Twelve tips for teaching quality improvement in the clinical environment.

Medical educators are expected to teach quality improvement (QI) skills alongside traditional clinical skills such as physical examination and bedside manner. Educational resources for intensive training in QI have proliferated. However, many physicians lack the time or resources to undergo this training, and may struggle with teaching these skills to their learners. In response, we offer twelve tips to help physicians teach basic QI concepts in the clinical environment. By following these tips physicians will be able to engage their learners interest in QI and provide experiential learning that makes a lasting impact.

Three hospital admissions in 9 days to diagnose azathioprine hypersensitivity in a patient with Crohn's disease.

Azathioprine (AZA) is commonly used as a steroid-sparing immunosuppressive medication for the treatment of immune-mediated disorders including Crohn's disease. There is ample awareness of the more common adverse effects of this drug, including myelosuppression and risk of malignancy. We present a case of a 57-year-old man with fistulizing Crohn's disease who underwent 3 hospital admissions for recurrent fever with an extensive work-up for infection before the diagnosis of AZA hypersensitivity was made. Clinicians should be vigilant for AZA hypersensitivity as a cause of otherwise unexplained fever. Furthermore, in patients with inflammatory bowel disease (IBD), the signs and symptoms of AZA hypersensitivity may overlap with typical findings of inflammatory bowel disease flare.

Outcomes in quality improvement and patient safety training: moving from in-person to synchronous distance education.

BACKGROUND: The COVID-19 pandemic necessitated increased synchronous distance education (SDE) in graduate medical education, presenting challenges for Quality Improvement and Patient Safety (QIPS) best practices, which call for integration with daily clinical care and investigation of real patient safety events. OBJECTIVE: To evaluate educational outcomes for QIPS training after conversion of a mature, in-person curriculum to SDE. METHODS: 68 postgraduate year (PGY)-1 residents were surveyed before and after the SDE Culture of Patient Safety training in June 2020, and 59 PGY-2s were administered the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) before and after the SDE QIPS seminar series in July-August 2020. Values before and after training were compared using sign tests for matched pairs (PGY-1) and Wilcoxon signed-rank tests (PGY-2). RESULTS: 100% (68 of 68) of PGY-1s and 46% (27 of 59) of PGY-2s completed precourse and postcourse surveys. Before the course, 55 PGY-1s (81%) strongly agreed that submitting patient safety event reports are a physician's responsibility, and 63 (93%) did so after (15% increase, p=0.004). For PGY-2s, the median composite QIKAT-R score was 17 (IQR 14.5-20) before and 22.5 (IQR 20-24.5) after the seminars, with a median difference of 4.5 (IQR 1.5-7), a 32% increase in QIPS competency (p=0.001). CONCLUSIONS: Patient safety attitudes and quality improvement knowledge increased after SDE QIPS training at comparable levels to previously published results for in-person training, supporting SDE use in future hybrid curricula to optimise educational value and reach.

Harnessing the Electronic Health Record to Actively Support Providers with Guideline-Directed Telemetry Use.

BACKGROUND: Overuse of cardiac telemetry monitoring (telemetry) can lead to alarm fatigue, discomfort for patients, and unnecessary medical costs. Currently there are evidence-based recommendations describing appropriate telemetry use, but many providers are unaware of these guidelines. OBJECTIVES: At our multihospital health system, our goal was to support providers in ordering telemetry on acute care in accordance with evidence-based guidelines and discontinuing telemetry when it was no longer medically indicated. METHODS: We implemented a multipronged electronic health record (EHR) intervention at two academic medical centers, including: (1) an order set requiring providers to choose an indication for telemetry with a recommended duration based on American Heart Association guidelines; (2) an EHR-generated reminder page to the primary provider recommending telemetry discontinuation once the guideline-recommended duration for telemetry is exceeded; and (3) documentation of telemetry interpretation by telemetry technicians in the notes section of the EHR. To determine the impact of the intervention, we compared number of telemetry orders actively discontinued prior to discharge and telemetry duration 1 year pre- to 1 year post-intervention on acute care medicine services. We evaluated sustainability at years 2 and 3. RESULTS: Implementation of the EHR initiative resulted in a statistically significant increase in active discontinuation of telemetry orders prior to discharge: 15% (63.4-78.7%) at one site and 13% at the other (64.1-77.4%) with greater improvements on resident teams. Fewer acute care medicine telemetry orders were placed on medicine services across the system (1,503-1,305) despite an increase in admissions and the average duration of telemetry decreased at both sites (62 to 47 hours, p < 0.001 and 73 to 60, p < 0.001, respectively). Improvements were sustained 2 and 3 years after intervention. CONCLUSION: Our study showed that a low-cost, multipart, EHR-based intervention with active provider engagement and no additional education can decrease telemetry usage on acute care medicine services.

Identification and characterization of genes involved in embryonic crystal cell formation during Drosophila hematopoiesis.

Parallels between vertebrate and Drosophila hematopoiesis add to the value of flies as a model organism to gain insights into blood development. The Drosophila hematopoietic system is composed of at least three classes of terminally differentiated blood cells: plasmatocytes, crystal cells, and lamellocytes. Recent studies have identified transcriptional and signaling pathways in Drosophila involving proteins similar to those seen in human blood development. To identify additional genes involved in Drosophila hematopoiesis, we have conducted a P-element-based genetic screen to isolate mutations that affect embryonic crystal cell development. Using a marker of terminally differentiated crystal cells, we screened 1040 P-element-lethal lines located on the second and third chromosomes and identified 44 individual lines that affect crystal cell development. Identifying novel genes and pathways involved in Drosophila hematopoiesis is likely to provide further insights into mammalian hematopoietic development and disorders.

A unique way to treat Goodpasture's disease.

A 21-year-old man with no medical history presented to the emergency department with fatigue, oliguria and lower extremity oedema. Initial laboratory tests showed that the patient was in acute renal failure with a creatinine of 12.8 mg/dL (normal 0.51-1.18 mg/dL). Further work up showed crescentic glomerulonephritis on renal biopsy, and serology was positive for antiglomerular basement antibody (titre 191 U/mL, normal 0-0.7 U/mL). Shortly after diagnosis he developed haemoptysis and chest imaging was consistent with pulmonary haemorrhage. The standard immunotherapy for Goodpasture's disease is cyclophosphamide, but due to known reproductive toxicities associated with cyclophosphamide and the patient's age, it was decided to use alternate but less studied therapies for treatment. At discharge, the patient had undergone five plasmapheresis treatments, had received two doses of Rituximab with a steroid taper, and his antiglomerular basement membrane level had decreased significantly.

MSSA brain abscess and pyomyositis presenting as brain tumour and DVT.

A 66-year-old man with a recent radiographic diagnosis of a parietal brain tumour presented with severe left thigh pain that prevented ambulation. On examination, his left anterior thigh was mildly swollen without erythema. Initial concern was for deep vein thrombosis in the setting of brain malignancy or necrotising soft tissue infection. Subsequent imaging and biopsies revealed methicillin sensitive Staphylococcus aureus (MSSA) pyomyositis of the left thigh and MSSA brain abscess.