First, do no harm: impact of the transition to an integrated curriculum on medical knowledge acquisition of the transitional cohort

INTRODUCTION

Many medical schools are moving toward integrated curricula in response to the 2010 Carnegie report. However, there is often apprehension that student performance on standard assessment metrics of medical knowledge acquisition could suffer during the transition period. Therefore, we sought to analyze the impact of curriculum redesign on the medical knowledge acquisition of the transitional cohort, as measured by NBME subject exam scores.

METHODS

The University of Wisconsin School of Medicine and Public Health Legacy curriculum followed a standard 2 + 2 medical school educational model, including traditional, department-based, third-year clinical clerkships. In the new ForWard curriculum, students enter clinical rotations one semester earlier, and those core clinical experiences are organized within four integrated blocks combining traditional clerkship specialties. This retrospective program evaluation compares NBME subject exam scores between the final cohort of Legacy third-year students (2016-17) and first cohort of ForWard students (2018) for the Adult Ambulatory Medicine, Medicine, Neurology, Obstetrics and Gynecology, Pediatrics, Psychiatry, and Surgery exams.

RESULTS

NBME subject exam mean scores ranged from 75.5-79.4 for the Legacy cohort and 74.9-78.7 for the ForWard cohort, with no statistically significant differences in scores identified for each individual exam analyzed. Results remained constant when controlled for student demographic variables.

DISCUSSION

Faculty and students may worry about impacts to the transitional cohort during curriculum redesign, however our results suggest no substantive negative effects to acquisition of medical knowledge during transition to an integrated curriculum. Further monitoring is necessary to examine whether medical knowledge acquisition remains stable or changes after the integrated curriculum is established.

Patient care, public health, and a pandemic: adapting educational experiences in the clinical years

The University of Wisconsin Madison School of Medicine and Public Health rapidly adapted its four‐year, three‐phase medical doctorate clinical curriculum at the onset of the COVID‐19 in Spring 2020. Medical students in clinical rotations, our Phase 2 and 3 of the ForWard curriculum, temporarily stopped face to face care of patients, transitioning instead to online learning. For Phase 2 students, this single 12‐ week interim course included didactic content from all required integrated blocks and the creation of a new content which taught public health principles in the context of historical pandemics. Phase 3 students were rescheduled into online electives, which course directors had offered in the past and agreed to offer again during this time. All Phase 3 students participated in a Public Health Preparedness course after its rapid redesign for online delivery and scaling for an entire class. Phase 2 students returned in July 2020 to abbreviated 8‐week integrated blocks that retained approximately 83% of the clinical time students would have received in the intended 12‐week integrated blocks. This was possible through the frontloading of teaching sessions to the interim course and creative scheduling of clinical experiences. The 2015 curricular redesign to the integrated curriculum facilitated effective coordination and teamwork that enabled these thoughtful, rapid adjustments to the curriculum.

Earlier Hospital Discharge With Prospectively Designated Discharge Time in the Electronic Health Record

BACKGROUND AND OBJECTIVES

Hospital discharge requires multidisciplinary coordination. Insufficient coordination impacts patient flow, resource use, and postdischarge outcomes. Our objectives were to (1) implement a prospective, multidisciplinary discharge timing designation in the electronic health record (EHR) and (2) evaluate its association with discharge timing.

METHODS

This quality-improvement study evaluated the implementation of confirmed discharge time (CDT), an EHR designation representing specific discharge timing developed jointly by a patient's family and the health care team. CDT was intended to support task management and coordination of multidisciplinary discharge processes and could be entered and viewed by all team members. Four plan-do-study-act improvement phases were studied: (1) baseline, (2) provider education, (3) provider feedback, and (4) EHR modification. Statistical process control charts tracked CDT use and the proportion of discharges before noon. Length of stay was used as a balancing measure.

RESULTS

During the study period from April 2013 through March 2017, 20 133 pediatric discharges occurred, with similar demographics observed throughout all phases. Mean CDT use increased from 0% to 62%, with special cause variations being detected after the provider education and EHR modification phases. Over the course of the study, the proportion of discharges before noon increased by 6.2 percentage points, from 19.9% to 26.1%, whereas length of stay decreased from 47 (interquartile range: 25-95) to 43 (interquartile range: 24-88) hours (both P < .001).

CONCLUSIONS

The implementation of a prospective, multidisciplinary EHR discharge time designation was associated with more before-noon discharges. Next steps include replicating results in other settings and determining populations that are most responsive to discharge coordination efforts.

Feeding during High-Flow Nasal Cannula for Bronchiolitis: Associations with Time to Discharge

BACKGROUND

High-flow nasal cannula (HFNC) is increasingly used to treat children hospitalized with bronchiolitis; however, the best practices for feeding during HFNC and the impact of feeding on time to discharge and adverse events are unknown. The study objective was to assess whether feeding exposure during HFNC was associated with time to discharge or feeding-related adverse events.

METHODS

This retrospective cohort study included inpatients aged 1-24 months receiving HFNC for bronchiolitis at an academic children's hospital from January 1, 2015 to March 1, 2017. Feeding exposures during HFNC were categorized as fed or not fed. Among fed children, we further evaluated mixed (oral and tube) or exclusive oral feeding. The primary outcome was time to discharge after HFNC cessation. Secondary outcomes were aspiration, intubation after HFNC, and seven-day readmission.

RESULTS

Of 123 children treated with HFNC, 45 (37 %) were never fed. A total of 78 children (63%) were fed; 50 (41%) were exclusively orally fed and 28 (23 %) had mixed feeding. Median (interquartile range) time to discharge after HFNC was 29.5 hours (23.5-47.9) and 39.8 hours (26.4-61.5) hours in the fed and not fed groups, respectively. In adjusted models, time to discharge was shorter with any feeding (hazard ratio [HR] 2.17; 95% CI: 1.34-3.50) and with exclusive oral feeding (HR 2.13; 95% CI: 1.31-3.45) compared with no feeding. Time to discharge from HFNC initiation was shorter for exclusive oral feeding versus not feeding (propensity weighted HR 1.97 [95% CI: 1.13-3.43]). Adverse events (one intubation, one aspiration pneumonia, one readmission) occurred in both groups.

LIMITATIONS

Assessment of feeding exposure did not account for quantity and duration.

DISCUSSION

Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those not fed. Feeding-related adverse events were rare regardless of the feeding method. Controlled prospective studies addressing residual confounding are needed to justify a change in the current practice.