Interprofessional education clinical placement program: a qualitative case study approach

The goal of health professional education programs is to produce competent graduates, with an ability to work collaboratively as effective healthcare team members. We explored the reflections of students and clinical facilitators, in response to participation in a structured interprofessional education (IPE) clinical placement program. In our qualitative study we used an exploratory case study design. In our analysis, we highlight the benefits of interprofessional practice. Key themes identified by students included: limited opportunities to engage in IPE across their course; lack of clarity around IPE; value of IPE for students, practitioners, and patient outcomes; and need for IPE opportunities to be integrated into placements. Key themes identified by the clinical facilitators included: being reminded of the value of IPE for students and patients; preparation for IPE placements need to be embedded in curricula; coordination and communication of IPE learning activities need to be clear for staff and students; and IPE should continue as part of the broader clinical education agenda. Our findings reinforce the notion that students and clinical facilitators value the importance of IPE for student learning within the clinical placement setting. The outcomes offer valuable insights for universities and hospital and health care contexts for setting up and implementing IPE activities, and we provide recommendations for improving ongoing IPE efforts within clinical placement setting.

The effect of pharmacists on ward rounds measured by the STOPP/START tool in a specialized geriatric unit

WHAT IS KNOWN AND OBJECTIVE

The STOPP/START tool has been validated to assess elderly patients for potentially inappropriate prescribing. This study aimed to assess the effect of inclusion of a pharmacist on a physician-led ward round on potentially inappropriate prescribing in hospitalized elderly patients.

METHODS

This was an observational study of prescribing for patients using the STOPP/START tool at three points during hospital stay; admission to hospital, on transfer to the specialized geriatric unit and on discharge from hospital. Data were collected over 4 months pre- and post-introduction of a pharmacist to a physician-led ward round. Demographic and clinical data, including total number of medications and STOPP/START criteria met, were collected. The mean number of STOPP/START criteria at each time-point was compared for pre- and post-introduction of a pharmacist using a Mann-Whitney U-test. The mean number of criteria for each time-point within each group was compared using a paired Student's t-test.

RESULTS AND DISCUSSION

The demographic characteristics of the participants in the pre- and post-intervention groups were similar. The post-intervention group had numerically less STOPP/START criteria, mean 1·18 (1·37) compared to the pre-intervention group 1·50 (1·41), P = 0·07 at discharge. The pre-intervention group had no significant change in the criteria from admission 1·78 (1·57) to geriatric unit transfer 1·72 (1·54) (P = 0·37); however, there was a significant decrease from geriatric unit transfer 1·72 (1·54) to discharge 1·50 (1·41) (P = 0·02). The post-intervention group had a significant decrease from hospital admission 2·30 (1·91) to geriatric unit transfer 1·59 (1·60) (P < 0·01) and again to discharge 1·18 (1·37) (P < 0·01).

WHAT IS NEW AND CONCLUSION

Pharmacist participation on the ward round in a specialized geriatric unit resulted in a numerical improvement in prescribing quality as measured by the STOPP/START tool.

Do risk factors for lactic acidosis influence dosing of metformin?

BACKGROUND

Metformin is commonly prescribed to treat type 2 diabetes mellitus, however it is associated with the potentially lethal condition of lactic acidosis. Prescribing guidelines have been developed to minimize the risk of lactic acidosis development, although some suggest they are inappropriate and have created confusion amongst prescribers. The aim of this study was to investigate whether metformin dose was influenced by the presence of risk factors for lactic acidosis.

METHODS

The study was prospective, and retrieved information from patients admitted to hospital who were prescribed metformin at their time of admission.

RESULTS

Eighty-three patients were included in the study, 60 of whom had a least one risk factor for lactic acidosis. Of those 60 patients, 78.3% had a dose adjustment, with renal impairment, hepatic impairment, surgery and use of radiological contrast media--the risk factors most likely to result in a dose adjustment. When dose adjustments did occur, metformin was withheld on 88.7% of occasions.

CONCLUSION

Metformin dose was influenced by the presence of risk factors for lactic acidosis, although it was dependent upon the number and particular risk factor/s present.

Monitoring intraoperative effectiveness of caudal analgesia through skin temperature variation

BACKGROUND/PURPOSE

A reliable noninvasive intraoperative marker of caudal analgesia effectiveness remains elusive. Caudal analgesia causes sympathetic inhibition resulting in vasodilatation, increased blood flow, and a resultant increase in temperature in the affected dermatomes. The authors hypothesize that this change in temperature between the affected and unaffected dermatomes is measurable and may represent a noninvasive method of monitoring effectiveness of caudal analgesia.

METHODS

Children undergoing lower abdominal surgery participated in the caudal or noncaudal (control) analgesia arm of the study. After induction of general anesthesia, 0.25% bupivicaine (1 mL/kg) was infiltrated for a field block in control patients or a caudal block in the experimental group. Temperature was measured at the C4 and L2 dermatomes starting after induction and 5 minutes before the caudal or field block and every 5 minutes after. T(o) is defined as the difference between the C4 and L2. Delta T (DeltaT) is the temperature variation between T(o). A change in the DeltaT is defined by an increase in the L2 temperature.

RESULTS

Forty-six families enrolled (36 experimental, 10 control). The DeltaT for controls was 0.2+/-0.09 degrees C (SEM). Each child in the experimental group had 2 temperature measurements before the caudal with an average DeltaT of 0.3+/-0.07 degrees C (SEM), thus, were internal controls. A marked increase in DeltaT at 5 minutes 0.5+/-0.06 degrees C (SEM) and at 10 minutes 0.6+/-0.07 degrees C (SEM; P <.05) was noted in the experimental group.

CONCLUSION

A significant transient change in temperature is observed after caudal analgesia and maybe a noninvasive marker of effectiveness. Further study may clarify its clinical utility.

Myocardial infarction and type II diabetes--preferential treatment for high risk patients?

OBJECTIVES

To compare variability of blood glucose concentration in patients with type II diabetes with (cases) and without (controls) myocardial infarction. A secondary objective was identification of predictive factors for higher blood glucose on discharge from hospital.

DESIGN

A retrospective matched case-control study.

PARTICIPANTS

Medical notes of 101 type II diabetic patients admitted with a myocardial infarction (MI) and 101 type II diabetic patients (controls) matched on gender and age with no MI were reviewed. Blood glucose concentrations over two consecutive 48-h periods were collected. Demographic data and therapy on admission/discharge were also collected.

RESULTS

Patient characteristics were comparable on recruitment excluding family history of cardiovascular disease (P=0.003), dyslipidaemia (P=0.004) and previous history of MI (P=0.007). Variability of blood glucose in cases was greater over the first 48 h compared with the second 48 h (P=0.03), and greater when compared with controls over the first 48 h (P=0.01). Cases with blood glucose on discharge >8.2 mmol / L (n=45) were less likely to have a history of previous MI (P=0.04), ischaemic heart disease (P=0.03) or hypertension (P=0.02).

CONCLUSIONS

Type II diabetics with an MI have higher and more variable blood glucose concentrations during the first 48 h of admission. Only cardiovascular 'high risk' patients had target blood glucose set on discharge. The desirability of all MI patients with diabetes, having standardized-glucose infusions to reduce variability of blood glucose, should be evaluated in a randomized controlled trial.

Do anaemia co-ordinators have to be nurses?

The role of the anaemia co-ordinator has developed subsequent to the introduction of erythropoietin therapy for renal anaemia, and posts have been established at an increasing number of hospitals in the UK. While co-ordinators have previously tended to come from a nursing background, the post at our hospital has been held jointly by a pharmacist and a clinical nurse specialist since July 1997. This paper presents an informal evaluation of our experience of joint working, and has drawn on diary entries to outline the components of the service provided. The main focus is on the boundary negotiated between pharmacist and nurse responsibilities and expertise, involving as it does areas of potential conflict and complementarity. Through a critical examination of the assumptions and expectations associated with 'generic' pharmacist and nurse roles, we begin to clarify the respective contributions which the disciplines make to anaemia management.