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Kothari LG, Shah K, Barach P. Simulation based medical education in graduate medical education training and assessment programs. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.02.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Kreutzer L, Dahlke AR, Love R, Ban KA, Yang AD, Bilimoria KY, Johnson JK. Exploring Qualitative Perspectives on Surgical Resident Training, Well-Being, and Patient Care. J Am Coll Surg 2017; 224:149-159. [DOI: 10.1016/j.jamcollsurg.2016.10.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
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Lobato RD, Jiménez Roldan L, Alen JF, Castaño AM, Munarriz PM, Cepeda S, Lagares A. [Competency-based Neurosurgery Residency Programme]. Neurocirugia (Astur) 2016; 27:75-86. [PMID: 26944384 DOI: 10.1016/j.neucir.2016.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 01/21/2016] [Indexed: 10/22/2022]
Abstract
UNLABELLED A programme proposal for competency-based Neurosurgery training adapted to the specialization project is presented. This proposal has been developed by a group of neurosurgeons commissioned by the SENEC (Spanish Society of Neurosurgery) and could be modified to generate a final version that could come into force coinciding with the implementation of the specialization programme. This document aims to facilitate the test of the new programme included in the online version of our journal. DURATION OF THE PROGRAMME Total training period is 6 years; initial 2 years belong to the surgery specialization and remaining 4 years belong to core specialty period. STRUCTURE OF THE PROGRAMME It is a competency-based programmed based on the map used by the US Accreditation Council for Graduate Medical Education (ACGME) including the following domains of clinical competency: Medical knowledge, patient care, communication skills, professionalism, practice-based learning and improvement, health systems, interprofessional collaboration and professional and personal development. Subcompetencies map in the domains of Knowledge and Patient care (including surgical competencies) was adapted to the one proposed by AANS and CNS (annex 1 of the programme). A subcompetency map was also used for the specialization rotations. INSTRUCTION METHODS Resident's training is based on personal study (self-learning) supported by efficient use of information sources and supervised clinical practice, including bioethical instruction, clinical management, research and learning techniques. EVALUATION METHODS Resident evaluation proposal includes, among other instruments, theoretical knowledge tests, objective and structured evaluation of the level of clinical competency with real or standardised patients, global competency scales, 360-degree evaluation, clinical record audits, milestones for residents progress and self-assessment (annex 2). Besides, residents periodically assess the teaching commitment of the department's neurosurgeons and other professors participating in rotations, and annually assess the overall operation of the programme. Results of evaluations are registered, together with other relevant data, in the Resident's Book. PROGRAMME'S NATIONAL COMMITTEE The creation of a Programme Committee directly attached to the SENEC (National Commission) that, aside from generating a final version of the programme, monitors its implementation (level of adherence and operation in the different departments), assumes the creation of test banks and the centralized administration of knowledge tests (in the middle of the residency and/or at the end of it) and centralizes information collected by tutors that could be used for re-accreditation of the services, is proposed.
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Affiliation(s)
- Ramiro D Lobato
- Servicio de Neurocirugía, Hospital «12 de Octubre», Facultad de Medicina, UCM, Madrid, España.
| | - Luis Jiménez Roldan
- Servicio de Neurocirugía, Hospital «12 de Octubre», Facultad de Medicina, UCM, Madrid, España
| | - José F Alen
- Servicio de Neurocirugía, Hospital «12 de Octubre», Facultad de Medicina, UCM, Madrid, España
| | - Ana M Castaño
- Servicio de Neurocirugía, Hospital «12 de Octubre», Facultad de Medicina, UCM, Madrid, España
| | - Pablo M Munarriz
- Servicio de Neurocirugía, Hospital «12 de Octubre», Facultad de Medicina, UCM, Madrid, España
| | - Santiago Cepeda
- Servicio de Neurocirugía, Hospital «12 de Octubre», Facultad de Medicina, UCM, Madrid, España
| | - Alfonso Lagares
- Servicio de Neurocirugía, Hospital «12 de Octubre», Facultad de Medicina, UCM, Madrid, España
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Inpatient Housestaff Discontinuity of Care and Patient Adverse Events. Am J Med 2016; 129:341-7.e21. [PMID: 26704696 DOI: 10.1016/j.amjmed.2015.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 08/06/2015] [Accepted: 11/09/2015] [Indexed: 11/21/2022]
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Bjorklund K, Eismann EA, Cornwall R. Medical Trainee Continuity of Care Following Emergency Department Consultations in a Pediatric Hospital. J Grad Med Educ 2016; 8:33-8. [PMID: 26913100 PMCID: PMC4763382 DOI: 10.4300/jgme-d-15-00018.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The importance of continuity of care in training is widely recognized; however, a broad-spectrum assessment across all specialties has not been performed. OBJECTIVE We assessed the continuity of care provided by trainees, following patient consultations in the emergency department (ED) across all specialties at a large pediatric tertiary care center. METHODS Medical records were reviewed to identify patients seen in consultation by a resident or fellow trainee in the ED over a 1-year period, and to determine if the patient followed up with the same trainee for the same condition during the next 6 months. RESULTS Resident and fellow trainees from 33 specialties participated in 3400 ED consultations. Approximately 50% (1718 of 3400) of the patients seen in consultation by a trainee in the ED followed up with the same specialty within 6 months, but only 4.1% (70 of 1718) followed up with the same trainee for the same condition. Trainee continuity of care ranged from 0% to 21% among specialties, where specialties with resident clinics (14.4%) have a greater continuity of care than specialties without resident clinics (2.7%, P < .001). Continuity of care did not differ between fellows (4.2%) and residents (4.0%, P = .87), but did differ between postgraduate years for residents (P < .001). CONCLUSIONS Trainee continuity of care for ED consultations was low across all specialties and levels of training. If continuity of care is important for patient well-being and trainee education, efforts to improve continuity for trainees must be undertaken.
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Affiliation(s)
| | | | - Roger Cornwall
- Corresponding author: Roger Cornwall, MD, Cincinnati Children's Hospital Medical Center, MLC 2017, 3333 Burnet Avenue, Cincinnati, OH 45229, 513.803.2560, fax 513.636.3928,
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Kogan JR, Lapin J, Aagaard E, Boscardin C, Aiyer MK, Cayea D, Cifu A, Diemer G, Durning S, Elnicki M, Fazio SB, Khan AR, Lang VJ, Mintz M, Nixon LJ, Paauw D, Torre DM, Hauer KE. The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors. TEACHING AND LEARNING IN MEDICINE 2015; 27:37-50. [PMID: 25584470 DOI: 10.1080/10401334.2014.979187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
UNLABELLED PHENOMENON: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students' and clerkship directors' perceptions of the effects of the 2011 DHR on internal medicine clerkship students' experiences with teaching, feedback and evaluation, and patient care. APPROACH Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation. FINDINGS Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. INSIGHTS: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student-patient relationship and students' clinical skills acquisition.
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Affiliation(s)
- Jennifer R Kogan
- a Department of Medicine , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , Pennsylvania , USA
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Blecker S, Shine D, Park N, Goldfeld K, Scott Braithwaite R, Radford MJ, Gourevitch MN. Association of weekend continuity of care with hospital length of stay. Int J Qual Health Care 2014; 26:530-7. [PMID: 24994844 DOI: 10.1093/intqhc/mzu065] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the association of physician continuity of care with length of stay, likelihood of weekend discharge, in-hospital mortality and 30-day readmission. DESIGN A cohort study of hospitalized medical patients. The primary exposure was the weekend usual provider continuity (UPC) over the initial weekend of care. This metric was adapted from an outpatient continuity of care index. Regression models were developed to determine the association between UPC and outcomes. SETTING An academic medical center. MAIN OUTCOME MEASURE Length of stay which was calculated as the number of days from the first Saturday of the hospitalization to the day of discharge. RESULTS Of the 3391 patients included in this study, the prevalence of low, moderate and high UPC for the initial weekend of hospitalization was 58.7, 22.3 and 19.1%, respectively. When compared with low continuity of care, both moderate and high continuity of care were associated with reduced length of stay, with adjusted rate ratios of 0.92 (95% CI 0.86-1.00) and 0.64 (95% CI 0.53-0.76), respectively. High continuity of care was associated with likelihood of weekend discharge (adjusted odds ratio 2.84, 95% CI 2.11-3.83) but was not significantly associated with mortality (adjusted odds ratio 0.72, 95% CI 0.29-1.80) or readmission (adjusted odds ratio 0.88, 95% CI 0.68-1.14) when compared with low continuity of care. CONCLUSIONS Increased weekend continuity of care is associated with reduced length of stay. Improvement in weekend cross-coverage and patient handoffs may be useful to improve clinical outcomes.
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Affiliation(s)
- Saul Blecker
- Department of Population Health, New York University School of Medicine, New York, NY, USA Department of Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Daniel Shine
- Department of Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Naeun Park
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Keith Goldfeld
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - R Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY, USA Department of Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Martha J Radford
- Department of Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Marc N Gourevitch
- Department of Population Health, New York University School of Medicine, New York, NY, USA
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Greene JG. Neurohospitalists enhance resident perception of the educational and clinical value of a night float rotation. Neurohospitalist 2014; 3:179-84. [PMID: 24198898 DOI: 10.1177/1941874413495879] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- James G Greene
- Department of Neurology, Emory University, Atlanta, GA, USA
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Simulation-Based Training in Radiology. J Am Coll Radiol 2014; 11:512-7. [DOI: 10.1016/j.jacr.2013.02.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 02/06/2013] [Indexed: 11/23/2022]
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Wu PE, Stroud L, McDonald-Blumer H, Wong BM. Understanding the effect of resident duty hour reform: a qualitative study. CMAJ Open 2014; 2:E115-20. [PMID: 25077127 PMCID: PMC4084747 DOI: 10.9778/cmajo.20130049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Concern surrounding the effect of resident fatigue on patient care recently led the National Steering Committee on Resident Duty Hours to publish Canadian recommendations suggesting that duty periods of 24 or more consecutive hours without restorative sleep should be avoided. We sought to characterize how different training programs are preparing for the effect of such changes on education, patient care and provider well-being. METHODS Using constructivist grounded theory methodology, we conducted 18 one-on-one semistructured interviews with program directors, division directors and department chiefs from 11 residency programs affiliated with one Canadian medical school. We gathered and analyzed data iteratively until we reached theoretical saturation. RESULTS The key theme articulated by our participants was that changes in resident duty hours would potentially lead to gaps in the provision of clinical care. These changes affect acute care specialties based primarily in the inpatient setting (e.g., medicine, surgery) more than primarily ambulatory (e.g., family medicine) or shift-model based (e.g., emergency) specialties. Potential strategies to address gaps in clinical care include resident-based solutions, faculty-based solutions and solutions based on other providers (e.g., nonacademic physicians, physician extenders). Each solution has unique advantages and disadvantages in terms of education, continuity of care, preparedness for practice and provider well-being. INTERPRETATION Our data-driven framework serves as a guide for programs to anticipate challenges of satisfying clinical care needs in the face of changes to resident duty hours, while balancing education, care continuity, preparedness for practice and provider well-being. Our findings challenge the "one-size-fits-all" approach to changes to resident duty hours and endorse flexibility in enacting duty hour regulations based on specialty-specific factors.
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Affiliation(s)
- Peter E Wu
- Department of Medicine, University of Toronto, Toronto, Ont. ; Department of Medicine, Toronto General Hospital, Toronto, Ont
| | - Lynfa Stroud
- Department of Medicine, University of Toronto, Toronto, Ont. ; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ont
| | | | - Brian M Wong
- Department of Medicine, University of Toronto, Toronto, Ont. ; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ont. ; Centre for Quality Improvement & Patient Safety, University of Toronto, Toronto, Ont
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Alquaiz AM, Abdulghani HM, Karim SI, Qureshi R. Views of Family Medicine Trainees of a Teaching Hospital in Riyadh regarding their Hospital Rotations: A Qualitative Study. Pak J Med Sci 2013; 29:4-9. [PMID: 24353498 PMCID: PMC3809209 DOI: 10.12669/pjms.291.2458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 07/06/2012] [Accepted: 10/03/2012] [Indexed: 11/15/2022] Open
Abstract
Objective: To explore Family Medicine Trainees views regarding the hospital component of their Family Medicine (FM) training program. Methodology: This is a qualitative focus group discussion based study. Thirteen trainees, eight from final year of FM training program and five from third year of the same program participated in the study. The structure for discussion included a previously distributed and completed questionnaire that included three sections. The first section was evaluation of the satisfaction of trainees with the different hospital specialties rotations. The second section related to reasons for rating the different rotations as excellent and very good. The third section related to deficiencies in training for those rotations which received a score of 3-5. The items in the questionnaire were utilized in the focus group discussion. Two facilitators who were investigators facilitated the discussion. The data was qualitatively analyzed to identify emergent themes and subthemes that described the trainees’ views. Results: The trainees highlighted the following views: Teaching in the hospital component is not relevant to the needs of Family Medicine trainees. Duration of the hospital posts should be reviewed. Emphasis should be on out-patient clinics rather than in-patient. More emphasis must be given to procedural skills, minor surgery and teaching in clinical contexts. Conclusion: Hospital training component of the Family Medicine training program should be reviewed, as the structure and its implementation doesn’t reflect the views of trainees regarding its relevance to their day to day practice.
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Affiliation(s)
- Aljohara M Alquaiz
- Aljohara M. Alquaiz, MD, MSc, MRCGP, Associate Professor, Department of Family Medicine, King Saud University, Saudi Arabia
| | - Hamza M Abdulghani
- Hamza. M Abdulghani, MD, ABFM, FRCGP, KSU Medical Education Chair for Research & Development, King Saud University, Saudi Arabia
| | - Syed Irfan Karim
- Syed Irfan Karim, MD, MCPS, MRCGP, Deputy Director Post Graduate Program Family Medicine, King Saud University, Saudi Arabia
| | - Riaz Qureshi
- Riaz Qureshi, FRCGP, Professor, Department of Family Medicine, King Saud University, Saudi Arabia
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Handoffs in general surgery residency, an observation of intern and senior residents. Am J Surg 2013; 206:693-7. [PMID: 24035213 DOI: 10.1016/j.amjsurg.2013.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 07/26/2013] [Accepted: 07/28/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Handoffs have become an area of concern as duty-hour restrictions impose an increasing number of shift changes. The objective of this study was to study handoffs in a general surgery residency and identify problems that exist in the current handoff process in preparation for a standardized implemented protocol. METHODS A resident researcher observed resident-to-resident handoffs for 5 surgical service teams, Monday through Friday, for the middle 2 weeks of the 3rd month of the academic year. Each handoff was observed for the presence, absence, or inconsistency of code status; anticipated problems; active problems; current baseline status; pending tests or consults; and closed-loop communication. RESULTS Thirty-eight residents in 2010 were observed, with a total of 52 handoffs ranging from 1 to 27 minutes in length. Five handoffs (10%) were by phone, 47 handoffs (90%) were observed in person, 10 handoffs (19%) were by senior residents, and 37 handoffs (71%) were performed by junior residents. Of the 47 in-person handoffs, code status was mentioned in 2 (4%), and 6 (12%) were given written notes. Of the 37 intern handoffs, the presence of measured criteria occurred in the following percentages: 59% for anticipated problems, 70% for active problems, 51% for current baseline status, 64% for pending tests or consults, and 81% for closed-loop communication. Of the 10 senior-level handoffs observed, all consistently included the previously mentioned criteria. CONCLUSIONS This study demonstrates the lack of consistency and propensity for error in unstructured handoffs among junior residents. The finding that senior-level residents exhibited consistently proficient handoffs demonstrates that handoffs are a learned skill. Therefore, teaching junior residents a structured handoff supervised by senior residents would most likely reduce the inconsistency and error-prone nature of the junior-level handoffs observed in our study.
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The echocardiography "boot camp": a novel approach in pediatric cardiovascular imaging education. J Am Soc Echocardiogr 2013; 26:1187-1192. [PMID: 23860091 DOI: 10.1016/j.echo.2013.06.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND Dynamic training schedules introduce novel challenges to medical specialty training programs that require manual dexterity. The aim of this study was to examine the effect of a 3-day, intensive pediatric echocardiography course ("boot camp") on trainee self-efficacy and on the acquisition and short-term retention of basic echocardiographic knowledge and skills for first-year pediatric cardiology fellows (CFs). METHODS The boot camp consisted of hands-on structured practice guided by sonographers and cardiology faculty members, didactic lectures, and reading. Pre-boot camp experience was assessed using an experience score. Outcome measures included written precamp and postcamp examinations, a performance-based test, precamp and postcamp self-efficacy assessments, and the number and quality of echocardiographic examinations performed in the first 3 months of fellowship. RESULTS Six CFs completed the boot camp. Two of the six CFs reported experience scores of 2 out of 10, whereas the remainder reported experience scores of 0 out of 10. Performance-based test scores ranged from 68 to 99 out of 147. All six CFs reported precamp self-efficacy scores of 21 (the minimum score), compared with median postcamp scores of 82 (range, 49-94) (P = .01). Scores on the written examination improved from median of 16 (range, 11-18) to 23.5 (range, 22-28) (P = .01). CFs who completed the boot camp completed 28 independent echocardiographic examinations (median, 4 per CF) during the first 3 months of fellowship, an increase from six independent examinations (median, 1 per CF) by CFs during the year before institution of the boot camp (P = .030). Echocardiograms obtained by CFs who had completed the boot camp scored higher on total quality (P = .004), overall two-dimensional image quality (P = .011), functional assessments (P = .015), and assessment for pericardial effusion (P = .031). CONCLUSIONS The echocardiography boot camp improves self-efficacy in performing an echocardiographic examination and the acquisition and short-term retention of skills and knowledge required to perform pediatric echocardiography.
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Yazici C, Abdelmalak H, Gupta S, Shmagel A, Albaddawi E, Tsang V, Potts S, Arora VM. Sustainability and effectiveness of a quality improvement project to improve handoffs to night float residents in an internal medicine residency program. J Grad Med Educ 2013; 5:303-8. [PMID: 24404278 PMCID: PMC3693699 DOI: 10.4300/jgme-d-12-00175.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 11/15/2012] [Accepted: 01/26/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Handoff is the process in which patient care is transitioned from one provider to another. In teaching hospitals, handoffs are frequent, and resident duty hour restrictions have increased the use of night float staff. To date, few studies have focused on long-term sustainability and effectiveness of a handoff quality improvement project. OBJECTIVE The objective of our resident-driven quality improvement project was to evaluate the effectiveness and sustainability of a standardized template for handoff quality in a community hospital internal medicine program. METHODS We used a multistep continuous quality improvement approach. Problems in the handoff process were identified through process mapping and anonymous needs assessment of the residents. A group of residents and faculty identified problems during biweekly discussions, created a standardized template, and adopted a new handoff process. We audited handoffs and surveyed residents at 3 and 9 months after implementation to assess effectiveness and sustainability. RESULTS Before the intervention, only 40% of residents reported regular morning handoff. Using the standardized template, statistically significant, sustained improvements were seen in morning handoff frequency (59% preintervention, 90% at 3 months, 89% at 9 months), along with decreases in unreported overnight events (84% preintervention, 58% at 3 months, 50% at 9 months) and uncertainty about decisions because of poor handoffs (72% preintervention, 49% at 3 months, 37% at 9 months). Statistically significant decreases in missed content (69%-46%) and copy-and-paste behavior (78%-38%) at 3 months were not sustained. CONCLUSIONS We demonstrated sustained improvements in unreported events and uncertainty caused by poor handoffs. Initial improvements in missed content and copy-and-paste behavior that were not sustained suggest a need for ongoing reinforcement and monitoring of handoff quality.
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Impact of Nurse Integrated Rounds on Self-Reported Comprehension, Attitudes, and Practices of Nurses and Resident Physicians in a Pediatric Intensive Care Unit. J Intensive Care Med 2013; 29:285-91. [DOI: 10.1177/0885066613486612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: To evaluate the impact of nurse integrated rounds (NIRs) on self-reported comprehension, attitudes, and practices of nurses and resident physicians (RPs) in a pediatric intensive care unit (PICU). Materials and methods: A self-reported comprehension, attitude, and practice survey of RPs and nurses was done prior to (T0), 3 months (T3), and 15 months (T15) after initiation of NIRs in our PICU. Responses were graded on Likert-type scale from 1 to 5. The RPs, attending physicians, and nurses also ranked their overall perception of NIRs during these 3 survey time periods. Results: All 3 components of the surveys showed statistically significant improvement ( P < .05) from the T0 to T3 and T15 in RPs and nurses. A complete or almost complete reversal of attitude was noted for most questions in the attitude section in both RPs and nurses when T15 was compared to T0. The overall perception that NIRs was good for patient care also showed significant improvement in the survey of nurses and physicians. Conclusions: The NIRs are well accepted by nurses and physicians and are accompanied by self-reported improvements in comprehension, attitudes, and practices of nurses and RPs in the PICU.
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Stelfox HT, Perrier L, Straus SE, Ghali WA, Zygun D, Boiteau P, Zuege DJ. Identifying intensive care unit discharge planning tools: protocol for a scoping review. BMJ Open 2013; 3:e002653. [PMID: 23562817 PMCID: PMC3641498 DOI: 10.1136/bmjopen-2013-002653] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 03/07/2013] [Accepted: 03/11/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Transitions of care between providers are vulnerable periods in healthcare delivery that expose patients to preventable errors and adverse events. Patient discharge from the intensive care unit (ICU) to a medical or surgical hospital ward is one of the most challenging and high risk transitions of care. Approximately 1 in 12 patients discharged will be readmitted to ICU or die before leaving the hospital. Many more patients are exposed to unnecessary healthcare, adverse events and/or are disappointed with the quality of their care. Our objective is to conduct a scoping review by systematically searching the literature to identify ICU discharge planning tools and their supporting evidence-base including barriers and facilitators to their use. METHODS AND ANALYSIS Systematic searching of the published health literature will be conducted to identify the existing ICU discharge planning tools and supporting evidence. Literature (research and non-research) reporting on the tools used to facilitate decision making and/or communication at ICU discharge with patients of any age will be included. Outcomes will include adverse events and provider and patient/family-reported outcomes. Two investigators will independently review the abstracts (screen 1) to identify those meeting the inclusion criteria and then independently assess the full text articles (screen 2) to determine if they meet the inclusion criteria. Data collection will include information on citations and identified tools. A quality assessment will be performed on original research studies. A descriptive summary will be developed for each tool. ETHICS AND DISSEMINATION Our scoping review will synthesise the literature for ICU discharge planning tools and identify the opportunities for knowledge to action and gaps in evidence where primary evidence is necessary. This will serve as the foundational element in a multistep research programme to standardise and improve the quality of care provided to patients during ICU discharge. Ethics approval is not required for this study.
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Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada
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Hilligoss B, Zheng K. Chart biopsy: an emerging medical practice enabled by electronic health records and its impacts on emergency department-inpatient admission handoffs. J Am Med Inform Assoc 2013; 20:260-7. [PMID: 22962194 PMCID: PMC3638186 DOI: 10.1136/amiajnl-2012-001065] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 08/10/2012] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To examine how clinicians on the receiving end of admission handoffs use electronic health records (EHRs) in preparation for those handoffs and to identify the kinds of impacts such usage may have. MATERIALS AND METHODS This analysis is part of a two-year ethnographic study of emergency department (ED) to internal medicine admission handoffs at a tertiary teaching and referral hospital. Qualitative data were gathered and analyzed iteratively, following a grounded theory methodology. Data collection methods included semi-structured interviews (N = 48), observations (349 hours), and recording of handoff conversations (N = 48). Data analyses involved coding, memo writing, and member checking. RESULTS The use of EHRs has enabled an emerging practice that we refer to as pre-handoff "chart biopsy": the activity of selectively examining portions of a patient's health record to gather specific data or information about that patient or to get a broader sense of the patient and the care that patient has received. Three functions of chart biopsy are identified: getting an overview of the patient; preparing for handoff and subsequent care; and defending against potential biases. Chart biopsies appear to impact important clinical and organizational processes. Among these are the nature and quality of handoff interactions, and the quality of care, including the appropriateness of dispositioning of patients. CONCLUSIONS Chart biopsy has the potential to enrich collaboration and to enable the hospital to act safely, efficiently, and effectively. Implications for handoff research and for the design and evaluation of EHRs are also discussed.
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Affiliation(s)
- Brian Hilligoss
- College of Public Health, Division of Health Services Management and Policy, Ohio State University, Columbus, OH 43210, USA.
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Trial of shift scheduling with standardized sign-out to improve continuity of care in intensive care units. Crit Care Med 2013; 40:3129-34. [PMID: 23034459 DOI: 10.1097/ccm.0b013e3182657b5d] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Since 2003, the Accreditation Council for Graduate Medical Education requires residency programs to restrict to 80 hrs/wk, averaged over 4 wks to improve patient safety. These restrictions force training programs with night call responsibilities to either maintain a traditional program with alternative night float schedules or adopt a "shift" model, both with increased handoffs. OBJECTIVE To assess whether a 65 hrs/wk shift-work schedule combined with structured sign-out curriculum is equivalent to a 65 hrs/wk traditional day coverage with night call schedule, as measured by multiple assessments. DESIGN Eight-month trial of shift-work schedule with structured sign-out curriculum (intervention) vs. traditional call schedule without curriculum (control) in alternating 1-2 month periods. SETTING A mixed medical-surgical intensive care unit at a tertiary care academic center. SUBJECTS Primary subjects: 19 fellows in a Multidisciplinary Critical Care Training Program; Secondary subjects: intensive care unit nurses and attending physicians, families of intensive care unit patients. INTERVENTIONS Implementation of shift-work schedule, combined with structured sign-out curriculum. MEASUREMENTS Workplace perception assessment through Continuity of Care Survey evaluation by faculty, fellows, and nurses through structured surveys; family assessment by the Critical Care Family Needs Index survey; clinical assessment through intensive care unit mortality, intensive care unit length of stay, and intensive care unit readmission within 48 hrs; and educational impact assessment by rate of fellow didactic lecture attendance. MAIN RESULTS There were no statistically significant differences in surveyed perceptions of continuity of care, intensive care unit mortality (8.5% vs. 6.0%, p = .20), lecture attendance (43% vs. 42%), or family satisfaction (Critical Care Family Needs Index score 24 vs. 22) between control and intervention periods. There was a significant decrease in intensive care unit length of stay (8.4 vs. 5.7 days, p = .04) with the shift model. Readmissions within 48 hrs were not different (3.6% vs. 4.9%, p = .39). Nurses preferred the intervention period (7% control vs. 73% intervention, n = 30, p = .00), and attending faculty preferred the intervention period and felt continuity of care was maintained (15% control vs. 54% intervention, n = 11, p = .15). CONCLUSIONS A shift-work schedule with structured sign-out curriculum is a viable alternative to traditional work schedules for the intensive care unit in training programs.
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Type of attending obstetrician call schedule and changes in labor management and outcome. Obstet Gynecol 2012; 118:1371-1376. [PMID: 22105267 DOI: 10.1097/aog.0b013e31823904d0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate whether a night-float call schedule for attending obstetricians is associated with different labor management or obstetric outcomes compared with a traditional call schedule. METHODS A chart review was performed for all women admitted for labor and delivery during two 3-month periods. One period occurred immediately before a single group of generalist obstetricians changed from a traditional call schedule to a night-float call schedule, whereas the second 3-month period occurred immediately after this change. A control group of women who were managed during the same 6-month time period by a group of generalist obstetricians at the same institution who did not alter their traditional call schedule was also identified. Data on labor management and perinatal outcomes were collected. RESULTS Change to a night-float call schedule was associated with a decreased use of induction of labor (30% to 16.7%, P=.02). Physicians also were more likely to use oxytocin augmentation (57.5% to 75.0%, P=.01) and less likely to manually extract the placenta (5.0% to 0%, P=.02) or perform an episiotomy (10.1% to 2.6%, P=.04). There were fewer observed third-degree and fourth-degree lacerations (10.3% to 3.3%, P=.045) and fewer neonates born with an umbilical artery pH less than 7.10 (9.3% to 2.2%, P=.03). CONCLUSION A night-float call schedule was associated with both a reduction in obstetric interventions, such as labor induction and episiotomy, and improvement of particular obstetric outcomes, such as the frequency of perineal lacerations. LEVEL OF EVIDENCE II.
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Tracking outpatient continuity and chronic disease indicators-a novel use of the new innovations clinic module. Am J Ther 2012; 19:76-80. [PMID: 22354126 DOI: 10.1097/mjt.0b013e31822119eb] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Accreditation Council for Graduate Medical Education common program requirements for Practice-based Learning and Improvement in Internal Medicine specify that trainees must "systematically analyze [his/her] practice using quality improvement methods, and implement changes with the goal of practice improvement" and that the training program "must include use of performance data" in the assessment of the resident's practice. Before implementation of an electronic health record at our academic medical center, we found meeting these requirements to be challenging. This prompted us to set up the New Innovations (New Innovations, Inc, Uniontown, OH) Software Suite's Patient Continuity module to permit analysis and tracking of both quality of care indicators and patient continuity. By using the system, our residents were better able to monitor their patient panel sizes and composition and to correlate their practices with quality of care data. Residency programs, which currently utilize New Innovations software but lack an electronic health record, may find the continuity clinic module useful for engaging their house staff in structured practice improvement initiatives and in satisfying the Accreditation Council for Graduate Medical Education's common program requirements for practice-based learning.
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Fletcher KE, Sharma G, Zhang D, Kuo YF, Goodwin JS. Trends in inpatient continuity of care for a cohort of Medicare patients 1996-2006. J Hosp Med 2011; 6:438-44. [PMID: 21990172 PMCID: PMC3201736 DOI: 10.1002/jhm.916] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Little is known about how changes in health care delivery, such as the use of hospitalists, have impacted inpatient continuity. OBJECTIVE To examine the extent of inpatient discontinuity (ie, being seen by more than one generalist physician) during hospitalization for selected patients. DESIGN Retrospective cohort. SETTING 4,859 US hospitals. PATIENTS Medicare fee-for-service beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD), pneumonia, and congestive heart failure (CHF) from 1996 through 2006. MEASUREMENTS We analyzed the proportion of Medicare beneficiaries who received care from 1, 2, or 3 or more generalist physicians during hospitalization. We also examined the factors associated with continuity during the hospitalization. RESULTS Between 1996 and 2006, 64.3% of patients received care from 1, 26.9% from 2 and 8.8% from 3 or more generalist physicians during hospitalization. The percentage of patients who received care from one generalist physician declined from 70.7% in 1996 to 59.4% in 2006 (P < 0.001). In a multivariable analysis, continuity with one generalist physician decreased by 5.5% (95% CI, 5.3%-5.6%) per year between 1996 and 2006. Patients receiving all care from hospitalists saw fewer generalist physicians compared to those who received all care from a non-hospitalist or both. Older patients, females, non-Hispanic whites, those with higher socioeconomic status, and those with more comorbidities were more likely to receive care from multiple generalist physicians. LIMITATIONS The results may not be generalizable to non-Medicare populations. CONCLUSIONS Hospitalized patients are experiencing less continuity than 10 years ago. The hospitalist model of care does not appear to play a role in this discontinuity.
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Affiliation(s)
- Kathlyn E Fletcher
- Division of Primary Care, Clement J. Zablocki VAMC and Division of General Internal Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, USA.
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Li P, Stelfox HT, Ghali WA. A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. Am J Med 2011; 124:860-7. [PMID: 21854894 DOI: 10.1016/j.amjmed.2011.04.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 03/23/2011] [Accepted: 04/07/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND Poor physician handoff can be a major contributor to suboptimal care and medical errors occurring in the hospital. Physician handoffs for intensive care unit (ICU)-to-ward patient transfer may face more communication hurdles. However, few studies have focused on physician handoffs in patient transfers from the ICU to the inpatient ward. METHODS We performed a hospitalized patient-based observational study in an urban, university-affiliated tertiary care center to assess physician handoff practices for ICU-to-ward patient transfer. One hundred twelve adult patients were enrolled. The stakeholders (sending physicians, receiving physicians, and patients/families) were interviewed to evaluate the quality of communication during these transfers. Data collected included the presence and effectiveness of communication, continuity of care, and overall satisfaction. RESULTS During the initial stage of patient transfers, 15.6% of the consulted receiving physicians verbally communicated with sending physicians; 26% of receiving physicians received verbal communication from sending physicians when patient transfers occurred. Poor communication during patient transfer resulted in 13 medical errors and 2 patients being transiently "lost" to medical care. Overall, the levels of satisfaction with communication (scored on a 10-point scale) for sending physicians, receiving physicians, and patients were 7.9±1.1, 8.1±1.0, and 7.9±1.7, respectively. CONCLUSION The overall levels of satisfaction with communication during ICU-to-ward patient transfer were reasonably high among the stakeholders. However, clear opportunities to improve the quality of physician communication exist in several areas, with potential benefits to quality of care and patient safety.
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Affiliation(s)
- Pin Li
- Department of Medicine, University of Calgary, Alberta, Canada.
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Hilligoss B, Cohen MD. Hospital handoffs as multifunctional situated routines: implications for researchers and administrators. Adv Health Care Manag 2011; 11:91-132. [PMID: 22908667 DOI: 10.1108/s1474-8231(2011)0000011008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Patient handoffs involve the exchange of information between health professionals accompanying a transfer of responsibility for, or control of, a patient. Concerns over the safety risks of poor handoffs have resulted in regulatory pressure to standardize practice and considerable growth in research. But handoffs involve more than information transfer, and their consequences for health care organizations extend beyond the safety of patients. Using an organization theory lens, we review the literature on handoffs and propose a framework that characterizes handoffs as multifunctional, situated organizational routines. We also identify implications for researchers and hospital policymakers. Standardization and improvement efforts run the risk of causing unintended problems if they overlook the complexity of handoff and the larger organizational functions it serves. Deepening our understanding of the multifunctional, situated nature of handoff can lead to improvement efforts that not only safeguard individual patients, but also enhance the capabilities of the larger health care organization.
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Affiliation(s)
- Brian Hilligoss
- College of Public Health, The Ohio State University, Columbus, USA
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DeFilippis AP, Tellez I, Winawer N, Di Francesco L, Manning KD, Kripalani S. On-site Night Float by Attending Physicians: A Model to Improve Resident Education and Patient Care. J Grad Med Educ 2010; 2:57-61. [PMID: 21975885 PMCID: PMC2931221 DOI: 10.4300/jgme-d-09-00073.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2009] [Revised: 11/24/2009] [Accepted: 01/11/2010] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND In 2003, the Accreditation Council for Graduate Medical Education instituted common duty hour limits, and in 2008 the Institute of Medicine recommended additional limits on continuous duty hours. Using a night-float system is an accepted approach for adhering to duty hour mandates. OBJECTIVE To determine the effect of an on-site night-float attending physician on resident education and patient care. METHODS Night-float residents and daytime ward residents were surveyed at the end of their rotation about the impact of an on-site night-float attending physician on education and quality of patient care. Responses were provided on a 5-point Likert scale ranging from 1, strongly agree, to 5, strongly disagree. RESULTS Overall, 92 of the 140 distributed surveys were completed (66% response rate). Night-float residents found the night-float attending physician to be helpful with cross-cover issues (mean = 2.00), initial history and physical examination (mean = 1.56), choosing appropriate diagnostic tests (mean = 1.79), developing a treatment plan (mean = 1.74), and improving overall patient care (mean = 1.91). Daytime ward residents were very satisfied with the quality of the admission workups (mean = 1.78), tests and diagnostic procedures (mean = 1.76), and initial treatment plan (mean = 1.62) provided by the night-float service. CONCLUSION A night-float system that includes on-site attending physician supervision can provide a valuable opportunity for resident education and may help improve the quality of patient care.
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Affiliation(s)
- Andrew Paul DeFilippis
- Corresponding author: Andrew Paul DeFilippis, MD, MSc, Johns Hopkins University, 600 North Wolfe Street, Carnegie 568, Baltimore, MD 21224,
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Lerner CF, Chung PJ. Continuity of care in fixed-day versus variable-day resident continuity clinics. Acad Pediatr 2010; 10:119-23. [PMID: 20206910 DOI: 10.1016/j.acap.2009.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 11/03/2009] [Accepted: 11/13/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Since the introduction of resident work-hour standards, pediatric residency programs have struggled to preserve robust continuity clinic experiences. Many programs have resorted to more flexible approaches to resident scheduling. We know little regarding the impact of such changes. We compared 2 continuity clinic scheduling models: a traditional fixed-day clinic and a variable-day clinic in which resident clinic days vary each week to accommodate resident schedules. METHODS The setting for our study was a large university resident continuity clinic. We analyzed 111 resident schedules and 1113 visits by children aged younger than 1 year during 2 periods: July 2007 to December 2007, when residents were scheduled by using a variable-day clinic model, and July 2008 to December 2008, when a fixed-day model was used. We compared the number of clinic sessions per resident and continuity of care. We used the usual provider of care definition of continuity: the proportion of visits in which a patient is seen by his or her primary resident. A multivariable logistic regression was used to model the relationship between patient continuity of care and clinic structure (fixed-day vs variable-day), resident level, patient age, and appointment type. RESULTS The number of clinics per resident during a 6-month period was higher using variable-day scheduling (19.6 vs 16.2; P < .01), whereas continuity of care was lower (0.54 vs 0.61; P = .01) In the multivariate model, continuity of care was significantly higher under the fixed-day model (odds ratio 1.40; P < .01). CONCLUSIONS Scheduling residents for continuity clinic on variable days results in lower patient continuity of care despite increased resident time in clinic.
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Affiliation(s)
- Carlos F Lerner
- David Geffen School of Medicine, University of California, Los Angeles, Calif, USA.
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Francis MD, Zahnd WE, Varney A, Scaife SL, Francis ML. Effect of number of clinics and panel size on patient continuity for medical residents. J Grad Med Educ 2009; 1:310-5. [PMID: 21975997 PMCID: PMC2931247 DOI: 10.4300/jgme-d-09-00017.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Accreditation Council for Graduate Medical Education program requirements for internal medicine residency training include a longitudinal, continuity experience with a panel of patients. OBJECTIVE To determine whether the number of resident clinics, the resident panel size, and the supervising attending physician affect patient continuity. To determine the number of clinics and the panel size necessary to maximize patient continuity. DESIGN We used linear regression modeling to assess the effect of number of attended clinics, the panel size, and the attending physician on patient continuity. PARTICIPANTS Forty medicine residents in an academic medicine clinic. MEASUREMENTS Percent patient continuity by the usual provider of care method. RESULTS Unadjusted linear regression analysis showed that patient continuity increased 2.3% ± 0.7% for each additional clinic per 9 weeks or 0.4% ± 0.1% for each additional clinic per year (P = .003). Conversely, patient continuity decreased 0.7% ± 0.4% for every additional 10 patients in the panel (P = .04). When simultaneously controlling for number of clinics, panel size, and attending physician, multivariable linear regression analysis showed that patient continuity increased 3.3% ± 0.5% for each additional clinic per 9 weeks or 0.6% ± 0.1% for each additional clinic per year (P < .001). Conversely, patient continuity decreased 2.2% ± 0.4% for every additional 10 patients in the panel (P < .001). Thus, residents who actually attend at least 1 clinic per week with a panel size less than 106 patients can achieve 50% patient continuity. Interestingly, the attending physician accounted for most of the variability in patient continuity (51%). CONCLUSIONS Patient continuity for residents significantly increased with increasing numbers of clinics and decreasing panel size and was significantly influenced by the attending physician.
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Affiliation(s)
- Maureen D. Francis
- Corresponding author: Maureen Francis, MDAssociate Program Director, SIU School of Medicine, 751 N. Rutledge, Springfield, IL 62794-9636, 217.545.0170,
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Lang VJ, Mooney CJ, O'Connor AB, Bordley DR, Lurie SJ. Association between hand-off patients and subject exam performance in medicine clerkship students. J Gen Intern Med 2009; 24:1018-22. [PMID: 19579049 PMCID: PMC2726882 DOI: 10.1007/s11606-009-1045-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Revised: 04/09/2009] [Accepted: 06/03/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Teaching hospitals increasingly rely on transfers of patient care to another physician (hand-offs) to comply with duty hour restrictions. Little is known about the impact of hand-offs on medical students. OBJECTIVE To evaluate the impact of hand-offs on the types of patients students see and the association with their subsequent Medicine Subject Exam performance. DESIGN Observational study over 1 year. PARTICIPANTS Third-year medical students in an Inpatient Medicine Clerkship at five hospitals with night float systems. PRIMARY OUTCOME Medicine Subject Exam at the end of the clerkship; explanatory variables: number of fresh (without prior evaluation) and hand-off patients, diagnoses, subspecialty patients, and full evaluations performed during the clerkship, and United Stated Medical Licensing Examination (USMLE) Step I scores. MAIN RESULTS Of the 2,288 patients followed by 89 students, 990 (43.3%) were hand-offs. In a linear regression model, the only variables significantly associated with students' Subject Exam percentile rankings were USMLE Step I scores (B = 0.26, P < 0.001) and the number of full evaluations completed on fresh patients (B =0.20, P = 0.048; model r (2) = 0.58). In other words, for each additional fresh patient evaluated, Subject Exam percentile rankings increased 0.2 points. For students in the highest quartile of Subject Exam percentile rankings, only Step I scores showed a significant association (B = 0.22, P = 0.002; r (2) = 0.5). For students in the lowest quartile, only fresh patient evaluations demonstrated a significant association (B = 0.27, P = 0.03; r (2) = 0.34). CONCLUSIONS Hand-offs constitute a substantial portion of students' patients and may have less educational value than "fresh" patients, especially for lower performing students.
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Affiliation(s)
- Valerie J Lang
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box MED-HMD, Rochester, NY 14642, USA.
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Psychiatric Evaluation of Mental Capacity in the General Hospital: A Significant Teaching Opportunity. PSYCHOSOMATICS 2009. [DOI: 10.1016/s0033-3182(09)70839-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Effects of resident work-hour restrictions on orthopaedic education and patient care. CURRENT ORTHOPAEDIC PRACTICE 2009. [DOI: 10.1097/bco.0b013e328316640a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hanlon JG, Hayter MA, Bould MD, Joo HS, Naik VN. Perceived sleepiness in Canadian anesthesia residents: a national survey. Can J Anaesth 2008; 56:27-34. [PMID: 19247775 DOI: 10.1007/s12630-008-9003-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Revised: 10/27/2008] [Accepted: 10/30/2008] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To compare the self-perceived sleepiness of Canadian anesthesia residents providing modified on-call duties (12-16 h) vs. traditional on-call duties (24 h). METHODS A 25-item online survey was distributed to all Canadian anesthesia residents who, at that time, were on anesthesia rotations. The survey assessed resident demographics, perceived work patterns, and sleepiness, as well as their opinions on resident work hour reform. Self-perceived sleepiness was quantified using the validated Epworth sleepiness scale (ESS). RESULTS Three hundred eight of 400 (77%) eligible Canadian anesthesia residents completed the survey. Forty-three percent of residents who worked traditional on-call (duration 24.1 +/- 0.5 h) shifts and 48% of residents who worked modified on-call (duration 15.5 +/- 1.8 h) shifts met ESS criteria for excessive daytime sleepiness. Overall mean ESS scores did not differ significantly between the traditional (9.1 +/- 4.9) and the modified call groups (9.5 +/- 4.8). Residents with an on-call frequency of >or=1:4 days or those who slept <or=2 h while on call perceived themselves as significantly more sleepy (P = 0.045 and P = 0.008, respectively). Six percent of residents admitted to taking "something other than caffeine" to stay awake on call. CONCLUSION Many anesthesia residents do exhibit excessive daytime sleepiness, with a similar incidence for those working within either modified or traditional call systems. Our study suggests that sleepiness may be reduced by scheduling on-call duties no more frequently than one in every five nights and by ensuring that residents sleep more than 2 h while on call.
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Affiliation(s)
- John G Hanlon
- Department of Anesthesia, St Michael's Anesthesia Research into Teaching (SMART), St Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, Canada M5B 1W8
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Abstract
Work limitations were mandated (2003) to increase safety and improve resident lifestyle. Is clinic continuity affected? Medical University of South Carolina pediatric residents' records for 6 months of 2002 (before regulation) and 2003 (after regulation) were reviewed. Continuity for physician formula, t tests, and multivariate linear regression were used. Continuity was calculated for 44 residents (2002) and 45 residents (2003). Mean continuity was 54% (2002) and 53% (2003; P = .5); continuity for well-child care visits was 78% (2002) and 73% (2003; P = .047). Continuity decreased most for interns (52% [2002], 47% [2003] for all visits; 76%, 67% for well-child care visits). In the multivariate model, year did not predict continuity. When only well-child care visits were considered, year showed a trend toward significance ( P = .07): 2003 had less continuity. Compared with third-year residents, interns had 8% points less continuity for all visits (6% points less for well-child care visits). Continuity can be maintained despite regulations. Interns are most vulnerable.
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Affiliation(s)
- Patricia G McBurney
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Fletcher KE, Parekh V, Halasyamani L, Kaufman SR, Schapira M, Ertl K, Saint S. Work hour rules and contributors to patient care mistakes: a focus group study with internal medicine residents. J Hosp Med 2008; 3:228-37. [PMID: 18570333 DOI: 10.1002/jhm.288] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The "Swiss cheese model" of systems accidents is commonly applied to patient safety, implying that many "holes" must align before an adverse event occurs. The Accreditation Council for Graduate Medical Education (ACGME) instituted work hour limitations to fill one such hole by reducing resident fatigue. OBJECTIVE The objective of this study was to determine how residents perceive the impact of the ACGME rules and other factors on patient safety. DESIGN The study was designed as a focus group study. PARTICIPANTS Participating in the study were 28 internal medicine residents, of whom 13 were from a university-based program that includes both an academic medical center and a Veterans Affair (VA) hospital, 9 were from a community-based program, and 6 were from a freestanding medical college that includes a large private teaching hospital and a VA hospital. MEASUREMENT Grounded theory analysis was used to examine transcripts of the focus group discussions. RESULTS A model of contributors to patient care errors emerged including fatigue, inexperience, sign-outs, not knowing patients, "entropy" (which we defined as "overall chaos in the system"), and workload. Participants described the impact of both intended and unintended consequences of the work hour rules on patient care. Residents reported improved well-being and less fatigue, but had concern about the effect of reduced continuity on patient care. CONCLUSION Our focus group participants perceived that the ACGME work hour limitations had minimized the impact of resident fatigue on patient care errors. Other contributors to errors remained and were often exacerbated by methods to maintain compliance with the rules.
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Kelz RR, Freeman KM, Hosokawa PW, Asch DA, Spitz FR, Moskowitz M, Henderson WG, Mitchell ME, Itani KMF. Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data. Ann Surg 2008; 247:544-52. [PMID: 18376202 DOI: 10.1097/sla.0b013e31815d7434] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To examine the association between surgical start time and morbidity and mortality for nonemergent procedures. SUMMARY BACKGROUND DATA Patients require medical services 24 hours a day. Several studies have demonstrated a difference in outcomes over the course of the day for anesthetic adverse events, death in the ICU, and dialysis care. The relationship between operation start time and patient outcomes is yet undefined. METHODS We performed a retrospective cohort study of 144,740 nonemergent general and vascular surgical procedures performed within the VA Medical System 2000-2004 and entered into the National Surgical Quality Improvement Program Database. Operation start time was the independent variable of interest. Logistic regression was used to adjust for patient and procedural characteristics and to determine the association between start time and, in 2 independent models, mortality and morbidity. RESULTS Unadjusted later start time was significantly associated with higher surgical morbidity and mortality. After adjustment for patient and procedure characteristics, mortality was not significantly associated with start time. However, after appropriate adjustment, operations starting between 4 pm and 6 pm were associated with an elevated risk of morbidity (OR = 1.25, P < or = 0.005) over those starting between 7 am and 4 pm as were operations starting between 6 pm and 11 pm (OR = 1.60, P < or = 0.005). CONCLUSIONS When considering a nonemergent procedure, surgeons must bear in mind that cases that start after routine "business" hours within the VA System may face an elevated risk of complications that warrants further evaluation.
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Affiliation(s)
- Rachel R Kelz
- Department of Surgery, Philadelphia VA Medical Center, Philadelphia, PA, USA.
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Balmer D, Ruzek S, Ludwig S, Giardino A. Pediatric Residents’ and Continuity Clinic Preceptors’ Perceptions of the Effects of Restricted Work Hours on Their Learning Relationship. ACTA ACUST UNITED AC 2007; 7:348-53. [PMID: 17870642 DOI: 10.1016/j.ambp.2006.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2005] [Revised: 05/05/2006] [Accepted: 05/16/2006] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The effects of the Work Hour Standard (WHS) on continuity of care and quality of education has stimulated much discussion, yet little is known about how it affects the resident-continuity clinic preceptor (CCP) dyad, the only longitudinal learning relationship in pediatric residency. This case study explored residents' and CCPs' perceptions of the effects of restricted work hours on their learning relationship. METHODS Direct observation of third-year pediatric residents (n = 10) and their CCPs (n = 10) was carried out in continuity clinic (CC) for 5 months; both groups attended clinic before and after the WHS. Semistructured, audiotaped interviews were conducted with residents before and after observation, and with CCPs after resident data were collected. Data from interview transcripts and observational notes were analyzed for major themes. RESULTS To comply with the WHS, postcall clinic was eliminated and residents were rescheduled to another afternoon CC. The consequence of eliminating postcall clinic, disruption in the resident-CCP relationship, was perceived differently by residents and CCPs. From the residents' perspective, rescheduling CC in response to the WHS benefited their learning because it exposed them to different CCPs with different practice styles. From the CCPs' perspective, rescheduling CC frustrated their efforts to be learner-centered teachers and effective mentors. CONCLUSIONS Intended changes to limit excessive work hours had unintended effects that were viewed more favorably by residents than by CCPs. Understanding the shared and different perspectives of residents and preceptors regarding WHS-related changes in CC extends the discussion of the effect of restricted work hours.
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Affiliation(s)
- Dorene Balmer
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Lin GA, Beck DC, Stewart AL, Garbutt JM. Resident perceptions of the impact of work hour limitations. J Gen Intern Med 2007; 22:969-75. [PMID: 17468888 PMCID: PMC2219723 DOI: 10.1007/s11606-007-0223-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Revised: 11/09/2006] [Accepted: 04/04/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Mandatory work hour limitations for residents began in July 2003. There has been little evaluation of the impact of the new limitations on Internal Medicine residency training. OBJECTIVE To assess Internal Medicine residents' perceptions of the impact of work hour limitations on clinical experiences, patient care, resident education, and well-being, and their compliance with the limitations. DESIGN AND PARTICIPANTS Cross-sectional survey administered to Internal Medicine residents at 1 large U.S. teaching hospital. MEASUREMENTS Resident perceptions using 5-point Likert scales, and self-reported compliance. Exploratory factor analysis was used to identify underlying domains and develop scales. RESULTS The survey response rate was 85%. Five domains were identified by factor analysis: 1) clinical experience, 2) patient care and safety, 3) communication, 4) satisfaction with training, and 5) work-rest balance. Residents perceived work hour limitations to have a negative impact on clinical experience (mean scale score 1.84, 1 = negative, 5 = positive), patient care and safety (2.64), and communication domains (1.98). Effects on satisfaction (3.12) and work-rest balance domains (2.95) were more positive. Senior residents perceived more negative effects of work hour limitations than interns. Compliance was difficult; 94% interns and 70% residents reported violating work hour limits. Patient care and teaching duties were the main reasons for work hour violations. CONCLUSIONS This study suggests that the current work hour limitations may be having unintended negative consequences on residency training. Ongoing monitoring to evaluate the impact of program changes as a result of work hour regulation is crucial to improving residency training.
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Affiliation(s)
- Grace A Lin
- Division of General Internal Medicine, University of California, San Francisco, Box 1364, SFGH, San Francisco, CA 94143, USA.
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West CP, Cook RJ, Popkave C, Kolars JC. Perceived impact of duty hours regulations: a survey of residents and program directors. Am J Med 2007; 120:644-8. [PMID: 17602942 DOI: 10.1016/j.amjmed.2007.03.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2006] [Revised: 12/26/2006] [Accepted: 03/30/2007] [Indexed: 11/22/2022]
Affiliation(s)
- Colin P West
- Department of Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA
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Bates T, Cecil E, Greene I. The effect of the EWTD on training in general surgery: an analysis of electronic logbook records. ACTA ACUST UNITED AC 2007. [DOI: 10.1308/147363507x177045] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The introduction of time-limited surgical training in the UK in 1994 following the Calman report raised concerns over the hands-on experience of trainees, heightened by the hours reduction demanded by the New Deal. From 1994, junior doctors' on-duty hours of work for hard-pressed posts were targeted to a limit of 56 hours but SpRs were allowed a voluntary extension from 73 on-duty hours to a maximum of 83 hours per week. By 1995 concern was being expressed at the reduction in training time and continuity of patient care and although calls for more targeted training were made, evidence of a negative impact on training has continued to surface.
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Affiliation(s)
- T Bates
- the Breast Unit, William Harvey Hospital, Ashford, Kent
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Boyle EM, Freer Y, Wong MC, McIntosh N, Anand KJS. Response to PAIN Editorial re: Boyle et al. (2006). Pain 2007; 127:302. [PMID: 17055647 DOI: 10.1016/j.pain.2006.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Accepted: 09/11/2006] [Indexed: 11/20/2022]
Affiliation(s)
- Elaine M Boyle
- Neonatal Unit, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Abstract
BACKGROUND The Joint Commission has made a "standardized approach to hand-off communications" a National Patient Safety Goal. METHOD An interactive 90-minute workshop (hand-off clinic) was developed in 2005 to (1) develop a standardized process for the handoff, (2) create a checklist of critical patient content, and (3) plan for dissemination and training. CONCLUSION To date, 7 of 10 residency programs have participated. Analysis of these protocols demonstrated that the hand-off process is highly variable and discipline-specific. Although all disciplines required a verbal handoff, because of competing demands, verbal communication did not always occur. In some cases, the transfer of professional responsibility was separated in time and space from the transfer of information. For example, in two cases, patient tasks were assigned to other team members to facilitate timely departure of a postcall resident (to meet resident duty-hour restrictions), but results were not formally communicated to anyone. The hand-off clinic facilitated the incorporation of "closed-loop" communication by requiring that follow-up on these tasks be conveyed to the on-call resident. DISCUSSION This model for design and implementation can be applied to other health care settings.
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Affiliation(s)
- Vineet Arora
- Department of Medicine, University of Chicago, USA.
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Woodrow SI, Segouin C, Armbruster J, Hamstra SJ, Hodges B. Duty hours reforms in the United States, France, and Canada: is it time to refocus our attention on education? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2006; 81:1045-51. [PMID: 17122467 DOI: 10.1097/01.acm.0000246751.27480.55] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Resident duty hours restrictions have now been instituted in many countries worldwide. Such policies have resulted in a broad-based discussion in the medical literature concerning their effects on patient care, resident education, and resident well-being. To better understand the impetuses behind these changes, the authors examine not only the duty hours mandates currently in effect in the United States, Canada, and France, but also the events influencing their independent development in these three countries. In the United States, an 80-hour resident workweek was mandated by the Accreditation Council for Graduate Medical Education out of concern for patient safety. In France, a 52.5-hour workweek was decreed by the government, reflecting the broader European Working Time Directive initiated out of concern for the negative impact of extended work hours on its population. In Canada, resident unions, whose primary interest has been one of resident well-being, have negotiated a series of reduced resident duty hours that approach those mandated in the United States. At the core of these changes are unique differences in these countries' health care and medical education systems. The resulting diversity in the origin and nature of such regulations serves to highlight the lack of evidence that has guided their development and the need to refocus on the educational elements of postgraduate training.
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Affiliation(s)
- Sarah I Woodrow
- Department of Surgery, University of Toronto, Wilson Centre for Research in Education, University of Toronto, Toronto, Canada.
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Cull WL, Mulvey HJ, Jewett EA, Zalneraitis EL, Allen CE, Pan RJ. Pediatric residency duty hours before and after limitations. Pediatrics 2006; 118:e1805-11. [PMID: 17142502 DOI: 10.1542/peds.2006-0210] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The goals were to examine pediatric resident and program director experiences implementing the Accreditation Council for Graduate Medical Education work hour limits and to compare duty hours, moonlighting, and fatigue before and after the limits became effective. METHODS National random samples of 500 pediatric residents who graduated in 2002 and in 2004 were surveyed to compare resident duty hours and fatigue before and after the Accreditation Council for Graduate Medical Education limits were implemented. In addition, all US pediatric residency program directors were surveyed at the end of the 2003/2004 academic year, to provide a complementary retrospective examination of limit implementation. RESULTS Totals of 65%, 61%, and 83% of 2002 residents, 2004 residents, and program directors, respectively, responded. The proportion of residents who reported working >80 hours per week declined from 49% for NICU/PICU rotations before the limits to 18% after limit implementation. Resident well-being was the factor identified most often by both residents and program directors as being improved since the limitations. Multivariate modeling also showed reductions in the proportions of residents who reported falling asleep while driving from work or making errors in patient care because of fatigue. Overall, 89% of pediatric residents and program directors reported that the current system is effective in ensuring appropriate working hours. CONCLUSIONS Since the Accreditation Council for Graduate Medical Education duty hour limits went into effect, pediatric residents report working fewer hours and making fewer patient care errors because of fatigue. Although room for additional improvement remains, the experiences of residents and program directors suggest that implementation of the Accreditation Council for Graduate Medical Education limits in pediatric residency programs is improving resident well-being.
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Affiliation(s)
- William L Cull
- Division of Health Services Research, American Academy of Pediatrics, 141 Northwest Point Blvd, Elk Grove Village, IL 60007, USA.
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Arora V, Fang MC, Kripalani S, Amin AN. Preparing for "diastole": advanced training opportunities for academic hospitalists. J Hosp Med 2006; 1:368-77. [PMID: 17219531 DOI: 10.1002/jhm.132] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Academic hospital medicine can be described as comprising periods of "systole," during which hospitalists provide clinical care, and periods of "diastole," the portion of a hospitalist's time spent in nonclinical activities. Far from being a period of relaxation, diastole is an active component of a hospitalist's work, the time devoted to the pursuit of career advancement. This period is a critical opportunity for career development in terms of medical research, education, quality improvement, or administration. An appropriate balance of systole and diastole may potentially prevent burnout and allow hospitalists opportunities to focus on academic advancement. Although an increasing number of residency graduates opt for a career in academic hospital medicine, few are prepared for the period of diastole. This article describes several career options in academic hospital medicine, specifically, opportunities in education, research, quality improvement, and administrative opportunities. By informing future hospitalists about the career opportunities within academic hospital medicine possible through managing their diastolic time, we hope that future generations of trainees will be better prepared to enter this field.
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Affiliation(s)
- Vineet Arora
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois 60637, USA.
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Frankel HL, Foley A, Norway C, Kaplan L. Amelioration of increased intensive care unit service readmission rate after implementation of work-hour restrictions. ACTA ACUST UNITED AC 2006; 61:116-21. [PMID: 16832258 DOI: 10.1097/01.ta.0000222579.48194.2b] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED In July 2003, we reallocated our resident workforce to address mandated duty-hour restrictions. In the subsequent academic year (AY), surgical intensive care unit (SICU) service readmission rates (RR) doubled. We hypothesized that a targeted intervention could reduce SICU service RR in academic year (AY) 2004-05. METHODS This study was conducted at an urban teaching hospital before (AY02-03, period 1), during (AY03-04, period 2), and after (AY04-05, period 3) implementation of the Accreditation Council for Graduate Medical Education guidelines. Demographics, RR, and reason were culled from Project Impact and a complications database. SICU staff (dedicated intensivist, two or three fellows, and six residents) remained constant. In periods 2 and 3 (versus 1), ward residents cross-covered > or = 3 services every 5 to 6 nights (versus every 3 in period 1) with physician assistant support (versus none in period 1). During period 3, a focused transfer phone call, charted care summary, and discharge checkup defined the intervention. Interperiod comparisons were by chi2 and t test analysis; p < 0.05 (versus period 1) defined significance. RESULTS In all, 1,570, 1,705 and 1,681 patients were treated in periods 1, 2, and 3, respectively. There were no demographic or APACHE score differences. RRs were 1.4%, 3.0% and 1.2% in periods 1, 2, and 3, respectively. The percentages of readmissions as a result of ward care were 16.7, 41, and 10%, respectively. The most common readmission indication was respiratory (46% in period 1; 51% in period 2, and 80% in period 3) and was associated with an increased proportion of readmission as a result of patient disease (46% in period 1; 41% in period 2; 80% in period 3). Intervention noncompliance preceded 30% of period 3 readmissions. CONCLUSION A targeted intervention can reduce the rate of SICU readmission caused by care inadequacies stemming from a resident reallocation strategy.
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Affiliation(s)
- Heidi L Frankel
- Department of Surgery, Division of Burn, Trauma, and Critical Care, UT Southwestern Medical Center, Dallas, Texas 75390-9158, USA.
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Nauta RJ. Five Uneasy Peaces: Perfect Storm Meets Professional Autonomy in Surgical Education. J Am Coll Surg 2006; 202:953-66. [PMID: 16735211 DOI: 10.1016/j.jamcollsurg.2006.02.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2005] [Revised: 02/21/2006] [Accepted: 02/21/2006] [Indexed: 01/13/2023]
Affiliation(s)
- Russell J Nauta
- Department of Surgery, Harvard Medical School, Boston, MA, USA
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Bradley P. The history of simulation in medical education and possible future directions. MEDICAL EDUCATION 2006; 40:254-62. [PMID: 16483328 DOI: 10.1111/j.1365-2929.2006.02394.x] [Citation(s) in RCA: 411] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Clinical simulation is on the point of having a significant impact on health care education across professional boundaries and in both the undergraduate and postgraduate arenas. SCOPE OF SIMULATION The use of simulation spans a spectrum of sophistication, from the simple reproduction of isolated body parts through to complex human interactions portrayed by simulated patients or high-fidelity human patient simulators replicating whole body appearance and variable physiological parameters. GROWTH OF SIMULATION After a prolonged gestation, recent advances have made available affordable technologies that permit the reproduction of clinical events with sufficient fidelity to permit the engagement of learners in a realistic and meaningful way. At the same time, reforms in undergraduate and postgraduate education, combined with political and societal pressures, have promoted a safety-conscious culture where simulation provides a means of risk-free learning in complex, critical or rare situations. Furthermore, the importance of team-based and interprofessional approaches to learning and health care can be promoted. CONCLUSION However, at the present time the quantity and quality of research in this area of medical education is limited. Such research is needed to enable educators to justify the cost and effort involved in simulation and to confirm the benefit of this mode of learning in terms of the outcomes achieved through this process.
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White CB, Haftel HM, Purkiss JA, Schigelone AS, Hammoud MM. Multidimensional effects of the 80-hour work week at the University of Michigan Medical School. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2006; 81:57-62. [PMID: 16377822 DOI: 10.1097/00001888-200601000-00016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
PURPOSE To examine the effects of the new resident work-hour restrictions on medical students, as measured by their perceptions of the quality of their experiences during the required clerkships. METHOD Evaluations of four clerkships were compared for two student cohorts at the University of Michigan Medical School. The first cohort, from the class of 2002-03, completed their clinical clerkships the year before the work-hour restrictions were implemented, and the second cohort, from the class of 2003-04, completed their clerkships the same year the restrictions were implemented. RESULTS There were significant and notable differences in the experiences of the two cohorts. Students' perceptions of the quality of their experiences in the surgery-oriented clerkships (obstetrics-gynecology and surgery) in particular were significantly lower (i.e., more negative) in the 2003-04 cohort than in the previous cohort for the same clerkships. The nonsurgery-oriented clerkships (internal medicine and pediatrics) hired hospitalists, who offset the residents' workload (internal medicine) and assumed teaching responsibilities (pediatrics). Between 2002-03 and 2003-04, students' perceptions of the quality of their experience in the internal medicine clerkship remained mostly stable, and increased in several areas for the students in the pediatrics clerkship. CONCLUSIONS Implementation of resident work-hour restrictions had significant effects on the education of the medical students studied. These effects need to be carefully analyzed and considered to ensure quality education for medical students. The findings also highlight that the nature of students' perceptions was related to preparations made (or not) by specific clerkships as restricted work-hour regulations were adopted.
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Affiliation(s)
- Casey B White
- Office of Medical Education, 3960 Taubman Medical Library, 1135 East Catherine Street, Box 0726, Ann Arbor, MI 48109, USA.
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Irani JL, Mello MM, Ashley SW, Whang EE, Zinner MJ, Breen E. Surgical residents' perceptions of the effects of the ACGME duty hour requirements 1 year after implementation. Surgery 2005; 138:246-53. [PMID: 16153433 DOI: 10.1016/j.surg.2005.06.010] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2005] [Revised: 06/07/2005] [Accepted: 06/08/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND In July 2003, the Accreditation Council for Graduate Medical Education implemented nationwide requirements on resident duty hours with the aim of improving quality of care. Our objectives were (1) to determine the extent and means of compliance with the ACGME requirements within general surgery residency programs and (2) to examine general surgery residents' perceptions of the effects of the ACGME requirements on patient care and residents' training experience. METHODS A survey was mailed to residents in 19 New England general surgery programs in spring 2004 (n=238). RESULTS The overall response rate was 36%. More than 89% of respondents reported that the requirements generally were being enforced, and respondents' mean work hours (80.8 +/- 11.7 per week) supported this claim. Forty-three percent felt that quality of care had deteriorated. Although 70% perceived decrements in continuity of care, only 32% believed that the risk of patient management errors had increased. Sixty percent reported doing fewer operations, and half felt that residents missed out on too many learning opportunities. Yet, only 39% reported that the requirements had worsened the quality of training. Residents consistently reported an improved quality of life. Seventy-five percent felt that, overall, the requirements were a good thing. CONCLUSIONS Most surgical residents do not believe that the ACGME duty hour requirements have had their intended effect of improving quality of care and are ambivalent about effects on the quality of their training. However, they report an improved quality of life, and most residents do support the requirements overall.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Keating RJ, LaRusso NF, Kolars JC. Perceived impact of duty hours limits on the fragmentation of patient care: results from an academic health center. Am J Med 2005; 118:788-93. [PMID: 15989916 DOI: 10.1016/j.amjmed.2005.04.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2005] [Indexed: 11/20/2022]
Affiliation(s)
- Richard J Keating
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Arora V, Guardiano S, Donaldson D, Storch I, Hemstreet P. Closing the gap between internal medicine training and practice: Recommendations from recent graduates. Am J Med 2005; 118:680-5; discussion 685-7. [PMID: 15922702 DOI: 10.1016/j.amjmed.2005.03.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Accepted: 03/16/2005] [Indexed: 11/20/2022]
Affiliation(s)
- Vineet Arora
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, Illinois, USA.
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