Prediction of post-acute care demand in medical and neurological inpatients: diagnostic assessment of the post-acute discharge score - a prospective cohort study.

BACKGROUND: Early identification of patients requiring transfer to post-acute care (PAC) facilities shortens hospital stays. With a focus on interprofessional assessment of biopsychosocial risk, this study's aim was to assess medical and neurological patients' post-acute care discharge (PACD) scores on days 1 and 3 after hospital admission regarding diagnostic accuracy and effectiveness as an early screening tool. The transfer to PAC facilities served as the outcome ("gold standard"). METHODS: In this prospective cohort study, registered at ClinicalTrial.gov (NCT01768494) on January 2013, 1432 medical and 464 neurological patients (total n = 1896) were included consecutively between February and October 2013. PACD scores and other relevant data were extracted from electronic records of patient admissions, hospital stays, and interviews at day 30 post-hospital admission. To gauge the scores' accuracy, we plotted receiver operating characteristic (ROC) curves, calculated area under the curve (AUC), and determined sensitivity and specificity at various cut-off levels. RESULTS: Medical patients' day 1 and day 3 PACD scores accurately predicted discharge to PAC facilities, with respective discriminating powers (AUC) of 0.77 and 0.82. With a PACD cut-off of ≥8 points, day 1 and 3 sensitivities were respectively 72.6% and 83.6%, with respective specificities of 66.5% and 70.0%. Neurological patients' scores showed lower accuracy both days: using the same cut-off, respective day 1 and day 3 AUCs were 0.68 and 0.78, sensitivities 41.4% and 68.7% and specificities 81.4% and 83.4%. CONCLUSION: PACD scores at days 1 and 3 accurately predicted transfer to PAC facilities, especially in medical patients on day 3. To confirm and refine these results, PACD scores' value to guide discharge planning interventions and subsequent impact on hospital stay warrants further investigation. TRIAL REGISTRATION: ClinialTrials.gov Identifier, NCT01768494 .

[Recent advances in internal medicine]. / Médecine interne générale: l'année 2017 en revue par les internistes hospitaliers.

In medicine, there are progresses which radically transform practices, change recommendations and win unanimous support in the medical community. There are some which divide, questioning principles that seemed established. There are also small advances, which can answer the questions that internists ask themselves in the daily care of their patients. Here are several articles published in 2017, read and commented for you by hospitalists, selected according to their impact on the medical world.

En médecine, il y a des découvertes qui révolutionnent les pratiques, changent les recommandations et rassemblent toute la communauté médicale. Il y en a qui divisent, en remettant en question des principes qui semblaient établis. Il y a aussi de petites avancées qui permettent de répondre aux questions que se posent les internistes dans la prise en charge quotidienne de leurs patients. Voici quelques articles parus en 2017, lus et commentés pour vous par des internistes hospitaliers et sélectionnés en fonction de leur retentissement dans le monde médical.

[Paracentesis and cirrhotic patients: should we fear hemorrhages ?] / Ponction d'ascite et patient cirrhotique : faut-il craindre les hémorragies ?

Paracentesis is a frequent procedure, especially in patients with cirrhosis. In these patients, given the fears of severe bleeding associated with coagulation disorders as well as thrombocytopenia, we were interested to review the literature on this subject. Few studies are available and, for the moment, recommendations are of a low level of evidence. Paracentesis seems to be a safe procedure without severe haemorrhagic complications (< 1%), regardless of coagulation disorders and platelet count. Renal insufficiency, Child-Pugh C cirrhosis, thrombocytes < 50 G/L and cirrhosis of alcoholic origin may however increase the risk of bleeding. Caution should be observed in these patients.

La ponction d'ascite est un geste fréquemment pratiqué, surtout chez des patients atteints de cirrhose. Chez ces patients, compte tenu des craintes d'hémorragies sévères, associées aux troubles de la coagulation ainsi qu'à la thrombopénie, nous avons été intéressés par une revue de la littérature sur ce sujet. Peu d'études ont été retrouvées et les recommandations sont, pour le moment, d'un faible niveau de preuve. La ponction d'ascite semble néanmoins être un geste sûr dont les complications hémorragiques sévères sont très rares (< 1 %) et indépendantes des troubles de la coagulation et du taux de plaquettes. Une insuffisance rénale, une cirrhose Child C, des thrombocytes < 50 G/l et une cirrhose d'origine alcoolique pourraient cependant augmenter le risque de saignement. La prudence reste de mise chez ces patients.

The quality of feedback during formative OSCEs depends on the tutors' profile.

BACKGROUND: During their pre-clinical years, medical students are given the opportunity to practice clinical skills with simulated patients. During these formative objective structured clinical encounters (OSCEs), tutors from various backgrounds give feedback on students' history taking, physical exam, and communication skills. The aim of the study was to evaluate whether the content and process of feedback varied according to the tutors' profile. METHODS: During 2013, all 2nd and 3rd year medical students and tutors involved in three formative OSCEs were asked to fill in questionnaires, and their feedback sessions were audiotaped. Tutors were divided into two groups: 1) generalists: primary care, general internist and educationalist physicians 2) specialists involved in the OSCE related to their field of expertise. Outcome measures included the students' perceptions of feedback quality and utility and objective assessment of feedback quality. RESULTS: Participants included 251 medical students and 38 tutors (22 generalists and 16 specialists). Students self-reported that feedback was useful to improve history taking, physical exam and communication skills. Objective assessment showed that feedback content essentially focused on history taking and physical exam skills, and that elaboration on clinical reasoning or communication/professionalism issues was uncommon. Multivariate analyses showed that generalist tutors used more learner-centered feedback skills than specialist tutors (stimulating student's self-assessment (p < .001; making the student active in finding solutions, p < .001; checking student's understanding, p < .001) and elaborated more on communication and professionalism issues (p < 0.001). Specialists reported less training in how to provide feedback than generalists. CONCLUSION: These findings suggest that generalist tutors are more learner-centered and pay more attention to communication and professionalism during feedback than specialist tutors. Such differences may be explained by differences in feedback training but also by differences in practice styles and frames of references that should be further explored.

Impact of postgraduate training on communication skills teaching: a controlled study.

BACKGROUND: Observation of performance followed by feedback is the key to good teaching of communication skills in clinical practice. The fact that it occurs rarely is probably due to clinical supervisors' perceived lack of competence to identify communication skills and give effective feedback. We evaluated the impact of a faculty development programme on communication skills teaching on clinical supervisors' ability to identify residents' good and poor communication skills and to discuss them interactively during feedback. METHODS: We conducted a pre-post controlled study in which clinical supervisors took part to a faculty development program on teaching communication skills in clinical practice. Outcome measures were the number and type of residents' communication skills identified by supervisors in three videotaped simulated resident-patient encounters and the number and type of communication skills discussed interactively with residents during three feedback sessions. RESULTS: 48 clinical supervisors (28 intervention group; 20 control group) participated. After the intervention, the number and type of communication skills identified did not differ between both groups. There was substantial heterogeneity in the number and type of communication skills identified. However, trained participants engaged in interactive discussions with residents on a significantly higher number of communication items (effect sizes 0.53 to 1.77); communication skills items discussed interactively included both structural and patient-centered elements that were considered important to be observed by expert teachers. CONCLUSIONS: The faculty development programme did not increase the number of communication skills recognised by supervisors but was effective in increasing the number of communication issues discussed interactively in feedback sessions. Further research should explore the respective impact of accurate identification of communication skills and effective teaching skills on achieving more effective communication skills teaching in clinical practice.

Effectiveness of a training program in supervisors' ability to provide feedback on residents' communication skills.

Teaching communication skills (CS) to residents during clinical practice remains problematic. Direct observation followed by feedback is a powerful way to teach CS in clinical practice. However, little is known about the effect of training on feedback skills in this field. Controlled studies are scarce as well as studies that go beyond self-reported data. The aim of the study was to develop and assess the effectiveness of a training program for clinical supervisors on how to give feedback on residents' CS in clinical practice. The authors designed a pretest-posttest controlled study in which clinical supervisors working in two different medical services were invited to attend a sequenced and multifaceted program in teaching CS over a period of 6-9 months. Outcome measures were self-perceived and observed feedback skills collected during questionnaires and three videotaped objective structured teaching encounters. The videotaped feedbacks made by the supervisors were analysed using a 20-item feedback rating instrument. Forty-eight clinical supervisors participated (28 in the intervention, 20 in the control group). After training, a higher percentage of trained participants self-reported and demonstrated statistically significant improvement in making residents more active by exploring residents' needs, stimulating self-assessment, and using role playing to test strategies and checking understanding, with effect sizes ranging from 0.93 to 4.94. A training program on how to give feedback on residents' communication skills was successful in improving clinical supervisors' feedback skills and in helping them operate a shift from a teacher-centered to a more learner-centered approach.

Acquisition of clinical competence: Added value of clerkship real-life contextual experience.

BACKGROUND: Medical students' limited access to patients induces a shift of learning activities from clinical wards to classrooms. AIM: Identify clinical competencies specifically acquired during real-life contextual clerkship added to case-based tutorials, by a prospective, controlled study. METHODS: Students entering our eight-week internal medicine (IM) clerkship attended paper case-based tutorials about 10 common presenting complaints and were assigned to an IM specialty ward. For each tutorial case, two groups of students were created: those assigned to a ward, the specialty of which was unrelated to the case (case-unrelated ward, CUW) and those assigned to a ward, the specialty of which was related to the case (case-related ward, CRW). RESULTS: Forty-one students (30 CUW and 11 CRW) volunteered for the study. Both groups had similar previous experiences and pre-clerkship exam scores. The CRW students collected more relevant clinical information from the patient (69% vs. 55% of expected items, p=0.001) and elaborated charts of better quality (47% vs. 39% of expected items, p=0.05). Clinical-knowledge mean score was similar (70%) in both groups (p=0.92). CONCLUSIONS: While paper-case tutorials did provide students with clinical knowledge, real contextual experience brought additional, specific competencies. This supports the preservation of clinical exposure with supervision and feedback.

Bringing explicit insight into cognitive psychology features during clinical reasoning seminars: a prospective, controlled study.

CONTEXT: Facets of reasoning competence influenced by an explicit insight into cognitive psychology features during clinical reasoning seminars have not been specifically explored. OBJECTIVE: This prospective, controlled study, conducted at the University of Geneva Faculty of Medicine, Switzerland, assessed the impact on sixth-year medical students' patient work-up of case-based reasoning seminars, bringing them explicit insight into cognitive aspects of their reasoning. METHODS: Volunteer students registered for our three-month Internal Medicine elective were assigned to one of two training conditions: standard (control) or modified (intervention) case-based reasoning seminars. These seminars start with the patient's presenting complaint and the students must ask the tutor for additional clinical information to progress through case resolution. For this intervention, the tutors made each step explicit to students and encouraged self-reflection on their reasoning processes. At the end of their elective, students' performances were assessed through encounters with two standardized patients and chart write-ups. FINDINGS: Twenty-nine students participated, providing a total of 58 encounters. The overall differences in accuracy of the final diagnosis given to the patient at the end of the encounter (control 63% vs intervention 74%, p = 0.53) and of the final diagnosis mentioned in the patient chart (61% vs 70%, p = 0.58) were not statistically significant. The students in the intervention group significantly more often listed the correct diagnosis among the differential diagnoses in their charts (75% vs 97%, p = 0.02). CONCLUSION: This case-based clinical reasoning seminar intervention, designed to bring students insight into cognitive features of their reasoning, improved aspects of diagnostic competence.

[Monitoring of heparins and of anticoagulants]. / Surveillance biologique des héparines et du fondaparinux.

Anticoagulation with unfractionated heparin, low molecular weight heparin or fondaparinux is common practice in thromboembolic disease, atrial fibrillation and mechanical heart valves. Some of these molecules, with specific pharmacokinetic, requires specific monitoring. Unfractionated heparin requires close monitoring by aPTT and/or anti-FXa activity while LMWH and fondaparinux do not require biological surveillance except in a few specific situations.

[Hospital based internal medicine: a year in review]. / Médecine interne hospitalière: l'année 2010 en revue (1).

Epidemiological studies and working hypotheses based on pathophysiology can lead to shortcuts and assumptions on which treatment may sometimes be based. As is often the case, prospective, randomized, controlled studies bring important insight into the actual benefits of various treatment options. This selective review describes some recent studies that provide insight in various areas such as cardiovascular disease, heart failure, renovascular disease, venous thromboembolic disease, pneumonia, as well as acute pancreatitis.

[Aspirin as primary prevention for diabetic patients]. / L'aspirine en prévention primaire chez les patients diabétiques.

Several meta-analysis support the prescription of aspirin for primary prevention of cardiovascular events in patients at risk. Though diabetics are particularly prone to these complications, a review of the literature shows that they have fewer benefits from the protective effects of such treatment. In these patients, controlling dyslipidemia, blood pressure and glycemia remains the main aim. Prescription of aspirin, in combination with an already existing medication, should not be solely based on the presence of diabetes, but on the overall risk profile of the patient, as well as his motivation.

[The role of direct inhibitors of renin]. / Y a-t-il une place aujourd'hui pour les inhibiteurs directs de la rénine?

Aliskiren is the first direct oral renin inhibitor approved for the treatment of hypertension. It acts by binding to the active site of renin and blocking its catalytic function, as a result preventing the formation of the angiotensin I and II. Used in monotherapy or in combination, this molecule proved its antihypertensive efficacy without showing, however, a clear superiority on the other antihypertensive drugs. Its benefit on cardiovascular morbidity and mortality and on target organ damage should be proved before aliskiren may be recommended as a first line therapy in essential hypertension. Data on cardiac insufficiency and diabetic nephropathy are preliminary.

Residents' perceived needs in communication skills training across in- and outpatient clinical settings.

CONTEXT: Residents' perceived needs in communication skills training are important to identify before designing context-specific training programmes, since learrners' perceived needs can influence the effectiveness of training. OBJECTIVES: To explore residents' perceptions of their training needs and training experiences around communication skills, and whether these differ between residents training in inpatient and outpatient clinical settings. METHODS: Four focus groups (FG) and a self-administered questionnaire were conducted with residents working in in- and outpatient medical service settings at a Swiss University Hospital. Focus groups explored residents' perceptions of their communication needs, their past training experiences and suggestions for future training programmes in communication skills. Transcripts were analysed in a thematic way using qualitative analytic approaches. All residents from both settings were asked to complete a questionnaire that queried their sociodemographics and amount of prior training in communication skills. FINDINGS: In focus groups, outpatient residents felt that communication skills were especially useful in addressing chronic diseases and social issues. In contrast, inpatient residents emphasized the importance of good communication skills for dealing with family conflicts and end-of-life issues. Felt needs reflected residents' differing service priorities: outpatient residents saw the need for skills to structure the consultation and explore patients' perspectives in order to build therapeutic alliances, whereas inpatient residents wanted techniques to help them break bad news, provide information and increase their own well-being. The survey's overall response rate was 56%. Its data showed that outpatient residents received more training in communication skills and more of them than inpatient residents considered communication skills training to be useful (100% vs 74%). DISCUSSION: Outpatient residents' perceived needs in communication skills were more patient-centered than the needs perceived by inpatient residents. Residents' perceived needs for communication skills may differ not only because of their differing service priorities but also because of differences in their previous experiences with communication skills training. These factors should be taken into account when designing a training programme in communication skills.

[Cardiac biomarkers and pulmonary embolism: prognostic stratification]. / Biomarqueurs cardiaques et embolie pulmonaire: stratification pronostique.

In hemodynamically stable patients with signs of right ventricular dysfunction, the mortality related to acute pulmonary embolism (PE) may be as high as 10%. In the absence of any haemodynamic and cardiac repercussion, the clinical evolution is benign and outpatient treatment may be contemplated. It is therefore mandatory to develop tools for early prognostic stratification in order to improve efficient patient care. This article discusses more specifically the role of cardiac biomarkers (natriuretic peptides and troponin) in assessing PE prognosis and severity at the time of the diagnosis.

Associations between early handoffs, length of stay and complications in internal medicine wards: A retrospective study.

BACKGROUND: In US healthcare system, handoffs are associated with an increase in medical error and in hospital length of stay. In non-US healthcare systems, this phenomenon has not been well studied. We studied the association between early handoffs (EH) in a non-US internal medicine ward with length of stay (LOS), use of resources, major complication (MC) and discharge to post-acute care (PAC) facility. METHODS: We conducted a retrospective cohort study on patients admitted to the general internal medicine division. Patients with EH (defined as a transfer of responsibility between primary teams within the first 72 h) were compared with patients without EH. The primary outcome was LOS in the general internal medicine division. Secondary outcomes were the use of resources, the incidence of MC (transfer to intensive care, to intermediate care or death) and discharge to a PAC facility. RESULTS: We included 11,869 patients, 38% of whom were in the EH group. Patients were 67.7±16.6 years old and 53% were males. EH was independently associated with an increase of LOS (+6.4% [95% CI, 3.5%-9.5%], P < .001) and with an increased rate of MC (OR 1.3 [95% CI, 1.1-1.7], P = .012). In our subgroup analysis, the association between early handoff and LOS and MC rate were not statistically significant when the admission occurred on public holidays and weekends. CONCLUSIONS: Among patients admitted in our general internal medicine division, early handoffs were associated with significantly higher length of stay and major complication rate, but not in patients admitted during week-ends.

A predictive score to identify hospitalized patients' risk of discharge to a post-acute care facility.

BACKGROUND: Early identification of patients who need post-acute care (PAC) may improve discharge planning. The purposes of the study were to develop and validate a score predicting discharge to a post-acute care (PAC) facility and to determine its best assessment time. METHODS: We conducted a prospective study including 349 (derivation cohort) and 161 (validation cohort) consecutive patients in a general internal medicine service of a teaching hospital. We developed logistic regression models predicting discharge to a PAC facility, based on patient variables measured on admission (day 1) and on day 3. The value of each model was assessed by its area under the receiver operating characteristics curve (AUC). A simple numerical score was derived from the best model, and was validated in a separate cohort. RESULTS: Prediction of discharge to a PAC facility was as accurate on day 1 (AUC: 0.81) as on day 3 (AUC: 0.82). The day-3 model was more parsimonious, with 5 variables: patient's partner inability to provide home help (4 pts); inability to self-manage drug regimen (4 pts); number of active medical problems on admission (1 pt per problem); dependency in bathing (4 pts) and in transfers from bed to chair (4 pts) on day 3. A score > or = 8 points predicted discharge to a PAC facility with a sensitivity of 87% and a specificity of 63%, and was significantly associated with inappropriate hospital days due to discharge delays. Internal and external validations confirmed these results. CONCLUSION: A simple score computed on the 3rd hospital day predicted discharge to a PAC facility with good accuracy. A score > 8 points should prompt early discharge planning.

Patients' knowledge of drug treatments after hospitalisation: the key role of information.

QUESTION UNDER STUDY: Patients often do not know the reasons for taking their medications after hospital discharge. We investigated whether lack of such knowledge was associated with patients' report of not having received information about their medications while hospitalised. METHODS: Patients with at least one long-term drug (ie, prescribed for more than 30 days) discharged from the wards of general internal medicine of a teaching hospital were included in the study. Patients' knowledge of the reasons for taking these drugs and their report of having received information while hospitalised were assessed by phone one week after discharge. RESULTS: 362 (98.6%) of 367 enrolled patients could be interviewed and provided data on 1693/1871 (90.5%) long-term drugs prescribed at discharge. Patients knew the reasons for taking 1382 (81.6%) drugs and reported having received information about 259 (15.3%) of them. In the adjusted analysis, the reason for taking a drug was less likely to be known when introduced during hospitalisation (OR: 0.7; 95%CI: 0.5 to 0.9), among older patients (OR for > or =80 years of age v/s 20-59: 0.41; 95%CI: 0.22 to 0.76) and among those staying longer (OR per additional hospital day: 0.96; 95%CI: 0.94 to 0.99); such knowledge was strongly and positively associated with the report of having received information during hospitalisation (OR: 7.3; 95%CI: 3.2 to 16.1). CONCLUSION: Patients' report of having received information about their long-term drugs during hospitalisation was associated with a significantly higher knowledge of the reasons for taking them. However, receipt of such information was only infrequently reported.