Using simulation-based interprofessional education to change attitudes towards collaboration among higher specialty trainee physicians and registered nurses: a mixed methods pilot study.

Interprofessional collaboration (IPC) is important for delivering safe patient care and can be enhanced through interprofessional education (IPE). In postgraduate medical education, the most effective model for delivering IPE remains unclear. A multi-site non-randomized mixed methods study was undertaken to investigate the effectiveness of a simulation-based IPE (SB-IPE) intervention on changing attitudes among higher specialty trainee (HST) physicians in general internal medicine and registered nurses (RNs). The intervention, underpinned by intergroup contact theory, is comprised of paired participants (HSTs:RNs) undertaking six simulated scenarios. The Jefferson Scale of Attitudes toward Interprofessional Collaboration (JeffSATIC) was administered pre-and-post intervention. Focus groups were conducted to explore participants' perceptions of IPC and the SB-IPE intervention. Fifty-six participants attended the SB-IPE intervention and 37 completed focus group interviews. Overall, attitudes toward IPC changed positively (p < .001), with greater change among HSTs (p = .001) compared to RNs (p = .12). Attitudes to "working relationships" significantly increased for HSTs (p < .001) but not RNs (p = .047). Focus group analysis identified three processes by which SB-IPE led to attitudinal change: 1) Shared vulnerability, 2) Positive affirmation, and 3) Negotiating professional hierarchies, mainly through relationship building. Further research is needed to investigate the long-term impact of attitudinal change, including the extent to which benefits transfer into practice.

Use of an educational, audiovisual podcast to maximise safety with variable rate intravenous insulin infusions.

Variable rate intravenous insulin infusions (VRIII) are used to maintain stable blood glucose in hospitalised patients with diabetes who are unable to eat or have a severe illness where good glycaemic control is paramount. With VRIII it is important to prescribe an adequate substrate to avoid hypoglycaemia and maintain electrolyte balance. Traditionally the substrate would have been varied to achieve this; current guidelines advise varying the infusion rate rather than the type of substrate. The local hospital Trust updated their VRIII prescription chart to reflect the Joint British Diabetes Societies' suggestions for inpatient care in October 2014. A local audit in January 2015 highlighted that 48% of patients on VRIII were prescribed the correct fluid as per the guideline. A questionnaire to assess prescriber knowledge regarding VRIII showed 40.4% of prescribers selected appropriate fluid for a patient with normal renal function and 11.5% of prescribers selected appropriate fluid for a patient with renal failure. An educational podcast was devised to explain the rationale behind appropriate fluid prescription with VRIII; this was shown to prescribers. Following the podcast, 75.8% of prescribers selected appropriate fluids for normal renal function and 54.5% for renal failure. Questionnaires were completed to assess prescriber knowledge prepodcast and postpodcast. Following the podcast, there was a significant increase in questionnaire scores, indicating improved prescriber knowledge surrounding VRIII. A reaudit of prescriptions for VRIII showed improvement in practice, where 63% of patients on VRIII were prescribed correct fluids. The use of a simple audiovisual podcast on VRIII led to a significant improvement in prescriber knowledge. Podcasts are an ideal medium to raise awareness around safety issues, including safe prescription of insulin. Further work will include the follow-up of participants to evaluate sustained knowledge and improvements of prescriptions in practice, with the overall aim of improving patient safety.

A qualitative evaluation of the role of simulation in policy development for service improvement.

Objective: To evaluate the efficacy of simulation-based techniques to prospectively assess developing polices prior to implementation. Methods: A self-selected sample of nursing staff from a local, acute hospital reviewed a draft intravenous drug administration policy before simulating drug administration of either an infusion or direct injection. The participants completed a postsimulation questionnaire regarding the new policy and simulation, took part in a semistructured interview and were observed during the simulation with their consent. Results: 10 staff attended the simulation. The emergent themes identified a wide range of factors relating to the everyday usability and practicalities of the policy. There were issues surrounding inconsistent language between different clinical teams and training requirements for the new policy. Conclusion: Simulation, using simple scenarios, allows the safe evaluation of new policies before publication to ensure they are appropriate for front-line use. It engages staff in user-centred design in their own healthcare system.

Gentamicin-associated acute kidney injury.

BACKGROUND: The incidence of gentamicin-associated acute kidney injury (AKI) as defined by the RIFLE criteria is unknown. AIM AND DESIGN: We performed a retrospective observational study to examine this and the predictive value of RIFLE stage on patient outcome in this setting. METHODS: We included all patients who were treated with gentamicin at our centre over a 1-month period. Data on 228 patients across all specialities were collected by manual searching of hospital notes and electronic pathology reporting systems. Information collected included baseline and peak serum creatinine results, gentamicin dose and serum levels, the presence of additional renal insults and the Stoke co-morbidity index. RESULTS: AKI occurred in 51 (24.4%) patients; 37 (17.7%) 'Risk', 9 (4.3%) 'Injury', 5 (2.4%) 'Failure'. Independent predictors of gentamicin associated AKI were number of gentamicin levels >2 mg/l (OR 1.845, 95% CI 1.22 to 2.79) and higher baseline serum creatinine (OR 1.014, 95% CI 1.001-1.028). There was a greatly increased risk of in-hospital mortality in the AKI group as compared to those without AKI (45.1% vs. 19.1%, OR 3.48, 95% CI 1.8-6.9, P = 0.0004). Risk of in hospital mortality increased with each RIFLE stage (P < 0.0001). CONCLUSION: This study shows that gentamicin-associated AKI remains a common and potentially serious clinical problem. There is a strong correlation between RIFLE class and in-hospital mortality.