARTICIPANTS

All patients aged 18 and older admitted to the acute or intermediate care units between 7:00 p.m. and 6:59 a.m. during the period before (April 2011-August 2012) and after (September 2012-April 2014) program implementation.

INTERVENTION

An on-site attending-level physician directly supervising medicine house staff overnight, providing clinical care during high-volume periods, and ensuring safe handoffs to daytime providers.

MAIN MEASURES

Primary outcomes included in-hospital mortality, 30-day hospital readmissions, length of stay, and upgrades in care on the night of admission and during hospitalization. Multivariable models estimated the effect on outcomes after adjusting for secular trends. Revenue generation and work tasks are reported descriptively.

KEY RESULTS

During the study period, 6484 patients were admitted to the medicine service: 2722 (42 %) before and 3762 (58 %) after implementation. No differences were found in mortality (1.1 % vs. 0.9 %, p=0.38), 30-day readmissions (14.8 % vs. 15.6 %, p=0.39), mean length of stay (3.09 vs. 3.08 days, p=0.86), or upgrades to intensive care on the night of admission (0.4 % vs. 0.7 %, p=0.11) or during hospitalization (3.5 % vs. 4.2 %, p=0.20). During the first year, hospitalists billed 1209 patient encounters (3.3/shift) and 63 procedures (0.2/shift), and supervised 1939 patient admissions (6.12/shift) while supervising house staff 3-h/shifts.

CONCLUSIONS

Implementation of an overnight academic hospitalist program showed no impact on several important clinical outcomes, and revenue generation was modest. As overnight hospitalist programs develop, investigations are needed to delineate the return on investment and focus on other outcomes that may be more sensitive to change, such as errors and provider/patient satisfaction.

Implementation of a Novel, Resident-Led, Nocturnal Curriculum

BACKGROUND

Duty hour restrictions for resident physicians have led to radical changes in graduate medical education, including a shift to more night float rotations. These rotations have been viewed by residents as predominantly service focused with little opportunity for formalized education.

OBJECTIVE

To develop and deliver a resident-driven, nocturnal curriculum to enhance the educational content and value of night float rotations.

METHODS

The Hospital of the University of Pennsylvania is a 695-bed, tertiary care academic medical center. Upper-level internal medicine residents developed and peer-reviewed case-based scripts designed to be delivered in 15- to 20-minute teaching sessions. We evaluated the quality of teaching using anonymous, free-response surveys.

RESULTS

Twenty-four scripts were developed that explored the differential diagnoses, diagnostic pitfalls, and management of clinical problems that interns frequently encounter on night float rotations. Of 83 eligible residents, 45 (54%) responded to the survey. Teaching occurred an average of 4 nights per week and was uniformly viewed as high yield and topical by night float interns.

CONCLUSIONS

A resident-driven, nocturnal curriculum was implemented through the use of case-based teaching scripts, allowing for delivery of a standardized curriculum that capitalizes on the teaching opportunities afforded by the night shift. This intervention may serve as a model for nocturnal education in other departments and institutions.

Present Status of Autonomy in Surgical Residency—a Program Director's Perspective

As surgery residents graduate and begin their careers as junior attending surgeons, the question of whether a surgeon can complete a case alone still lingers. Allowing autonomy during residency answers this question. The purpose of this study was to gather input from general surgery residency program directors on how they achieve autonomy for residents in their programs. An online survey of 18 questions was sent to all general surgery residency program directors in the United States between April and June of 2013 via e-mail. Questions were asked regarding classification of autonomy, percentage of case completed by the resident independently, and in what area a resident worked with minimal supervision. Of the 202 delivered, 85 program directors were responded (42%). Seventy-eight per cent of programs classified a resident as surgeon junior whether the resident completed more than 50 per cent of the case. Most classified autonomy as either the resident completing >75 per cent of a case (41%) or completing the critical steps of a surgery (41%). Eighty-eight per cent stated that chief residents completed the majority of cases under supervision, whereas only 12 per cent stated the chief had autonomy in the operating room and also acted as teaching assistant. While, 60 per cent stated their chief residents did not work in any area of the hospital independently. Despite differences in how autonomy is defined among programs, most program directors feel that their chief residents do not achieve complete autonomy. Programs should allow their residents to work in a progressive responsibility as they progress into their fourth and fifth years of residency to achieve autonomy.

Strategies for improving education on night-float rotations: a review

INTRODUCTION

Night float rotations (NF) have been developed as a means of achieving duty hour compliance among residency programs. These were initially pioneered in the late 1980s as a response to fatigue among residents. The NF experience had its genesis in work hour reform and providing hospital service moreso than education. However, as NF has become ubiquitous, it is not clear that we have adequately revisited the educational component of this experience. We systematically reviewed the literature on educational aspects of a night float experience.

METHODS

PubMed searches were conducted for the terms "night float" and "night, curriculum, residency." This yielded 320 articles. Concerning educational aspects of the NF reduced the total to 134 articles. Editorials and those concerning procedural volumes or handoffs were also excluded. Most articles used surveys as methodology, so formal statistical analysis was not possible.

RESULTS

In total, 42 independent articles were found that directly related to the educational value of NF rotations, spanning all of the medical disciplines. Each study was searched for interventions or strategies that may affect the educational value of the NF experience. These may be grouped broadly into 3 discrete categories: (1) attention to the sleep-wake cycle, (2) addition of personal to augment the experience and (3) incorporation of formal educational elements to night rotations. A summary of these strategies is presented in Table 3.

CONCLUSIONS

NF is a practical solution to the challenge of work hour restrictions in residency, and is likely to persist in the future. Some educational issues arise due to the altered physiology of a reversed sleep-wake cycle, which may be best resolved through structural limitations of the night rotations. Other deficiencies are based on lack of interactions, for which there are strategies to improving the NF educational experience.

Factors influencing escalation of care by junior medical officers

Patients can acutely deteriorate unexpectedly. Junior medical officers (JMOs) are often first to review patients who become unwell. Opportunities to escalate care to a senior colleague may exist prior to the need for a rapid response team review. Little is known about the factors that influence JMO decisions to escalate care. In this study, our objective was to investigate the self-reported factors that influence escalation of care by JMOs in a university-affiliated, tertiary level hospital. We designed a face-to-face questionnaire of JMOs using standardised introduction to minimise interviewer bias. Fifty JMOs participated in the study (a 100% response rate). Most (63.3%) felt that they would be able to identify a clinically deteriorating patient. They would be more likely to escalate care if they were not familiar with the patient's clinical problem. If handover plans were seen to be adequate, JMOs felt it was less necessary to escalate care. Few JMOs (12%) agreed that they limited escalation due to fear of criticism or fear of conflict with senior medical staff. Although 36% agreed that they were concerned about waking seniors overnight, only 6% feared that escalating care overnight would affect their future career prospects. Escalation of care appears to be mostly influenced by the confidence and familiarity of the JMO with the cause of deterioration. JMOs identified clear handover with documented goals of treatment and suggested actions in event of clinical deterioration as the best means by which to improve the process of escalation of care for clinically deteriorating patients.

Quality and safety during the off hours in medicine units: a mixed methods study of front-line provider perspectives

BACKGROUND

Hospital off-hours care is associated with poor outcomes. Mutual conceptualization among provider groups may facilitate improvement efforts. Provider-perceived threats to quality are unreported.

OBJECTIVES

The objectives of this study were to identify perceived off-hours quality and safety issues, assess the most significant, and evaluate differences between nurses, and attending and housestaff physicians, and providers with day and night experience.

DESIGN

Prospective, sequential, exploratory mixed-methods study.

MEASURES

Open-ended descriptions of adverse events/near misses occurring overnight (n = 190) were analyzed using thematic analysis. From these results, a survey was developed to assess perceptions of quality/frequency of each issue (7-point scale, 7 = the highest rating) and highest-quality overnight period (7-10 pm, 10 pm-1 am, 1-4 am, 4-7 am).

RESULTS

Primary issues related to mismanagement, delivery processes, and communication/coordination. Of 214 surveys, 160 responses (75%) were received. Least-optimal issues related to "communication" (2.93) and "timeliness/safety" (3.89) of emergency department transfers; most-optimal issues related to timely lab reporting (4.70). On the 7-point scale, comparisons among nurses, and attending and housestaff physicians revealed differences in quality of "communication between physicians" (4.29 vs 6.00 vs 5.14) and "communication between consultants-primary providers" (3.46 vs 5.75 vs 4.35, P < 0.001). Comparisons between day-night providers revealed lower ratings from day providers in 12/24 items (P < 0.05), including "communication during emergency department transfers" (4.81 vs 3.86). All groups ranked 4 to 7am lowest in quality.

CONCLUSIONS

Nurses, and attending and housestaff physicians lack a shared mental model of off-hours care. Several issues, including emergency department transfers and timeliness of consults, were identified by all providers as problematic, meriting further investigation and intervention.

Changes in inpatient staffing following implementation of new residency work hours

BACKGROUND

In 2011, the Accreditation Council for Graduate Medical Education added additional resident work-hour restrictions that limited the number of hours residents could work, with increased emphasis on attending supervision.

OBJECTIVE

Our objective was to determine how residency programs have responded to residency work hours, specifically assessing residency night float systems and in-house attending physicians.

DESIGN

In May 2012, an electronic survey was sent to all US pediatric residency training programs via the Association of Pediatric Program Directors listserv with e-mail reminders to nonresponding programs. We analyzed data to assess the use of resident night float systems, admission caps, and attending physicians in-house at night.

RESULTS

Out of 198 programs contacted, 152 programs responded (77% response rate). Residency programs utilizing a night float system increased from 43% to 71% after new work hours were implemented. Overall use of resident admission caps did not change significantly. Twenty-three percent of programs increased the number of attending physicians in-house at night; 57% of those programs increased the number of pediatric hospitalist attendings, whereas 37% increased the number of pediatric intensivists. There is a trend toward increased pediatric hospitalist attending in-house 24/7 coverage. Of programs without 24/7 coverage, 26% plan to add coverage within 5 years. Only 12% of programs have no in-house attending coverage at night.

CONCLUSIONS

Although programs vary in their response to changes in residency work restrictions, they most commonly utilize night float systems and increased the amount of in-house attending coverage at night, especially pediatric hospitalist attendings. Many programs plan to add 24/7 pediatric hospitalist coverage within 5 years.

Defining the role of the academic neurohospitalist in residency education

OBJECTIVE

We sought to better understand the potential impact of the burgeoning neurohospitalist model of inpatient care on education of neurology residents and to better define possible roles for "neurohospitalists" in residency education.

METHOD

We designed a brief qualitative open-ended survey directed toward academic leaders in neurology and distributed it by e-mail to every academic neurology department in the United States and Canada.

RESULTS

Of 83 respondents, 36 (43%) had an active neurohospitalist program and only 10% felt certain they would not have 1 within the next 5 years. All respondents expected to have residents continue to be involved with inpatient care. The main perceived advantage for resident education associated with neurohospitalists was inpatient care expertise, and the main expected disadvantage was decreased exposure to subspecialty attendings. The majority anticipated positive impact on all Accreditation Council for Graduate Medical Education core competencies predominantly based on neurohospitalists' expertise in the inpatient setting.

CONCLUSION

The majority of academic neurology departments are expected to have a neurohospitalist program within the next 5 years. There are several perceived advantages and disadvantages to such a program for education of neurology residents. In general, the impact of these programs is expected to improve resident education. Regardless of expectations, neurohospitalists will likely play a prominent role in the education of the next generation of neurologists.

Neurohospitalists enhance resident perception of the educational and clinical value of a night float rotation

BACKGROUND AND PURPOSE

Neurology residency training programs have been profoundly impacted by recent changes in resident duty hours, workloads, and supervisory requirements. In response, many programs have adopted a night float coverage system to minimize the requirements for overnight call. The majority involves residents working a block of night shifts in what is typically a service-oriented rotation. Recently, concerns have arisen regarding the impact of this design on resident education and patient care. We have developed a novel on-site nighttime neurohospitalist model for the explicit purpose of steepening the initial learning curve for neurology residents in an effort to rapidly improve their neurological skills and, in conjunction, overnight patient care. We surveyed residents after the initiation of this system to assess their perception of the impact of direct overnight supervision on education and patient care.

METHODS

As part of ongoing quality improvement efforts, surveys were administered to neurology house staff at a tertiary academic medical center after they had completed service on the night float rotation both with and without an attending in the hospital using a retrospective pre/postdesign.

RESULTS

There was a robust positive impact on resident's perception of overall quality, educational value, and clinical quality on the night float rotation with an attending on-site. Despite an overall perception that their autonomy was maintained, residents believed barriers to contact the attending were lower, and attending interaction during critical decision making was more frequent.

CONCLUSIONS

Direct overnight supervision by a neurohospitalist enhances the educational value and care quality on overnight resident rotations.

Specialties performing paracentesis procedures at university hospitals: implications for training and certification

BACKGROUND

Paracentesis procedure competency is not required for internal medicine or family medicine board certification, and national data show these procedures are increasingly referred to interventional radiology (IR). However, practice patterns at university hospitals are less clear.

OBJECTIVE

To evaluate which specialties perform paracentesis procedures at university hospitals, compare characteristics of patients within each specialty, and evaluate length of stay (LOS) and hospital costs.

DESIGN, SETTING, PATIENTS

Observational administrative database review of patients with liver disease who underwent paracentesis procedures in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through December 2012. UHC is an alliance of 120 academic medical centers and their 290 affiliated hospitals.

EXPOSURE

Patients with liver disease who underwent inpatient paracentesis procedures.

MEASUREMENTS

We compared characteristics of patients who underwent paracentesis procedures by physician specialty, modeling the effects of patient characteristics on the likelihood of IR referral. We also analyzed LOS and hospital costs among patients with a >20% predicted probability of IR referral.

RESULTS

There were 97,577 paracentesis procedures performed during 70,862 hospital stays in 204 hospitals. IR performed 29% of paracenteses versus 49% by medicine and medicine subspecialties including gastroenterology/hepatology. Patients who were female, obese, and those with lower severity of illness were more likely to be referred to IR. Patients with a medicine or gastroenterology/hepatology paracentesis had a similar LOS compared to IR. Hospital costs were an estimated as $1308 less for medicine and $803 less for gastroenterology/hepatology compared to admissions with IR procedures (both P = 0.0001).

CONCLUSIONS

Internal medicine- and family medicine-trained clinicians frequently perform paracentesis procedures on complex inpatients but are not currently required to be competent in the procedure. Increasing bedside paracentesis procedures may reduce healthcare costs.

Twelve tips for overnight teaching

BACKGROUND

The European Working Time Directive and the United States' duty hour restrictions have changed resident physicians' schedules, specifically increasing overnight shifts and decreasing overall time spent in the hospital. As residents' perception of night shifts is that they have little educational value, efforts to improve educational opportunities and night attending teaching are desirable. However, resources about and recommendations for best practices for overnight teaching by faculty are scarce.

AIM

To provide 12 tips to highlight strategies intended to optimize attending physicians' overnight teaching skills and strategies.

METHOD

The tips provided are based on our experiences and reflections as in-house faculty supervising residents working overnight, by our experience and group discussions as medical educators, and the available literature.

RESULTS

The 12 tips presented offer specific strategies to optimize attending physicians' overnight teaching for resident physicians, specifically highlighting the unique logistics, pedagogy and follow-up of overnight teaching.

CONCLUSION

Preparation for teaching is important in any environment, but understanding the unique timing and circumstances associated with overnight teaching is vital to ensure that overnight teaching is effective. Acknowledging and addressing the physical and cognitive obstacles associated with overnight teaching and learning is necessary to maximize the educational value of overnight teaching.

The new education frontier: clinical teaching at night

Regulations that restrict resident work hours and call for increased resident supervision have increased attending physician presence in the hospital during the nighttime. The resulting increased interactions between attendings and trainees provide an important opportunity and obligation to enhance the quality of learning that takes place in the hospital between 6 PM and 8 AM. Nighttime education should be transformed in a way that maintains clinical productivity for both attending and resident physicians, integrates high-quality teaching and curricula, and achieves a balance between patient safety and resident autonomy. Direct observation of trainees, instruction in communication, and modeling of cost-efficient medical practice may be more feasible during the night than during daytime hours. To realize the potential of this educational opportunity, training programs should develop skilled nighttime educators and establish metrics to define success.

Tempering pediatric hospitalist supervision of residents improves admission process efficiency without decreasing quality of care

BACKGROUND

Many academic pediatric hospital medicine (PHM) divisions have recently increased in-house supervision of residents, often providing 24/7 in-house attending coverage. Contrary to this trend, we removed mandated PHM attending input during the admission process. We present an evaluation of this process change.

METHODS

This cohort study compared outcomes between patients admitted to the PHM service before (July 1, 2011-September 30, 2011) and after (July 1, 2012-September 30, 2012) the process change. We evaluated time from admission request to inpatient orders, length of stay (LOS), frequency of change in antibiotic choice, and rapid response team (RRT) calls within 24 hours of admission. Data were obtained via chart abstraction and from administrative databases. Wilcoxon rank sum and Fisher exact tests were used for analysis.

RESULTS

We identified 182 and 210 admissions in the before and after cohorts, respectively. Median time between emergency department admission request and inpatient orders was significantly shorter after the change (123 vs 62 minutes, P < 0.001). We found no significant difference in LOS, the number of changes to initial resident antibiotic choice, standard of care, or RRTs called within the first 24 hours of admission.

CONCLUSION

Removing mandated attending input in decision making for PHM admissions significantly decreased time to inpatient resident admission orders without a change in measurable clinical outcomes.

Teaching in the ICU

Teaching in the fast-paced, high-pressure environment of the ICU can be very demanding. Thus, the educator-intensivist must learn teaching strategies that are time-efficient, simple, and successful. In this article, we provide an overview of the current and relevant teaching theories and highlight potential obstacles and limitations to teaching in the ICU. In the second part, we discuss a sample of simple approaches to optimize the ICU-rotation curriculum as well as effective techniques to improve teaching, while not compromising quality of care.

Answering questions on call: pediatric resident physicians' use of handoffs and other resources

BACKGROUND

Little is known in the literature about the types of questions being asked of on-call housestaff and the resources used to provide answers.

OBJECTIVE

To characterize questions being asked of pediatric interns on call and evaluate their use of written handoffs, verbal handoffs, and other resources.

DESIGN/METHODS

Prospective direct observational study.

SETTING

Inpatient wards at an academic tertiary care children's hospital.

PARTICIPANTS

Pediatric interns.

RESULTS

Trainees were asked 2.6 questions/hour (interquartile range: 1.4-4.7); most involved medications (28%), general care plans (27%), diagnostic tests/procedures (22%), diet/fluids (15%), and physical exams (9%). Interns reported using information provided in written or verbal handoffs to answer 32.6% questions (written 7.3%; verbal 25.3%). Other resources utilized included general medical knowledge, the medical record, and parental report. Questions pertaining to diet/fluids were associated with increased written handoff use (odds ratio [OR]: 3.64, 95% confidence interval [CI]: 1.51-8.76), whereas having worked more consecutive nights was associated with decreased written handoff use (OR: 0.29, 95% CI: 0.09-0.93). Questions regarding general care plans (OR: 2.07, 95% CI: 1.13-3.78), those asked by clinical staff (OR: 1.95, 95% CI: 1.04-3.66), and questions asked of patients with longer lengths of stay (OR: 1.97, 95% CI: 1.02-3.80) were predictive of verbal handoff use.

CONCLUSIONS

Pediatric housestaff face frequent questions during overnight shifts and frequently use information received during handoffs to provide answers. A better understanding of how handoffs and other resources are utilized by housestaff could inform future targeted initiatives to improve trainees' access to key information at night.