The impact of the COVID-19 pandemic on family medicine residency training.

BACKGROUND: Family physicians have played a unique clinical role during the COVID-19 pandemic. We hypothesized that the pandemic would be associated with significant deleterious effects on clinical activity, educational training, personal safety and well-being. OBJECTIVE: We conducted a national survey to obtain preliminary data that would assist in future targeted data collection and subsequent evaluation of the impact of the pandemic on family medicine residents and teaching faculty. METHODS: An anonymous online survey of residents and faculty was distributed via the Association of Family Medicine Residency Directors list serve between 5/21/2020 and 6/18/2020. Survey questions focused on clinical and educational activities, safety and well-being. RESULTS: One hundred and fifty-three residents and 151 teaching faculty participated in the survey. Decreased clinical activity was noted by 81.5% of residents and 80.9% of faculty and the majority began conducting telehealth visits (97.9% of residents, 91.0% of faculty). Distance learning platforms were used by all residents (100%) and 39.6% noted an overall positive impact on their education. Higher levels of burnout did not significantly correlate with reassignment of clinical duties (residents P = 0.164; faculty P = 0.064). Residents who showed significantly higher burnout scores (P = 0.035) and a decline in levels of well-being (P = 0.031) were more likely to participate in institutional well-being support activities. CONCLUSIONS: Our preliminary data indicate that family medicine residents and teaching faculty were profoundly affected by the COVID-19 pandemic. Future studies can be directed by current findings with focus on mitigation factors in addressing globally disruptive events such as COVID-19.

Family physicians have played a unique clinical role during the COVID-19 pandemic. We hypothesized that the pandemic would be associated with significant deleterious effects on clinical activity, educational training, personal safety and well-being. Towards setting a foundation for further studies, we conducted a national survey to obtain preliminary data that would assist in future targeted data collection and subsequent evaluation of the impact of the pandemic on family medicine residents and teaching faculty. Our preliminary data indicate that family medicine residents and teaching faculty were profoundly affected by the COVID-19 pandemic in all domains studied. Future studies can be directed by current findings with focus on mitigation factors in addressing globally disruptive events such as COVID-19.

Service Requirements of Liver Transplant Anesthesia Teams: Society for the Advancement of Transplant Anesthesia Recommendations.

There are disparities in liver transplant anesthesia team (LTAT) care across the United States. However, no policies address essential resources for liver transplant anesthesia services similar to other specialists. In response, the Society for the Advancement of Transplant Anesthesia appointed a task force to develop national recommendations. The Conditions of Transplant Center Participation were adapted to anesthesia team care and used to develop Delphi statements. A Delphi panel was put together by enlisting 21 experts from the fields of liver transplant anesthesiology and surgery, hepatology, critical care, and transplant nursing. Each panelist rated their agreement with and the importance of 17 statements. Strong support for the necessity and importance of 13 final items were as follows: resources, including preprocedure anesthesia assessment, advanced monitoring, immediate availability of consultants, and the presence of a documented expert in liver transplant anesthesia credentialed at the site of practice; call coverage, including schedules to assure uninterrupted coverage and methods to communicate availability; and characteristics of the team, including membership criteria, credentials at the site of practice, and identification of who supervises patient care. Unstructured comments identified competing time obligations for anesthesia and transplant services as the principle reason that the remaining recommendations to attend integrative patient selection and quality review committees were reduced to a suggestion rather than being a requirement. This has important consequences because deficits in team integration cause higher failure rates in service quality, timeliness, and efficiency. Solutions are needed that remove the time-related financial constraints of competing service requirements for anesthesiologists. In conclusion, using a modified Delphi technique, 13 recommendations for the structure of LTATs were agreed upon by a multidisciplinary group of experts.

A Mixed Methods Evaluation of an Inclusive Sexual History Taking and HIV Prevention Curriculum for Trainees.

BACKGROUND: Health disparities exist in HIV risk in the USA among the lesbian-gay-bisexual-transgender-queer (LGBTQ) community. There is also scarce literature on curricula for HIV prevention and pre-exposure prophylaxis (PrEP) for trainees. AIM: To create a curriculum to train residents to perform inclusive sexual history taking and HIV prevention care. The curriculum covers sexual history, LGBTQ health, sexually transmitted infections, and HIV risk assessment and risk reduction counseling including use of PrEP. SETTING: A dedicated PrEP Clinic was created within an Academic Medical Center Outpatient HIV Clinic. Patients were primarily LGBTQ identified, but also included HIV sero-discordant couples, cisgender individuals, heterosexual invididuals, and those with experience of homelessness, sex work, and substance abuse. PARTICIPANTS: Thirty-four internal medicine residents completed the course between November 2017 and May 2018. PROGRAM DESCRIPTION: The curriculum was delivered as Just in Time Teaching (JiTT) via online virtual patient cases followed by directly observed clinical care at a large urban PrEP clinic. PROGRAM EVALUATION AND RESULTS: The effectiveness of the curriculum was assessed through paired pre/post-self-assessment surveys (n = 19), additional post-surveys on the online modules (n = 22), and interviews (n = 9). Many respondents reported no prior training or inadequate prior training in the course content. As a result of the course, participants reported statistically significant increased confidence and comfort in all seven HIV prevention topic areas, with the greatest gains in safe sex counseling for LGBTQ patients and in discussing PrEP (mean changes of 1.21, 1.58 on 5-point Likert scale, respectively, p < 0.0001). Six of nine interviewees post-course had applied what they learned to patient care; five indicated their learning would benefit patients. DISCUSSION: An HIV prevention curriculum focused on cultural humility in care can improve trainee's skills in HIV risk reduction counseling, including PrEP, among all patients including those identifying as LGBTQ.

A Randomized Trial of an Intensive Physical Therapy Program for Patients with Acute Respiratory Failure.

RATIONALE: Early physical therapy (PT) interventions may benefit patients with acute respiratory failure by preventing or attenuating neuromuscular weakness. However, the optimal dosage of these interventions is currently unknown. OBJECTIVES: To determine whether an intensive PT program significantly improves long-term physical functional performance compared with a standard-of-care PT program. METHODS: Patients who required mechanical ventilation for at least 4 days were eligible. Enrolled patients were randomized to receive PT for up to 4 weeks delivered in an intensive or standard-of-care manner. Physical functional performance was assessed at 1, 3, and 6 months in survivors who were not currently in an acute or long-term care facility. The primary outcome was the Continuous Scale Physical Functional Performance Test short form (CS-PFP-10) score at 1 month. MEASUREMENTS AND MAIN RESULTS: A total of 120 patients were enrolled from five hospitals. Patients in the intensive PT group received 12.4 ± 6.5 sessions for a total of 408 ± 261 minutes compared with only 6.1 ± 3.8 sessions for 86 ± 63 minutes in the standard-of-care group (P < 0.001 for both analyses). Physical function assessments were available for 86% of patients at 1 month, for 76% at 3 months, and for 60% at 6 months. In both groups, physical function was reduced yet significantly improved over time between 1, 3, and 6 months. When we compared the two interventions, we found no differences in the total CS-PFP-10 scores at all three time points (P = 0.73, 0.29, and 0.43, respectively) or in the total CS-PFP-10 score trajectory (P = 0.71). CONCLUSIONS: An intensive PT program did not improve long-term physical functional performance compared with a standard-of-care program. Clinical trial registered with www.clinicaltrials.gov (NCT01058421).

Internal Medicine Residents' Perceived Responsibility for Patients at Hospital Discharge: A National Survey.

BACKGROUND: Medical residents are routinely entrusted with transitions of care, yet little is known about the duration or content of their perceived responsibility for patients they discharge from the hospital. OBJECTIVE: To examine the duration and content of internal medicine residents' perceived responsibility for patients they discharge from the hospital. The secondary objective was to determine whether specific individual experiences and characteristics correlate with perceived responsibility. DESIGN: Multi-site, cross-sectional 24-question survey delivered via email or paper-based form. PARTICIPANTS: Internal medicine residents (post-graduate years 1-3) at nine university and community-based internal medicine training programs in the United States. MAIN MEASURES: Perceived responsibility for patients after discharge as measured by a previously developed single-item tool for duration of responsibility and novel domain-specific questions assessing attitudes towards specific transition of care behaviors. KEY RESULTS: Of 817 residents surveyed, 469 responded (57.4 %). One quarter of residents (26.1 %) indicated that their responsibility for patients ended at discharge, while 19.3 % reported perceived responsibility extending beyond 2 weeks. Perceived duration of responsibility did not correlate with level of training (P = 0.57), program type (P = 0.28), career path (P = 0.12), or presence of burnout (P = 0.59). The majority of residents indicated they were responsible for six of eight transitional care tasks (85.1-99.3 % strongly agree or agree). Approximately half of residents (57 %) indicated that it was their responsibility to directly contact patients' primary care providers at discharge. and 21.6 % indicated that it was their responsibility to ensure that patients attended their follow-up appointments. CONCLUSIONS: Internal medicine residents demonstrate variability in perceived duration of responsibility for recently discharged patients. Neither the duration nor the content of residents' perceived responsibility was consistently associated with level of training, program type, career path, or burnout, suggesting there may be unmeasured factors such as professional role modeling that shape these perceptions.

Reliability and Validity of Diabetes Nutrition Self-Efficacy and Behavior Measures for the "What Can I Eat" Diabetes Nutrition Education Program for American Indian and Alaska Native Adults With Type 2 Diabetes.

BACKGROUND: American Indian and Alaska Native (AI/AN) people have high rates of diabetes and limited access to nutrition education. The "What Can I Eat? Healthy Choices for People With Type 2 Diabetes" (WCIE) diabetes nutrition education program was culturally adapted for AI/AN adults. OBJECTIVE: This analysis was designed to evaluate the reliability and validity of items developed to measure diabetes nutrition self-efficacy (ie, confidence one can engage in specific behaviors) and diabetes nutrition behavior among participants in the WCIE program for AI/AN adults. DESIGN: This study was a secondary analysis of data from a randomized controlled trial designed to evaluate the WCIE program for AI/AN adults. Baseline data were used to assess the reliability and validity of the self-efficacy and behavior items, which were collected via survey. Due to COVID-19 safety protocols, the intervention was conducted via Zoom (Zoom Video Communications), and both survey and clinical data were collected at home by participants. PARTICIPANTS/SETTING: The study was conducted from January to December 2021 with 5 AI/AN-serving health care programs in Oklahoma, Illinois, North Carolina, California, and New York. AI/AN adults with type 2 diabetes who spoke English and had internet access were eligible. Sixty people participated. MAIN OUTCOME MEASURES: Analyses examined validity and reliability of diabetes nutrition self-efficacy and behavior items. STATISTICAL ANALYSIS PERFORMED: To test reliability, internal consistency and factor structures of the scales were examined. To evaluate convergent validity, Pearson correlations were computed to examine the association of the self-efficacy and behavior measures with each other and with clinical indicators (ie, body mass index, blood pressure, and hemoglobin A1c). RESULTS: Two self-efficacy factors were identified. Each showed strong internal consistency (Cronbach α ≥ 0.85; McDonald ω ≥ 0.88) and was directly associated with diabetes nutrition behavior (P < .001). The factor assessing Confidence in Using the Diabetes Plate was inversely associated with hemoglobin A1c (Pearson correlation = -0.32, P = .0243). The behavior measure capturing Healthy Nutrition Behavior showed strong internal consistency (α = 0.89; ω = 0.92) and was inversely associated with hemoglobin A1c (Pearson correlation = -0.38, P = .0057). CONCLUSIONS: Diabetes nutrition self-efficacy and behavior items developed for the WCIE program for AI/AN adults are valid and reliable. These items can facilitate rigorous and consistent evaluation of the AI/AN WCIE program.

Evaluation of a Novel Hospice-Specific Patient Decision Aid.

Background: We tested a novel hospice-specific patient decision aid to determine whether the decision aid could improve hospice knowledge, opinions of hospice, and decision self-efficacy in making decisions about hospice. Methods: Two patient-level randomized studies were conducted using two different cohorts. Recruitment was completed from March 2019 through May 2020. Cohort #1 was recruited from an academic hospital and a safety-net hospital and Cohort #2 was recruited from community members. Participants were randomized to review a hospice-specific patient decision aid. The primary outcomes were change in hospice knowledge, hospice beliefs and attitudes, and decision self-efficacy Wilcoxon signed rank tests were used to evaluate differences on the primary outcomes between baseline and 1-month. Participants: Participants were at least 65 years of age. A total of 266 participants enrolled (131 in Cohort #1 and 135 in Cohort #2). Participants were randomized to the intervention group (n = 156) or control group (n = 109). The sample was 74% (n = 197) female, 58% (n = 156) African American and mean age was 74.9. Results: Improvements in hospice knowledge between baseline and 1-month were observed in both the intervention and the control groups with no differences between groups (.43 vs .275 points, P = .823). There were no observed differences between groups on Hospice Beliefs and Attitudes scale (3.29 vs 3.08, P = .076). In contrast, Decision Self-Efficacy improved in both groups and the effect of the intervention was significant (8.04 vs 2.90, P = -.027). Conclusions: The intervention demonstrated significant improvements in decision self-efficacy but not in hospice knowledge or hospice beliefs and attitudes.

Factors Associated With Clinician Self-Reported Resource Use in Acute Care and Ambulatory Pediatrics.

The objective of this study is to determine predictors of resource use among pediatric providers for common respiratory illnesses. We surveyed pediatric primary care, emergency department (ED)/urgent care (UC), and hospital medicine providers at a free-standing children's hospital system. Five clinical vignettes assessed factors affecting resource use for upper respiratory infections, bronchiolitis, and pneumonia, including provider-type, practice location, tolerance to uncertainty, and medical decision-making behaviors. The response rate was 75.3% (168/223). The ED/UC and primary care providers had higher vignette scores, indicating higher resource use, compared with inpatient providers; advanced practice providers (APPs) had higher vignette scores compared with physicians. In multivariate analysis, being an ED/UC provider, an APP, and greater concern for bad outcomes were associated with higher vignette scores. Overall, provider type and location of practice may predict resource use for children with respiratory illnesses. Interventions targeted at test-maximizing providers may improve quality of care and reduce resource burden.

Engage, Develop, Learn: a pilot randomized clinical trial to test if a mobile application can enhance home support for early cognitive development among children living in poverty.

Background: Mobile applications (apps) exist to promote early child development; however, few studies have examined use of these apps among low-income families. Our objectives were to measure engagement with the Engage, Develop, Learn (EDL) app and determine if it promoted engagement and behavior change among low-income caregivers. Methods: We conducted a pilot study among English and Spanish-speaking, low-income families with children ages 12 to 15 months who received either the EDL app or injury prevention text messages. Baseline data were collected and interventions delivered over two home visits. App engagement was measured using messages opened. Caregiver development-promoting behaviors were measured with STIMQ score changes from baseline to follow-up at child age 2 years. We conducted key informant interviews among families randomized to receive the EDL app to identify barriers and facilitators to app use. Results: A total of 100 caregivers were recruited at their children's preventive care visit with 50 randomized to receive the EDL app and 50 to receive the injury prevention text messages; however, only 25 in the development app and 34 in the injury prevention group completed both home visits. Follow-up data were collected from 14 in the development app group and 30 in the injury prevention group. Over 10 weeks, 24% (6/25) remained engaged with the development app. STIMQ scores did not differ between groups. Barriers included technical difficulties accessing the app, social stressors, and 'forgetting' to use it. Conclusions: Our pilot randomized trial of a child development app suggests that it may not be effective for promoting behavior change among low-income caregivers due to low engagement. Trial Registration: This pilot trial was registered with ClinicalTrials.gov (ID NCT02717390).

Evaluation of a Synchronous, Online Diabetes Nutrition Education Program for American Indians and Alaska Natives With Type 2 Diabetes: Facilitators and Participants' Experiences.

OBJECTIVE: To explore the overall experiences of key players involved in a culturally adapted, online, synchronous diabetes nutrition education program across 5 reservation tribal and intertribal urban Indian clinics. METHODS: A multimethods design, including postclass surveys with Likert-scale and short-answer questions, was completed after each of the 5 classes. Participants (n = 54) and class facilitators/coordinators (n = 10) completed postclass surveys (n = 189 and 58, respectively). A subset of participants (n = 24) and all class facilitators/coordinators (n = 10) engaged in online focus groups after the conclusion of program implementation. Qualitative thematic methods and frequency distributions were used to analyze the data. RESULTS: Most participants reported that the classes were enjoyable (94%), culturally respectful (77%), and easily accessed online (68%). Qualitative themes included (1) class satisfaction, (2) class improvements, (3) preference for class facilitator, and (4) recommendations to improve recruitment and retention. CONCLUSIONS AND IMPLICATIONS: These findings will guide program modifications to provide improved diabetes nutrition education for American Indians and Alaska Natives adults with type 2 diabetes.

Quality of life and the negative impact of comorbidities in long-term colorectal cancer survivors: a population-based comparison.

PURPOSE: Colorectal cancer (CRC) is the third most common cancer in the USA. The objective of this study was to compare quality of life (QoL) across long-term colorectal cancer survivors and unaffected matched controls while adjusting for comorbidities. METHODS: The National Cancer Institute (NCI)-funded Colon Cancer Family Registry (CCFR) was used to randomly select and recruit CRC survivors (≥ 5 years from diagnosis) and matched controls for a cross-sectional survey. Nine geographically diverse sites in the USA from the CCFR participated in the study. Telephone interviews were conducted using computer-assisted methods to assess QoL. RESULTS: A total of 403 cases and 401 controls were included in the final sample. Unadjusted comparison revealed no significant difference between CRC survivors and controls with respect to measures of fatigue, social, emotional, functional, and physical well-being. Multivariate logistic regression revealed that case status had a significant negative influence on colorectal cancer-specific QoL measures. Higher comorbidity indices had a significant negative influence on overall QoL regardless of case status. CONCLUSIONS: Quality of life among long-term CRC survivors is similar to control subjects, with the exception of worse CRC-specific QoL measures. Higher comorbidity indices were independently associated with poor QoL for both cases and controls. IMPLICATIONS FOR CANCER SURVIVORS: Survivors and healthcare providers should be aware that long-term QoL is comparable to the general population; however, there is potential that digestive tract-specific issues may persist.

The Current State of Physics Plan Review Training in Medical Physics Residency Programs in North America.

PURPOSE: This study aimed to identify the current state of residency training in physics plan reviews. METHODS AND MATERIALS: A voluntary, anonymous survey was sent to all program directors of accredited therapeutic medical physics residency programs in North America. Survey questions were developed to determine whether and how residents are trained in physics plan reviews. Survey questions were developed using expert validation and cognitive pretesting. RESULTS: Using a prospectively approved study (COMIRB 18-1073), responses were collected from 70 program directors, representing a 70% response rate. All respondents (100%) designated patient safety to be the purpose of physics plan reviews. Of the respondents, 94% indicated that physicists should first receive training in physics plan reviews while in a residency program. The vast majority of respondents (99%) provide training to residents in physics plan reviews. Although 57 programs (81% of respondents) have residents perform physics plan reviews as part of clinical practice (with varying levels of independence), 13 programs (19% of respondents) do not. The majority of respondents use the following training methods: observe staff physicists (96%), perform supervised reviews on actual patients for training or clinical practice (93%), use a checklist (80%), and read reference materials (62%). Although simulation plans with embedded errors would be implemented by 71% of respondents, they are currently used in only 19% of programs. CONCLUSIONS: The present study is the first to characterize chart-check teaching practices in medical physics residency programs. The vast majority of programs currently train residents in physics plan reviews. The most common teaching methods are observing and performing physics plan reviews, but there is variability in the level of resident involvement in clinical practice for physics plan reviews. There is room for the field to consider advancing current training methods, which is especially important given the critical roles that physics plan reviews have with regard to patient safety.

Associations among nurse and certified nursing assistant hours per resident per day and adherence to guidelines for treating nursing home-acquired pneumonia.

BACKGROUND: Nursing home (NH)-acquired pneumonia (NHAP) causes excessive mortality, hospitalization, and functional decline, partly because many NH residents do not receive appropriate care. Care structures like nurse/resident staffing ratios can impede or abet quality care. This study examines the relationship between nurse/resident staffing ratios, turnover, and adherence to evidence-based guidelines for treating NHAP. METHODS: A prospective, chart-review study was conducted among residents of 16 NHs in three states with > or = 2 signs and symptoms of NHAP during the 2004--2005 influenza season. NH medical records were reviewed concurrently for functional status, comorbidity, NHAP severity, and guideline adherence. Ratio of licensed nurse and Certified Nursing Assistant (CNA) hours per resident per day (hrpd) and ratio of newly hired nursing staff/year to current nursing staff were provided by Directors of Nursing. Associations among guideline adherence, nurse and CNA hrpd, and turnover were assessed using multiple regression to adjust for case mix, facility characteristics, and clustering of residents in facilities. RESULTS: Mid (1.7-2.0) and high (> 2.0) CNA hrpd were significantly associated with better pneumococcal and influenza vaccination rates. More than 1.2 licensed nurse hrpd was significantly associated with appropriate hospitalization (odds ratio [OR] 12.4; 95% confidence interval [CI], 3.5-43.8) and guideline-recommended antibiotics (OR 3.8; 95% CI, 1.7-8.7). A > 70% turnover was inversely related to timely physician notification (OR 0.4; 95% CI, 0.2-0.7) and appropriate hospitalization (OR 0.09; 95% CI, 0.05-0.26). CONCLUSIONS: NHAP treatment guideline adherence is associated with nurse and CNA hrpd and stability. An NH's ability to implement evidence-based care may depend on adequate staffing ratios and stability.

Does a text-messaging program to promote early childhood development reach the highest risk families?

BACKGROUND: Bright by Three (BB3), a non-profit organization that promotes caregiver behaviors to support language development in young children was augmented with a text-messaging program, Bright by Text (BBT), in 2015. While some evidence suggests that text-messaging can promote early development, it is unknown if these interventions are reaching children at increased sociodemographic risk for developmental delay. The purpose of this study is to compare socio-demographic characteristics of caregivers who did and did not enroll in BBT. METHODS: Retrospective analysis of caregivers who received BB3 written materials and were eligible to sign up for BBT in 2016. Outcomes: (I) provision of a mobile phone number; (II) enrollment in BBT (receipt of 3+ messages). Predictors: education, marital status, race/ethnicity, insurance, language, and urban vs. rural residence. A multivariable generalized linear model was used to determine characteristics of caregivers more likely to sign up for BBT. RESULTS: A total of 18,145 caregivers received BB3 written materials; 10,843 (60%) provided a mobile phone number and 2,314 (21%) enrolled in BBT. The relative risk (RR) of enrollment was higher for caregivers who were non-minority (RR 1.15, 95% CI, 1.04-1.28), had higher education (1.60, 1.35-1.89), had private insurance (1.15, 1.15-1.28) and lived in urban areas (1.21, 1.06-1.37). Non-English speaking caregivers were less likely to enroll (0.73, 0.59-0.90). CONCLUSIONS: Caregivers with lower incomes and education, minorities and non-English speakers were less likely to enroll in BBT. Future research could identify ways to increase engagement among these populations and determine if BBT is effective in changing parent behavior and improving children's development.

Resident and Preceptor Perceptions of Preceptor Integration Into Resident Clinic Scheduling Templates.

BACKGROUND: Some internal medicine residency programs on X+Y schedules have modified clinic preceptor schedules to mimic those of the resident cohort (resident matched). This is in contrast to a traditional model, in which preceptors supervise on the same half-day each week. OBJECTIVE: We assessed preceptor and resident perceptions of the 2 precepting models. METHODS: We surveyed 44 preceptors and 97 residents at 3 clinic sites in 2 academic medical centers. Two clinics used the resident-matched model, and 1 used a traditional model. Surveys were completed at 6 months and 1 year. We assessed resident and preceptor perceptions in 5 domains: relationships between residents and preceptors; preceptor familiarity with complex patients; preceptor ability to assess milestone achievements; ability to follow up on results; and quality of care. RESULTS: There was no difference in perceptions of interpersonal relationships or satisfaction with patient care. Preceptors in the resident-matched schedule reported they were more familiar with complex patients at both 6 months and 1 year, and felt more comfortable evaluating residents' milestone achievements at 6 months, but not at 1 year. At 1 year, residents in the resident-matched model perceived preceptors were more familiar with complex patients than residents in the traditional model. The ability to discuss patient results between clinic weeks was low in both models. CONCLUSIONS: The resident-matched model increased resident and preceptor perceptions of familiarity with complex patients and early preceptor perceptions of comfort in assessment of milestone achievements.

Residents' Exposure to Educational Experiences in Facilitating Hospital Discharges.

BACKGROUND: There is an incomplete understanding of the most effective approaches for motivating residents to adopt guideline-recommended practices for hospital discharges. OBJECTIVE: We evaluated internal medicine (IM) residents' exposure to educational experiences focused on facilitating hospital discharges and compared those experiences based on correlations with residents' perceived responsibility for safely transitioning patients from the hospital. METHODS: A cross-sectional, multi-center survey of IM residents at 9 US university- and community-based training programs in 2014-2015 measured exposure to 8 transitional care experiences, their perceived impact on care transitions attitudes, and the correlation between experiences and residents' perceptions of postdischarge responsibility. RESULTS: Of 817 residents surveyed, 469 (57%) responded. Teaching about care transitions on rounds was the most common educational experience reported by residents (74%, 327 of 439). Learning opportunities with postdischarge patient contact were less common (clinic visits: 32%, 142 of 439; telephone calls: 12%, 53 of 439; and home visits: 4%, 18 of 439). On a 1-10 scale (10 = highest impact), residents rated postdischarge clinic as having the highest impact on their motivation to ensure safe transitions of care (mean = 7.61). Prior experiences with a postdischarge clinic visit, home visit, or telephone call were each correlated with increased perceived responsibility for transitional care tasks (correlation coefficients 0.12 [P = .004], 0.1 [P = .012], and 0.13 [P = 001], respectively). CONCLUSIONS: IM residents learn to facilitate hospital discharges most often through direct patient care. Opportunities to interact with patients across the postdischarge continuum are uncommon, despite correlating with increased perceived responsibility for ensuring safe transitions of care.

Screening for critical illness polyneuromyopathy with single nerve conduction studies.

PURPOSE: The ability to diagnose patients with critical illness polyneuromyopathy (CIPNM) is hampered by impaired patient sensorium, technical limitations, and the time-intensive nature of performing electrophysiological testing. Therefore, we sought to determine whether single nerve conduction studies (NCS) could accurately screen for CIPNM. METHODS: Critically ill patients at increased risk for developing CIPNM were identified. Bilateral NCS of six nerves, and concentric needle electromyography were performed within 24 h of meeting inclusion criteria, and subsequently on a weekly basis until CIPNM was diagnosed or the patient was discharged from the intensive care unit (ICU). RESULTS: A total of 75 patients were enrolled into the study. Patients who developed CIPNM had a higher hospital mortality (50 vs. 13%, p = 0.002), and fewer ICU-free days (0 vs. 11, p = 0.04). There were no differences between the right and left amplitudes (p = 0.59, 0.91, and 0.21) for nerves that could be simultaneously tested bilaterally (sural, peroneal, and tibial). The amplitudes for each of the six individual nerves were significantly diminished in patients with CIPNM when compared to patients without CIPNM. The nerves with the best diagnostic accuracy were the peroneal nerve [AUC = 0.8856; sensitivity = 94% (95% CI = 88-100%); specificity = 74% (95% CI = 63-85%)], and the sural nerve [AUC = 0.8611; sensitivity = 94% (95 % CI = 88-100%); specificity = 70% (95 % CI = 59-81%)]. The combined diagnostic accuracy for the amplitudes of the peroneal and sural nerves increased significantly [AUC = 0.9336; sensitivity = 100% (95% CI = 100-100%) and specificity = 81% (95% CI = 71-91%)]. CONCLUSIONS: Unilateral peroneal and sural NCS can accurately screen for CIPNM in ICU patients and detect a limited number of patients that would need concentric needle electromyography to confirm a diagnosis of CIPNM. These results identify a more streamlined method to diagnose CIPNM that may facilitate routine diagnostic testing and monitoring of weakness in critically ill patients.

A multifaceted intervention to implement guidelines did not affect hospitalization rates for nursing home-acquired pneumonia.

OBJECTIVE: Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home-acquired pneumonia (NHAP) affected hospitalization rates. DESIGN: Quasi-experimental, mixed-methods, multifaceted, unblinded intervention trial. SETTING: Sixteen nursing homes (NHs) from 1 corporation: 8 in metropolitan Denver, CO; 8 in Kansas and Missouri during 3 influenza seasons, October to April 2004 to 2007. PARTICIPANTS: Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI); NH staff and physicians were eligible. INTERVENTION: Multifaceted, including academic detailing to clinicians, within-facility nurse change agent, financial incentives, and nursing education. MEASUREMENTS: Subjects' NH medical records were reviewed for resident characteristics, disease severity, and care processes. Bivariate analysis compared hospitalization rates for subjects with stable and unstable vital signs between intervention and control NHs and time periods. Qualitative interviews were analyzed using content coding. RESULTS: Hospitalization rates for stable residents in both NH groups remained low throughout the study. Few critically ill subjects in the intervention NHs were hospitalized in either the baseline or intervention period. In control NHs, 8.7% of subjects with unstable vital signs were hospitalized during the baseline and 33% in intervention year 2, but the difference was not statistically significant (P = .10). Interviews with nursing staff and leadership confirmed there were significant pressures for, and enablers of, avoiding hospitalization for treatment of acute infections. CONCLUSIONS: Secular pressures to avoid hospitalization and the challenges of reaching NH physicians via academic detailing are likely responsible for the lack of intervention effect on hospitalization rates for critically ill NH residents.

Impact of a multidisciplinary intervention on antibiotic use for nursing home-acquired pneumonia.

BACKGROUND: Academic detailing in nursing homes (NHs) has been shown to improve drug use patterns and adherence to guidelines. OBJECTIVE: The purpose of this study was to evaluate the impact of a multidisciplinary intervention that included academic detailing on adherence to national nursing home-acquired pneumonia (NHAP) guidelines related to use of antibiotics. METHODS: This quasi-experimental study evaluated the effects of a 2-year multifaceted and multidisciplinary intervention targeting implementation of national evidence-based guidelines for NHAP. Interventions took place in 8 NHs in Colorado; 8 NHs in Kansas and Missouri served as controls. Interventions included (1) educational sessions for nurses to improve recognition and timely treatment of NHAP symptoms and (2) academic detailing to clinicians by pharmacists regarding diagnostic and prescribing practices. Differences in antibiotic use between groups were compared after 2 intervention years relative to baseline. RESULTS: A total of 549 episodes of NHAP were evaluated in the intervention group and 574 in the control group. Compared with baseline, 1 facility in the intervention group significantly improved in guideline adherence for optimal antibiotic use (P = 0.007), whereas no facilities in the control group improved. The mean adherence score for optimal antibiotic use in intervention NHs increased from 60% to 66%, whereas the control NHs increased from 32% to 39% (P = 0.3). Mean adherence to guidelines recommending antibiotic use within 4 hours of NHAP diagnosis increased from 57% to 75% in intervention NHs but decreased from 38% to 31% in control NHs (P = 0.0003 for difference). There was no difference between intervention and control NHs for guideline adherence regarding optimal duration of antibiotic use. CONCLUSIONS: The ability of this multifaceted study to repeatedly remind nursing staff of the importance of timely antibiotic administration contrasts with its limited academic detailing interaction with clinicians. This difference within the intervention may explain the differential impact of the intervention on antibiotic guideline adherence.

Impact of NHAP guideline implementation intervention on staff and resident vaccination rates.

OBJECTIVES: Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home acquired pneumonia (NHAP), including influenza and pneumococcal vaccination, improves resident subject and staff vaccination rates. METHODS: Quasi-experimental, mixed-methods multifaceted intervention trial conducted at 16 nursing homes (NHs) from 1 corporation (8 in metropolitan Denver, Colorado; 8 in Kansas and Missouri) during 3 influenza seasons, October to April 2004 to 2007. Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI) and NH staff and physicians were eligible. Subjects' NH records were reviewed for vaccination. Each director of nursing (DON) completed a questionnaire assessing staffing and the number of direct care staff vaccinated against influenza. DONs and study liaison nurses were interviewed after the intervention. Bivariate analysis compared vaccination outcomes and covariates between intervention and control homes, and risk-adjusted models were fit. Qualitative interview transcripts were analyzed using content coding. RESULTS: No statistically significant relationship between the intervention and improved resident vaccination rates was found, so other factors associated with improved rates were explored. Estimated direct patient care staff vaccination rates were better during the baseline and improved more in the intervention NHs. Qualitative results suggested that facility-specific factors and national policy changes impacted vaccination rates. CONCLUSIONS: External factors influence staff and resident vaccination rates, diluting the potential impact of a comprehensive program to improve care for NHAP on vaccination.