Toward Safe Hospital Discharge: A Transitions in Care Curriculum for Medical Students

BACKGROUND  

Medical errors often occur when patients move between care settings. Physicians generally receive little formal education on improving patient care transitions.     

Impact of Participation in a Community-Based Intimate Partner Violence Prevention Program on Medical Students: A Multi-Center Study

Background  Physicians are generally poorly trained to recognize, treat or refer adolescents at risk for intimate partner violence (IPV). Participation in community programs may improve medical students’ knowledge, skills, and attitudes about IPV prevention. Objective  To determine whether the experience of serving as educators in a community-based adolescent IPV prevention program improves medical students’ knowledge, skills, and attitudes toward victims of IPV, beyond that of didactic training. Participants  One hundred and seventeen students attending 4 medical schools. Design  Students were randomly assigned to didactic training in adolescent IPV prevention with or without participation as educators in a community-based adolescent IPV prevention program. Students assigned to didactic training alone served as community educators after the study was completed. Measurement  Knowledge, self-assessment of skills and attitudes about intimate partner violence and future plans to pursue outreach work. Results  The baseline mean knowledge score of 10.25 improved to 21.64 after didactic training (p ≤ .001). Medical students in the “didactic plus outreach” group demonstrated higher levels of confidence in their ability to address issues of intimate partner violence, (mean = 41.91) than did students in the “didactic only” group (mean = 38.94) after controlling for initial levels of confidence (p ≤ .002). Conclusions  Experience as educators in a community-based program to prevent adolescent IPV improved medical students’ confidence and attitudes in recognizing and taking action in situations of adolescent IPV, whereas participation in didactic training alone significantly improved students’ knowledge. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. At the time of this study, Dr. Bigby and Dr. Miller were with the Harvard Medical School Center of Excellence in Women’s Health.     

Collaborative Medical Engagement and Needs Assessment in the Democratic Republic of the Congo: A Preliminary Report from Muanda

The Democratic Republic of the Congo is the second largest and fourth most populous country in Africa. More than two decades of ongoing conflicts have degraded its healthcare system. A broad range of tropical diseases, along with opportunities for collaborative medical engagements (CMEs), are prevalent. However, reports from such events in this country are sparse. In June 2013, a CME was conducted in the western town of Muanda. Twenty-two hours of didactic sessions were collaboratively presented, and 158 patients were collaboratively evaluated. Durable dental and respiratory equipment, infrastructure improvements, and training opportunities were the top needs identified by the providers. Whether the regional referral hospital received sustainable benefit remains under investigation. However, the approach and needs assessment described herein provide a framework for future engagements or assistance. This CME established a precedence of medical partnership in the region because it led to the largest multidisciplinary joint collaboration in the history of the Democratic Republic of the Congo.With a population of more than 65 million persons, the Democratic Republic of the Congo is the fourth most populous nation in Africa and nineteenth most populous nation in the world. It is the second largest country in Africa and eleventh largest in the world, but a lack of infrastructure, including roads, makes travel throughout the country difficult.¹ For much of the past two decades, this country has been torn by conflict. The Second Congo War left almost six million people dead in one of the most violent conflicts in the world and prompted security sector reform and professionalization of the military in the Democratic Republic of the Congo.² Even today, conflicts continue in the eastern provinces of the country.³As in all nascent states engaged in or recovering from conflict, access to healthcare had been limited throughout the Democratic Republic of the Congo in areas free from conflict, as well as those still engaged in it.^3,4 These fragile states are often far from achieving health-related Millennium Development Goals, and improving health in these settings is a high priority.^5,6 This effort often requires a combination of relief and health system strengthening from governmental and non-governmental partners. To direct relief in a timely and relevant manner, needs assessments must be performed before any decision to provide aid had been made. However, in these unstable states, needs assessments are often difficult to complete.⁵Opportunities in the Democratic Republic of the Congo for assistance and collaborative engagement are plentiful, but because of difficulties inherent in performing these engagements, data and reports from such are sparse. In June 2013, we conducted a collaborative medical engagement (CME) type event outside the western town of Muanda. Muanda was chosen because, compared with Kinshasha or eastern Democratic Republic of the Congo, it provided a low risk/high yield opportunity because of its stability and positive relationship with the United States. Muanda is also the location of a multi-disciplinary training center.Details of the CME model have been described.⁶ That same three-part approach was followed here. In brief, initial meet-and-greet planning sessions, during which mutual objectives and capabilities were discussed, were followed by collaborative patient evaluations and consultations, and then by bi-lateral didactic sessions. Topics for the didactic sessions were derived from the expressed desires of the Congolese and U.S. participants and from suggestions by local Congolese leaders. The U.S. medical team included adult and pediatric infectious diseases specialists, a preventive medicine physician, a public health nurse, and a clinical laboratory officer. In addition, six senior physicians of the Forces Armées de la République Démocratique du Congo (Armed Forces of the Democratic Republic of the Congo) traveled from the capital of Kinshasa to participate. The objectives of the CME were to foster relations between U.S. and Democratic Republic of the Congo partners, to demonstrate the potential value of future engagements, and to conduct a preliminary needs assessment.The CME was held at Kitona Military Referral Hospital, which functions as a 200-bed tertiary care center for the Ministry of Defense Health Zone of Kitona and the Rural Health Zone of Kitona, one of the few locations where the military hospital serves as a health zone center. The hospital is usually staffed by six Forces Armées de la République Démocratique du Congo physicians and four post-doctoral civilian physicians seeking advanced training. There are a total of 50 nurses of varying levels of training. There were also three Congolese clinical laboratory officers, one pharmacist, one radiographic technician, one physical therapist, and a dentist.The structure of the healthcare system in the Democratic Republic of the Congo is three tiered: national, provincial, and operational levels. Policy and benchmarks are established at the national level, and the provincial level functions as an intermediary between the national and operational levels, somewhat akin to state health departments in the United States. The operational level contains zones, which correspond to a territory covered by a referral hospital and approximately 10–15 referring primary healthcare centers. Kitona Rural Health Zone, 1 of 6 military health zones and 1 of 515 operational health zones, consists of a population of 90,024 persons in an area of 180 km². This health zone is further divided into six health areas: four military areas (Banana, Baki-Ville, Troupe, and Camp Permanent) and two civilian (Nteva and Kibamba) areas.In addition to clinical and academic activities, health statistics for the hospital and the Kitona Health Zone were obtained from briefs and presentations by hospital leaders and specialty staff. Throughout Kitona Health Zone, there were 28,594 patients with malaria in 2012, which was 24.9% of the population of the health zone. Eighty-one cases resulted in death. There were also 139 new cases of tuberculosis, of which 36 were co-infected with human immunodeficiency virus (HIV). The Military Referral Hospital of Kitona has been offering HIV counseling and testing since August 2005. Since that time, 9,280 patients have been counseled and screened, and 1,606 (17% of the screened population) patients were positive for HIV. A total of 631 patients were given anti-retroviral therapy in during that time. Overall, the prevalence of HIV in the Kitona Health Zone is estimated to be 1.8%.In February 2013, the Kitona Health Zone saw the end of a cholera epidemic that lasted 12 months; there were 226 patients and 4 deaths. Leaders and administrators at the hospital credit strict attention to hygiene and aggressive resuscitation protocols. There were confirmed outbreaks of infection with Ebola virus, yellow fever, human monkey pox, and measles in other parts of the Democratic Republic of the Congo, but no cases were reported in this health zone.⁷ During the CME, the U.S. team and the Congolese health care providers evaluated 158 patients (81 male and 77 female) side by side as co-attending physicians. Most patients had infection-related disorders. The top ten presumptive diagnoses were malaria, upper and lower urinary tract infection, intestinal parasites, influenza, tuberculosis, HIV/acquired immunodeficiency syndrome (AIDS), meningitis, diarrheal/dysentery disorders, constipation, and dyspepsia.Throughout the engagement, the U.S. team conducted needs assessments by asking every available physician and healthcare worker what they identified as the top three needs for the hospital. At least half of the 65 staff members and nearly every physician were available for interview and responded. Responses to the needs assessment varied and can be broken into categories of equipment, training, and infrastructure. Equipment needs included nebulizers, updated ultrasound and x-ray machines, a computed tomography scanner, better beds, stethoscopes for the providers, more books for the medical library, a new dental chair, tools, cameras, educational materials, and hemoculture. Training needs identified include opportunities to train abroad, and how to maintain and repair existing equipment, and better training was stated by many without specific ideas of how to go about providing this training. Finally, infrastructure needs identified included stable electricity, generators, running water, computers with internet access, increased laboratory capabilities, and more frequent insecticide treatment on the hospital grounds.During the CME, there were academic sessions, which included lectures from U.S. and Congolese medical personnel. This was preferred over a model in which the U.S. team gave all presentations because it enabled the national directors of the HIV/AIDS, malaria, and tuberculosis programs to ensure that the medical staff of Kitona was aware of these national programs, which helped them achieve compliance. It also enabled the staff in Kitona to demonstrate their experiences and difficulties with these diseases and programs, as well as to present their recent experience and final data from the cholera outbreak that ended in February 2013. Other topics included antimicrobial stewardship, best laboratory practices, measles, wound infections, and medical dispositioning of military service members who are HIV positive. The length of the CME was seven days, although some U.S. team members were in the area more than two weeks (EH), and others live there permanently (MM and EAO). A notable strength of this exercise was the collaboration between the U.S. and Congolese, thereby meeting the diplomatic guidance and overarching goal of doing things with African partners instead of for them (Entwistle JF, Embassy of the United States Kinshasha, 2013, unpublished data).At this time, the follow-up period is not sufficient to determine if the public health and infectious disease capabilities of the Referral Hospital of Kitona have been sustainably improved, but the needs assessment provides a guide for future engagements, donations of supplies, and other aid to help achieve this objective. Through the participation of the senior-level Congolese medical officers and regional program directors, the medical staff at Muanda and Kitona received updates on their programs for HIV/AIDS, malaria, and tuberculosis. Discussions were immediately undertaken among staff and directors to correct identified deficiencies in those programs. Finally, the CME appeared to foster good working relationships between the U.S. and Congolese because further engagements between the two countries are in planning and underway. It is unlikely that a traditional unidirectional donation and assistance type mission, where primary medical care was provided without further education, training, or needs assessments, would have achieved these same objectives.The Muanda CME established a precedence of medical engagement that has led to the development of the first U.S. interagency, joint, multidisciplinary engagement in the history of the United States and the Democratic Republic of the Congo. The fact that such a complex follow-on event could be coordinated and linked to the CME in such a short period suggests that the CME and needs assessment performed therein were successful.     

A Needs Assessment: Infection Control Practices in Home Healthcare and Current Standards of Care

ISSUE: There is little research evidence on infection control practices in home healthcare agencies. Clinical guidelines set for acute- and long-term-care institutions have been used to “bridge the gap” to the home-care setting. Very little research evidence exists regarding the use of supplies for wound care and best practices in the home-care setting.PROJECT: A needs assessment was conducted to assess both the extent of the problem of wound care supplies in the home and the microbiological impact on patients with special emphasis placed on the presence of multidrug-resistant organisms. Items that the home-care nurses take from home to home as possible sources of fomites were examined, especially when multidrug-resistant organisms from institutions have been identified.RESULTS: Clearly, the needs assessment established that the extent of the problem of wound care supplies in the home, and guidelines for the treatment of wound infections in the home, require more research. The one research study done on bacterial contamination and wound care supplies found that bacteria were present in 75% of all wound care supplies left in homes for 7 days or more. Further research is necessary in this area to provide agencies with sound scientific data and to serve as guidelines for the development of evidence-based policies and procedures.LESSONS LEARNED: A tool for the quantification of the living conditions of the home-healthcare patients must be generated. Strong evidence can be provided for cause-and-effect relationships, with control of potential bias in the measurement of predictor variables.     

A Prospective Evaluation of Discharge Efficiency in a University General Medical Unit

To determine whether a significant delay existed between the date when patients admitted to the University General Medical Unit (UGMU) at Princess Alexandra Hospital were considered to be medically fit for discharge, and the date of actual discharge from the ward, we undertook a prospective evaluation of all general medical patients admitted under the care of the UGMU physicians during the period 1 August to 31 October 1995 inclusive. A delay in discharge from the ward of more than one day occurred in 31.1% of patients, with the total number of days attributed to discharge delays representing 17% of all bed days. The two major causes of delays in discharge identified were insufficient institutional care beds and failure to plan patient discharges. Strategies proposed to improve discharge efficiency include early discharge planning, the provision of interim care wards and in the longer term, the provision of increased nursing home and hostel beds.     

Pending Studies at Hospital Discharge: A Pre-post Analysis of an Electronic Medical Record Tool to Improve Communication at Hospital Discharge

Background

Achieving safe transitions of care at hospital discharge requires accurate and timely communication. Both the presence of and follow-up plan for diagnostic studies that are pending at hospital discharge are expected to be accurately conveyed during these transitions, but this remains a challenge.

Objective

To determine the prevalence, characteristics, and communication of studies pending at hospital discharge before and after the implementation of an electronic medical record (EMR) tool that automatically generates a list of pending studies.

Design

Pre-post analysis.

Patients

260 consecutive patients discharged from inpatient general medicine services from July to August 2013.

Intervention

Development of an EMR-based tool that automatically generates a list of studies pending at discharge.

Main Measures

The main outcomes were prevalence and characteristics of pending studies and communication of studies pending at hospital discharge. We also surveyed internal medicine house staff on their attitudes about communication of pending studies.

Key Results

Pre-intervention, 70 % of patients had at least one pending study at discharge, but only 18 % of these were communicated in the discharge summary. Most studies were microbiology cultures (68 %), laboratory studies (16 %), or microbiology serologies (10 %). The majority of study results were ultimately normal (83 %), but 9 % were newly abnormal. Post-intervention, communication of studies pending increased to 43 % (p < 0.001).

Conclusions

Most patients are discharged from the hospital with pending studies, but in usual practice, the presence of these studies has rarely been communicated to outpatient providers in the discharge summary. Communication significantly increased with the implementation of an EMR-based tool that automatically generated a list of pending studies from the EMR and allowed users to import this list into the discharge summary. This is the first study to our knowledge to introduce an automated EMR-based tool to communicate pending studies.KEY WORDS: Applied informatics, Care transitions, Electronic health records, Continuity of care, Health information technology, Hospital medicine, Medical informatics, Patient safety, Quality improvement, Communication     

Against Medical Advice Discharge: A Narrative Review and Recommendations for a Systematic Approach

Approximately 1%-2% of hospitalizations in the United States result in an against medical advice discharge. Still, the practice of discharging patients against medical advice is highly subjective and variable. Discharges against medical advice are associated with physician distress, patient stigma, and adverse outcomes, including increased morbidity and mortality. This review summarizes discharge against medical advice research, proposes a definition for against medical advice discharge, and recommends a standard approach to a patient's request for discharge against medical advice.     

Teaching Geriatric Fellows How to Teach: A Needs Assessment Targeting Geriatrics Fellowship Program Directors

The entire healthcare workforce needs to be educated to better care for older adults. The purpose of this study was to determine whether fellows are being trained to teach, to assess the attitudes of fellowship directors toward training fellows to be teachers, and to understand how to facilitate this type of training for fellows. A nine‐question survey adapted from a 2001 survey issued to residency program directors inquiring about residents‐as‐teachers curricula was developed and administered. The survey was issued electronically and sent out three times over a 6‐week period. Of 144 ACGME‐accredited geriatric fellowship directors from geriatric, internal medicine, and family medicine departments who were e‐mailed the survey, 101 (70%) responded; 75% had an academic affiliation, 15% had a community affiliation, and 10% did not report. Academic and community programs required their fellows to teach, but just 55% of academic and 29% of community programs offered teaching skills instruction as part of their fellowship curriculum; 67% of academic programs and 79% of community programs felt that their fellows would benefit from more teaching skill instruction. Program directors listed fellow (39%) and faculty (46%) time constraints as obstacles to creation and implementation of a teaching curriculum. The majority of fellowship directors believe that it is important for geriatric fellows to become competent educators, but only approximately half of programs currently provide formal instruction in teaching skills. A reproducible, accessible curriculum on teaching to teach that includes a rigorous evaluation component should be created for geriatrics fellowship programs.     

Medical Care Needs of Returning Veterans with PTSD: Their Other Burden

BACKGROUND  

There has been considerable focus on the burden of mental illness (including post-traumatic stress disorder, PTSD) in returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, but little attention to the burden of medical illness in those with PTSD.     

Utilizing a Meals on Wheels Program to Teach Falls Risk Assessment to Medical Students

Falls are a critical public health issue for older adults, and falls risk assessment is an expected competency for medical students. The aim of this study was to design an innovative method to teach falls risk assessment using community-based resources and limited geriatrics faculty. The authors developed a Fall Prevention Program through a partnership with Meals-on-Wheels (MOW). A 3rd-year medical student accompanies a MOW client services associate to a client’s home and performs a falls risk assessment including history of falls, fear of falling, medication review, visual acuity, a Get Up and Go test, a Mini-Cog, and a home safety evaluation, reviewed in a small group session with a faculty member. During the 2010 academic year, 110 students completed the in-home falls risk assessment, rating it highly. One year later, 63 students voluntarily completed a retrospective pre/postsurvey, and the proportion of students reporting moderate to very high confidence in performing falls risk assessments increased from 30.6% to 87.3% (p < .001). Students also reported using most of the skills learned in subsequent clerkships. A single educational intervention in the MOW program effectively addressed geriatrics competencies with minimal faculty effort and could be adopted by many medical schools.     

Use of a Geriatric Home Visit Experience to Teach Medical Students the Functional Status Assessment

INTRODUCTION  Functional status measures strongly predict hospital outcomes and mortality, yet teaching of these measures is often missing from medical schools’ curricula. To address this deficiency, we developed a Geriatric Home-based Assessment (GHA) module for third-year medical students. The module was composed of a workshop and two to three home visits. OBJECTIVE  To determine whether the GHA module would improve students’ knowledge and proficiency in the functional status assessment. PROGRAM EVALUATION  Students completed a validated questionnaire and evaluated a standardized patient in an Observed Structured Clinical Examination (OSCE). Scores from students completing the GHA were compared to the scores of students without this experience. RESULTS  Thirty-one students participated in the GHA module, and 19 students were in the control group. The mean score on the written assessment was 87% among GHA students vs. 46% in the control group (p < 0.001). The mean clinical examination score of the intervention group was also better than that of the control group (76% vs. 46%, p < 0.001). CONCLUSIONS  Our GHA module was effective in improving students’ knowledge and proficiency in the functional status assessment. “Hands on” experiences like the GHA allow students to develop a solid foundation for assessing functional status and mobility.     

A Comprehensive Needs Assessment Tool for Planning RHD Control Programs in Limited Resource Settings

Rheumatic heart disease (RHD) is an important cause of disability and death in low- and middle-income countries. However, evidence-based interventions have not been implemented systematically in many countries. We present a RHD Needs Assessment Tool (NAT) that can be used at country or regional levels to systematically develop and plan comprehensive RHD control programs and to provide baseline data for program monitoring and evaluation. The RHD NAT follows a mixed-methods approach using quantitative and qualitative data collection instruments. Evidence is mapped to a conceptual model that follows a patient through the natural history of RHD. The NAT has 4 phases: 1) situational assessment; 2) facility-based assessment of epidemiology and health system capacity; 3) patient and provider experience of RHD using ethnographic methods; and 4) intervention planning, including stakeholder mapping and development of a monitoring and evaluation framework. The RHD NAT is designed to paint a comprehensive picture of RHD care in an endemic setting and to identify the major gaps to disseminating and implementing evidence-based interventions.