South Texas Residency Screening, Brief Intervention, and Referral to Treatment (SBIRT) Training: 12-Month Outcomes.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious and cost-effective skill set when implemented in primary care settings regarding hazardous alcohol use. This study assesses the impact of medical resident SBIRT training across 3 specialties and identifies predictors of change in trainee behavior, attitudes, and knowledge over 12 months. METHODS: This program's substance use SBIRT training was developed and tailored to fit diverse curricular objectives and settings across an array of medical residency programs in South Texas. The 329 residents training in pediatrics, family medicine, and internal medicine during 2009-2012 constituted the trainee group reported in this analysis. Surveys assessing SBIRT-related knowledge, current practice, confidence, role responsibility, attitudes, beliefs, and readiness to change were completed by 234 (71%) trainees at 3 time points: pre-training, then 30 days and 12 months post-initial training. RESULTS: SBIRT-related knowledge, confidence, and practice increased from pre-training to 12-month follow-up. Residents who reported the least amount of pre-training clinical and/or prior academic exposure to substance use reported the greatest SBIRT practice increases. When controlling for demographic and prior exposure variables, the largest contributor to variance in SBIRT practice was attributed to residents' confidence in their SBIRT skills. CONCLUSIONS: SBIRT training that employs diverse educational methodologies as part of customizing the training to residency specialties can similarly enhance SBIRT-related knowledge, confidence, and practice. Trainee report of limited prior clinical or academic exposure to substance use and/or low confidence regarding SBIRT skills and their professional role responsibilities related to substance use predicted trainee success and sustained SBIRT strategy application. When customizing SBIRT training, curriculum developers should consider leveraging and capacity building related to those factors predicting continued use of SBIRT practices.

Exploring end-of-residency transitions in a VA Patient Aligned Care Team.

BACKGROUND: End-of-residency transitions create disruptions in primary care continuity. The national implementation of Patient Aligned Care Teams (PACT) in Veterans Health Administration (VA) primary care clinics creates an opportunity to mitigate this discontinuity through the provision of team-based care. OBJECTIVES: To identify team-based solutions to end-of-residency transitions in a resident PACT continuity clinic by assessing the knowledge, attitudes, and perceptions of non-physician PACT members and resident PACT physicians. DESIGN AND PARTICIPANTS: Cross-sectional survey of 27 resident physicians and 24 non-physician PACT members in the Internal Medicine Clinic at the Audie L. Murphy VA Hospital in the South Texas Veterans Health Care System. RESULTS: Twenty-seven residents and 24 non-physician PACT members completed the survey, with response rates of 90 % and 100 %, respectively. All residents and 96 % of non-physician PACT members agreed or strongly agreed that the residents were responsible for informing patients about end-of-residency transitions. Only 38 % of non-physician PACT members versus 52 % of residents indicated that non-physician PACT members should be responsible for this transition. Approximately 80 % of resident physicians and non-physician PACT members agreed there should be a formalized approach to these transitions; 67 % of non-physician PACT members were willing to support this transition. Potential barriers to team-based care transitions were identified. Major themes of write-in suggestions for improving the transition focused on communication and relationships between the patient and PACT and among the PACT members. CONCLUSIONS: PACT implementation changes the roles and relationship structures among all team members. While end-of-residency transitions create a disruption in the relationship system, the remainder of the PACT may bridge this transition. Our results demonstrate the importance of a team-based solution that engages all PACT members by improving communication and fostering effective team relationships.

Preoperative evaluation for postoperative pulmonary complications.

Preoperative risk assessment for postoperative pulmonary complications is essential when counseling patients about the risks of surgery because of their significant associated morbidity and mortality. There are many patient-related, operation-related, and anesthesia-related risk factors for the development of PPCs. Though many of these risk factors are not modifiable, they can be useful in evaluating preoperative risk, especially when combined into formal risk indices. Preoperative risk assessment enables clinicians to target preoperative testing and perioperative risk reduction strategies to high-risk patients. Reducing PPC risk at the patient level will require a greater understanding of the impact of modifying risk factors through interventional trials. Reducing hospital PPC rates will require future research into the processes of care associated with PPCs through controlled observational and interventional trials.

Preoperative pulmonary update.

Postoperative pulmonary complications are an important source of surgical morbidity. In this paper, the authors review recent studies that shed light on emerging risk factors, a multifactorial index for respiratory failure, and the value of specific risk reduction strategies. Novel risk factors include advanced age, congestive heart failure, pulmonary hypertension, and obstructive sleep apnea. Important risk reduction strategies include postoperative lung expansion maneuvers, the selective use of nasogastric tubes, epidural analgesia, and inspiratory muscle training.