Reducing Time to Antibiotic Administration for Febrile Neutropenia in the Emergency Department.

PURPOSE: Febrile neutropenia (FN) is an oncologic emergency, and prolonged time to antibiotic administration (TTA) is associated with increased hospital length of stay (LOS) and worse outcomes. We hypothesized that a febrile neutropenia pathway (FNP) quality initiative project would reduce TTA delays for febrile patients with cancer presenting to the emergency department (ED). METHODS: This prospective study compared ED FNP patients (> 18 years old), between June 2012 and June 2013 with both historical and direct admissions (DA) cohorts at a multispecialty academic center. Interventions included providing patients with FN-Alert cards, standardizing the definition of FN and recognizing it as a distinct chief complaint, revising ED triage level for FN, creating electronic FN order sets, administering empiric antibiotics before neutrophil count result, and relocating FN antibiotics to the ED. The primary outcome was TTA, with a target goal of 90 minutes after ED presentation. RESULTS: In total, 276 FN episodes in 223 FNP patients occurred over the 12-month study period and were compared with 107 episodes in 87 patients and 114 episodes in 101 patients in the historical and DA cohorts, respectively. Use of the FNP reduced TTA from 235 and 169 minutes in historical and DA cohorts, respectively, to 81 minutes, and from 96 to 68 minutes when the order set was not used versus used in the FNP group (P < .001 for all comparisons). Decrease in hospital LOS was not statistically significant. CONCLUSION: The ED FNP is a significant quality initiative with sustainable interventions, and was able to demonstrate value by decreasing TTA compared to both historical and DA controls in cancer patients presenting to the ED.

Enhancing the hospice curriculum within the family medicine clerkship.

BACKGROUND: Medical schools are improving end-of-life (EOL) care curricula; however, students rarely practice EOL communication skills in a safe learning environment. OBJECTIVE: Our objective was to study which curriculum improves students' ability to discuss hospice care. METHODS: We conducted a study of six family medicine clerkship blocks; three taught with a didactic curriculum (A) and three with an interactive curriculum (B). RESULTS: Students reported improvement in their skill and comfort in discussing hospice care in both groups. Subjectively more students commented on the instructiveness of curriculum B due to role-plays. CONCLUSION: A variety of curricular methods helped students' confidence and self-reflection around hospice discussions in a comfortable environment.

Perspectives on confidential care for adolescent girls.

PURPOSE: We wanted to obtain perspectives of mothers and daughters on facilitators of and barriers to with adolescent girls' timely access to risk-appropriate reproductive care. METHODS: We conducted 5 separate focus groups with Latina and black mothers and their adolescent daughters. All participants resided in impoverished neighborhoods of New York City. Participants addressed mothers' roles in helping girls initiate gynecologic care, perceived role of physicians in daughters' sexual health, including the provision of confidential care, and perceived need for girls' gynecologic care. Data were analyzed using qualitative data analysis methods. RESULTS: Mothers see themselves as their daughters' primary protectors against daughters' poor reproductive outcomes. Many believe that confidential care promotes risky behavior and undermines mothers' efforts to protect girls. Mothers endorse facilitating gynecologic care and entering alliances with physicians but see the need for care as arising only after girls' sexual debut. Unfortunately, maternal awareness of sexual activity is low. Adolescent girls express considerable discomfort around reproductive health care and negotiating maternal involvement, and they fear breaches in confidentiality. CONCLUSIONS: A lack of trust in health care clinicians and the mother's gatekeeper role are key barriers to girls' transition to reproductive care. Consistently including a confidential component to health care visits in early adolescence, with preparation for both mothers and daughters, may reduce the distrust and discomfort.

Teaching clinical skills through videotape review: a randomized trial of group versus individual reviews.

BACKGROUND: Video review is a valuable educational tool for teaching communication skills. Many studies have demonstrated its efficacy with individual learners, but few studies have addressed its use in a group format. PURPOSE: To assess the educational benefits of group versus individual video review of standardized patient encounters through the evaluations of 4th-year students at the Albert Einstein College of Medicine. METHODS: Students (128) who participated in a 7-station, standardized patient, clinical competency exam were randomly assigned to an individual or small group video review of selected segments of these encounters in 2000-2001. Students filled out an anonymous 13-item questionnaire assessing the experience and provided open-ended responses. RESULTS: With both review formats, most students had a positive learning experience (80%), found it less stressful than they expected (67%), and would not have preferred to do the review the other way (84%). Students randomized to individual reviews had a significantly higher level of satisfaction with the amount of time for the session (91% vs. 78%, p < .05) and the amount of feedback they received (95% vs. 79%, p = .01) and were more likely to view the session as a positive learning experience (88% vs. 73%, p < .05). Students in the individual review format were more likely to choose self-assessed weak segments (63% vs. 49%, p = .01). Students' comments indicated that they appreciated the value of peer review in a group setting. CONCLUSIONS: Although both group reviews and individual reviews of videotaped standardized patient encounters were received well by the students, there were several statistical differences in favor of the individual format.

A new way to integrate clinically relevant technology into small-group teaching.

Medical educators need to teach learners to efficiently access the best available evidence at the point of care and apply it in a patient-centered manner. As information becomes more readily available via the Internet and handheld computers, strategies to use these tools as part of the educational process become more important. New teaching skills are needed when attempting to seamlessly introduce technology into small-group settings in the midst of blending old and new teaching methods. The authors' development of a conceptual model known as "e-microskills" at the University of Connecticut School of Medicine in 2002 has facilitated the smooth integration of technology into teaching. This model's cornerstone is direct empowerment of learners during small-group sessions to perform observed searches for the best medical evidence on the Internet and with handheld computer resources. This is done in the context of a mnemonic, PEARL: (1) Choose a "Preplanned search intervention"; (2) allow learners to "Execute the search," thus committing themselves; (3) "Allow learners to teach other learners" about their search process; (4) "Review the quality of evidence" for the information found; and (5) discuss "Lessons of the search." Additional features of this teaching model include ground rules for teaching with technology that optimizes teaching time by reducing anticipated obstacles. The rules add structure in an otherwise impromptu setting thus maximizing the teachable moment. While "e-microskills" are described here within the context of a third-year family medicine clerkship, they can easily be adapted to other small-group teaching settings.

Health care seeking among urban minority adolescent girls: the crisis at sexual debut.

PURPOSE: We wanted to explore the context of help seeking for reproductive and nonreproductive health concerns by urban adolescent girls. METHODS: We undertook a qualitative study using in-depth interviews of African American and Latina girls (n = 22) aged 13 to 19 years attending public high schools in the Bronx, NY. RESULTS: Before the onset of sexual activity, most girls meet health needs within the context of the family, relying heavily on mothers for health care and advice. Many new needs and concerns emerge at sexual debut. Key factors modulating girls' ability to address their health needs and concerns include (1) the strategy of selective disclosure of information perceived to be harmful to close family relationships or threaten privacy; (2) the desire for personalized care, modeled on the emotional and physical care received from mother; and (3) relationships with physicians that vary in quality, ranging from distant relationships focused on providing information to close continuity relationships. Core values shaping these processes include privacy, a close relationship with the mother, and a perception of sexual activity as dangerous. No girl was able to meet her specific reproductive health needs within the mother-daughter relationship. Some find nonmaternal sources of personalized health care and advice for reproductive health needs, but many do not. CONCLUSIONS: Adolescent girls attempt to meet reproductive health needs within a context shaped by values of privacy and close mother-daughter relationships. Difficulty balancing these values often results in inadequate support and care.

Assessing medical students' training in end-of-life communication: a survey of interns at one urban teaching hospital.

PURPOSE: Although interns are responsible for caring for dying patients, little is known about end-of-life education and training, including communication skills, in U.S. medical schools. This study of three consecutive cohorts of new interns assessed their perceptions of the amount and types of classroom and clinical instructional strategies used during medical school, their self-rated skill and comfort levels in different aspects of end-of-life communication, and the associations between these measures. METHOD: A self-administered questionnaire was given to three consecutive cohorts (1996-1998) of incoming interns (n = 162). Measures were self-reported amount and type of education and clinical experience with four end-of-life communication domains (giving bad news, discussing advance directives, discussing prognosis with the patient, and discussing with the patient's family) and self-perceived comfort and skill levels in relation to different types of end-of-life communication. RESULTS: A total of 157 interns completed the questionnaire. They reported very little classroom teaching, clinical observation, or clinical experience with end-of-life communication during medical school. They lacked comfort and skill in the end-of-life communication domains that were studied. More reported clinical observation and experience with caring for and communicating with dying patients was associated with greater perceived comfort and skill, while classroom teaching was not. CONCLUSIONS: These interns, mostly U.S. medical school graduates (98.7%, n = 155) reported little training and low self-perceived comfort and skill with important elements of end-of-life communication that might contribute to a lack of preparedness to address these issues during their internship. Further research that confirms and explains the underlying reasons for these findings seems warranted.