A Process of Acceptance of Patient Photographs in Electronic Medical Records to Confirm Patient Identification

Appropriate patient identification is a critical component of safe health care delivery. With increasing reliance on electronic medical records (EMRs), errors of test ordering and documentation have become commonplace. Incorporating patients’ photograph in the EMR has considerably decreased error frequency and improved health care delivery by making it easier for physicians to identify a patient. We conducted a survey of all 35 physicians working in the Executive Health Program to determine the importance of having patient photographs in the EMR. Of the 35 physicians who received the survey, 26 (74.3%) responded, 24 (92.3%) of whom agreed that it was important to improve patient identification, care, and safety. Based on these data, we implemented a quality improvement project to increase the percentage of new patients having a photograph included in the EMR. Our goal was to increase photograph inclusion by more than 20% from baseline within 6 months without any unintended consequences (ie, not slowing down any of the workflow during the intake process). The intervention took place between June 1, 2015, and February 8, 2016. Using Define-Measure-Analyze-Improve-Control models, the baseline rate of photographs in the EMR was 49.5% (302 of 607). We initiated 3 Plan-Do-Study-Act cycles targeting awareness and data sharing campaigns. After the Plan-Do-Study-Act cycles, the weekly rate of patient photographs incorporated into the EMR was at 71.4%, which was significantly improved compared with baseline (F test, P<.001). No unintended consequences were identified. Increased inclusion of patient photographs in the EMR aided in patient identification and improved staff satisfaction with minimal interruption to workflow.

Clinical pearls in perioperative medicine

At the 2001 annual meeting of the American College of Physicians (ACP), a new and innovative teaching format, the "Clinical Pearls" session, was introduced. Clinical Pearls sessions were designed to teach physicians using clinical cases. The session format involves specialty speakers presenting a number of short cases to a physician audience. Each case is followed by a multiple-choice question, answered by each attendee using an electronic audience-response system. After a summary of the answer distribution is shown, the correct answer is displayed and the speaker discusses important teaching points and clarifies why one answer is most clinically appropriate. Each case presentation ends with 1 or 2 "Clinical Pearls," defined as a practical teaching point, supported by the literature, and generally not well known to most internists. The Clinical Pearls sessions are consistently one the most popular and well attended sessions at the American College of Physicians' national meeting each year. Herein, we present the Clinical Pearls in Perioperative Medicine, presented at the ACP National Meeting in San Francisco, California, April 11-13, 2013.

Cancer effect on periprocedural thromboembolism and bleeding in anticoagulated patients

BACKGROUND

Patients with active cancer are often on chronic anticoagulation and frequently require interruption of this treatment for invasive procedures. The impact of cancer on periprocedural thromboembolism (TE) and major bleeding is not known.

PATIENTS AND METHODS

Two thousand one hundred and eighty-two consecutive patients referred for periprocedural anticoagulation (2484 procedures) using a standardized protocol were followed forward in time to estimate the 3-month incidence of TE, major bleeding and survival stratified by anticoagulation indication. For each indication, we tested active cancer and bridging heparin therapy as potential predictors of TE and major bleeding.

RESULTS

Compared with patients without cancer, active cancer patients (n=493) had more venous thromboembolism (VTE) complications (1.2% versus 0.2%; P=0.001), major bleeding (3.4% versus 1.7%; P=0.02) and reduced survival (95% versus 99%; P<0.001). Among active cancer patients, only those chronically anticoagulated for VTE had higher rates of periprocedural VTE (2% versus 0.16%; P=0.002) and major bleeding (3.7% versus 0.6%; P<0.001). Bridging with heparin increased the rate of major bleeding in cancer patients (5% versus 1%; P=0.03) without impacting the VTE rate (0.7% versus 1.4%, P=0.50).

CONCLUSIONS

Cancer patients anticoagulated for VTE experience higher rates of periprocedural VTE and major bleeding. Periprocedural anticoagulation for these patients requires particular attention to reduce these complications.

Perspective: a practical approach to defining professional practice gaps for continuing medical education

The Accreditation Council for Continuing Medical Education mandates that continuing medical education (CME) be developed around professional practice gaps. Accordingly, CME course directors must identify the intended learners, assess learners' needs, identify gaps in knowledge, and evaluate their CME activities. Writing gap statements is challenging for CME course directors because there is not a universally accepted format for writing these statements. The authors describe a practical approach to defining gaps for CME accreditation, which involves four steps indicated by the mnemonic LASO (learner, assessment, standard, outcomes): (1) define the learner population's characteristics, (2) create a learning needs assessment, (3) determine if the standard is met, and (4) state educational outcome for the CME activity. Based on this model, the difference between the practice standard and the current practice represents the gap in practice. The LASO approach has assisted in making CME content learner centered, relevant, and measurable at the authors' institution. The authors anticipate that LASO will be able to provide all CME course directors with a practical approach to defining educational gaps for CME accreditation.

A novel advance directives course provides a transformative learning experience for medical students

BACKGROUND

Inadequate physician training may be a barrier to physician-patient discussions of advance directives (ADs).

DESCRIPTION

The purpose of this study was to determine the effects of an ADs course, which includes completing a directive, on medical students' perceived knowledge of and preparedness for discussing ADs with patients. All 4th-year medical students completed a 10-hr bioethics course comprising interactive lecture and small-group discussion formats. Curriculum content included ethical and legal aspects of ADs. An 8-item survey with free-text entry was administered 1 month after course completion. Internal consistency reliability of survey scores was determined. Two authors independently coded the free-text comments and reached consensus on underlying themes.

EVALUATION

Of the 89 students who completed the survey (response rate 80%), 87 (98%) felt more knowledgeable and 88 (99%) better equipped to counsel patients about ADs. Forty-two (47%) reported they had counseled others to complete ADs during the month after the course. Internal consistency reliability of survey scores was very good (Cronbach's alpha =.78). Dominant themes of responses to the question, "What was the most eye opening, troubling, or difficult aspect about filling out your advance directive?" included difficulties articulating wishes, legal language, selecting a surrogate, and facing mortality.

CONCLUSIONS

These findings suggest an ADs course that includes completing a directive enhances medical students' empathy for and preparedness to discuss ADs with patients.

Periprocedural Anticoagulation Management of Patients With Venous Thromboembolism

Objective— Patients with venous thromboembolism (VTE) often require temporary warfarin interruption for an invasive procedure. The incidence of thromboembolism and bleeding related to periprocedural anticoagulation management of such patients is unknown.

Methods and Results— In a protocol-driven, inception cohort design study, all VTE patients (n=775) referred for periprocedural anticoagulation management (1997–2007) were followed-up to estimate the 3-month cumulative incidence of thromboembolism and bleeding. Patients were stratified by thrombus acuity (acute, <30 days; subacute, 31–90 days; or chronic ≥91 days). Decisions to provide “bridging” low-molecular-weight heparin were based on estimated thromboembolism and bleeding risk. Low-molecular-weight heparin was more often administered in acute (87%) and subacute (81%) VTE compared to chronic VTE (59%; P <0.001). The 3-month cumulative incidence of thromboembolism (1.8%), major hemorrhage (1.8%), and mortality (1.7%) were low and did not differ by management strategy. Active cancer was the only independent predictor of thrombotic recurrence (HR, 4.86; 95% CI, 1.6–14.5; P =0.005), major hemorrhage (HR, 6.8; 95% CI, 2.1–21.7; P =0.001), and death (HR, 32.7; 95% CI, 4.3–251.2; P =0.0008).

Conclusion— Thromboembolism, bleeding, and death among VTE patients in whom anticoagulation is temporarily interrupted for an invasive procedure is low. Cancer patients require particular care given their propensity for both clotting and bleeding.

Periprocedural anticoagulation management of patients with nonvalvular atrial fibrillation

OBJECTIVE

To estimate the 3-month cumulative incidence of thromboembolism (TE), bleeding, and death among consecutive patients with nonvalvular atrial fibrillation (AF) who were receiving long-term anticoagulation therapy and were referred to the Thrombophilia Center at Mayo Clinic for periprocedural anticoagulation management.

PATIENTS AND METHODS

In a prospective cohort study of consecutive patients receiving long-term anticoagulation therapy who were referred to the Thrombophilia Center for periprocedural anticoagulation management over the 7-year period, January 1, 1997, to December 31, 2003, 345 patients with nonvalvular AF were eligible for inclusion. Warfarin was stopped 4 to 5 days before and was restarted after surgery as soon as hemostasis was assured. The decision to provide bridging therapy with heparin was individualized and based on the estimated risks of TE and bleeding.

RESULTS

The 345 patients with AF (mean +/- SD age, 74+/-9 years; 33% women) underwent 386 procedures. Warfarin administration was not interrupted for 44 procedures. Periprocedural heparin was provided for 204 procedures. Patients receiving heparin were more likely to have prior TE (43% vs 24%; P<.001) and a higher CHADS2 (congestive heart failure, hypertension, age, diabetes, stroke) score (2.2 vs 1.9; P=.06). Four patients had 6 episodes of TE (3 strokes and 3 acute coronary episodes; TE rate, 1.1%; 95% confidence interval, 0.0%-2.1%). Nine patients had 10 major bleeding events (major bleeding rate, 2.7%; 95% confidence interval, 1.0%-4.4%). There were no deaths. Neither bleeding nor TE rates differed by anticoagulant management strategy.

CONCLUSION

The 3-month cumulative incidence of TE and bleeding among patients with AF in whom anticoagulation was temporarily interrupted for an invasive procedure was low and was not significantly influenced by bridging therapy.

Current status of medical grand rounds in departments of medicine at US medical schools

OBJECTIVE

To assess the status of medical grand rounds (MGR) as an educational endeavor.

METHODS

A survey of 133 departments of medicine at US medical schools was performed from September 2003 to March 2004; the results were compared with those of a previous (1988) survey.

RESULTS

Ninety-nine departments (74%) responded to the survey; all 99 conducted MGR. Providing updates in diagnosis, treatment, and medical research, educating house staff and faculty, and promoting collegiality were the most important objectives of MGR. Regarding objectives, responses to the current survey differed significantly from the responses to the 1988 survey for providing updates in medical research (P=.047), providing continuing medical education credit (P<.001), educating house staff (P=.048), and educating faculty (P<.001); the differences were primarily due to higher proportions of current survey respondents rating these objectives as "quite" or "very" important. The most common format was the didactic lecture. Case presentations were uncommonly used, and patients were rarely present. Only 44% of departments used educational needs assessments, and only 13% assessed knowledge gained by attendees. Feedback was irregularly provided to presenters. Most departments (64%) relied on industry to pay for MGR. Lack of presenter-attendee interaction and conflicting meetings were cited as Important challenges. Nevertheless, most (62%) of the current survey respondents thought the quality of MGR had increased.

CONCLUSIONS

Departments of medicine regard MGR as an important educational and social endeavor. However, most departments use suboptimal teaching, planning, and evaluation methods, and many rely on industry to pay for MGR. Addressing these concerns and other challenges may enhance the value of MGR.

Quality in the technical performance of screening flexible sigmoidoscopy: recommendations of an international multi-society task group

BACKGROUND

Flexible sigmoidoscopy (FS) is a complex technical procedure performed in a variety of settings, by examiners with diverse professional backgrounds, training, and experience. Potential variation in technical quality may have a profound impact on the effectiveness of FS on the early detection and prevention of colorectal cancer.

AIM

We propose a set of consensus and evidence based recommendations to assist the development of continuous quality improvement programmes around the delivery of FS for colorectal cancer screening.

RECOMMENDATIONS

These recommendations address the intervals between FS examinations, documentation of results, training of endoscopists, decision making around referral for colonoscopy, policies for antibiotic prophylaxis and management of anticoagulation, insertion of the FS endoscope, bowel preparation, complications, the use of non-physicians as FS endoscopists, and FS endoscope reprocessing. For each of these areas, continuous quality improvement targets are recommended, and research questions are proposed.