Helping Residents Excel in Team-Based Care: An Interactive Case-Based Interprofessional Education Curriculum.

INTRODUCTION: Communication and collaboration with an interprofessional team is vital for patient care, yet teaching these skills to resident physicians faces multiple challenges. METHODS: We developed an interactive, case-based curriculum on interprofessional communication and collaboration and implemented it at a large Veterans Affairs hospital. A pre/post survey study design was used to evaluate the curriculum, with 31 residents completing both surveys (100% response rate). RESULTS: After the curriculum, there was improvement in the residents' knowledge, comfort, and satisfaction in communicating and collaborating with the interprofessional team. Satisfaction scores with clinic also improved in all measures. DISCUSSION/CONCLUSIONS: Overall, a curriculum aimed at teaching interprofessional communication and collaboration improved residents' comfort and satisfaction in this realm and may help them achieve competence in these challenging-to-teach skills.

The Missing Record of Mental Status in Written Sign-Outs.

OBJECTIVE: The aim of the study was to determine how frequently mental status and mental status changes are documented in the written patient summary ("sign-out") provided to covering physicians. PATIENTS AND METHODS: This was a retrospective cohort study of general medical patients hospitalized between March 16, 2009, and March 15, 2010, conducted at 2 teaching hospitals. Participants included patients with mental status change adverse events (MSAEs) and their providers. Chart review was performed to identify patients with MSAEs and details about these events. Sign-outs were reviewed for documentation of mental status. Main outcome measures were (1) proportion of patients with MSAEs who had mental status ever recorded in sign-out entries and (2) the proportion of patients with MSAEs whose change in mental status was recorded in the sign-out. RESULTS: Sixty-eight patients had MSAEs and were included in the sample. Fifty percent of MSAEs were attributed to medications; 75% of these events were first detected by nurses. Only 25% of patients with MSAEs had their change in mental status recorded in sign-outs. CONCLUSIONS: Recording mental status in written sign-outs is uncommon. Particularly concerning is that patients with MSAEs identified by chart review seldom had sign-outs that reflected those events. Interventions should be designed to increase the recording of this information in sign-outs.

Feedback to achieve improved sign-out technique.

To maximize the quality of sign-out documents within the internal medicine residency, a quality improvement intervention was developed and implemented. Written sign-outs were collected from general medicine ward teams and graded using an 11-point checklist; in-person feedback was then given directly to the ward teams. Documentation of many of the 11 elements improved: mental status (22% to 66%, P < .0001), decisionality (40% to 66%, P < .0001), lab/test results (63% to 69%, P < .0001), level of acuity (34% to 50%, P < .0001), anticipatory guidance (69% to 82%, P < .0001), and future plans (35% to 38%, P < .0005). The use of vague language declined (41% to 26%, P < .0001). The mean total scores improved from 7.0 to 8.2 out of a possible 11 (P < .0001). As new house staff rotated onto the services, improvement over time was sustained with 1 feedback session per team, per month. Similar interventions could be made in other programs and other institutions.

A Comparative Effectiveness Meta-Analysis of Drugs for the Prophylaxis of Migraine Headache.

OBJECTIVE: To compare the effectiveness and side effects of migraine prophylactic medications. DESIGN: We performed a network meta-analysis. Data were extracted independently in duplicate and quality was assessed using both the JADAD and Cochrane Risk of Bias instruments. Data were pooled and network meta-analysis performed using random effects models. DATA SOURCES: PUBMED, EMBASE, Cochrane Trial Registry, bibliography of retrieved articles through 18 May 2014. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included randomized controlled trials of adults with migraine headaches of at least 4 weeks in duration. RESULTS: Placebo controlled trials included alpha blockers (n = 9), angiotensin converting enzyme inhibitors (n = 3), angiotensin receptor blockers (n = 3), anticonvulsants (n = 32), beta-blockers (n = 39), calcium channel blockers (n = 12), flunarizine (n = 7), serotonin reuptake inhibitors (n = 6), serotonin norepinephrine reuptake inhibitors (n = 1) serotonin agonists (n = 9) and tricyclic antidepressants (n = 11). In addition there were 53 trials comparing different drugs. Drugs with at least 3 trials that were more effective than placebo for episodic migraines included amitriptyline (SMD: -1.2, 95% CI: -1.7 to -0.82), -flunarizine (-1.1 headaches/month (ha/month), 95% CI: -1.6 to -0.67), fluoxetine (SMD: -0.57, 95% CI: -0.97 to -0.17), metoprolol (-0.94 ha/month, 95% CI: -1.4 to -0.46), pizotifen (-0.43 ha/month, 95% CI: -0.6 to -0.21), propranolol (-1.3 ha/month, 95% CI: -2.0 to -0.62), topiramate (-1.1 ha/month, 95% CI: -1.9 to -0.73) and valproate (-1.5 ha/month, 95% CI: -2.1 to -0.8). Several effective drugs with less than 3 trials included: 3 ace inhibitors (enalapril, lisinopril, captopril), two angiotensin receptor blockers (candesartan, telmisartan), two anticonvulsants (lamotrigine, levetiracetam), and several beta-blockers (atenolol, bisoprolol, timolol). Network meta-analysis found amitriptyline to be better than several other medications including candesartan, fluoxetine, propranolol, topiramate and valproate and no different than atenolol, flunarizine, clomipramine or metoprolol. CONCLUSION: Several drugs good evidence supporting efficacy. There is weak evidence supporting amitriptyline's superiority over some drugs. Selection of prophylactic medication should be tailored according to patient preferences, characteristics and side effect profiles.