Disseminated Balamuthia mandrillaris Infection.

Balamuthia mandrillaris is a rare cause of human infection, but when infections do occur, they result in high rates of morbidity and mortality. A case of disseminated Balamuthia infection is presented. Early diagnosis and initiation of recommended therapy are essential for increased chances of successful outcomes.

Bringing technology to the bedside: using smartphones to improve interprofessional communication.

The purpose of this project was to evaluate the impact of using Smartphones at the bedside on the quality of interprofessional communication and measure the response time between nurses and physicians compared with the usual paging device. Smartphones were provided to nurses and physicians on a 26-bed medical unit during a 2-month study period. Data were collected using Nurse-Physician Communication Questionnaires and Time and Motion data collection tools. Baseline data gathered from a convenience sample of general medicine nurses (n=61) and physicians (n=44) indicated that both nurses and physicians were dissatisfied with the current one-way paging devices and were frequently interrupted during patient care (P=.000). Postimplementation data suggested that the use of Smartphones significantly reduced patient interruptions (P=.021), allowed nurses to stay with patients (P=.002), and reduced wait times for a returned call (P=.001). Nurse travel time to answer a telephone call and time spent on hold by nurses and physicians also decreased by 100% from a range of 8 to 79 minutes down to 0 minutes. Staff reported improvement in quality of communication, and significant workflow efficiency was noted. Further research on the impact on patient safety and satisfaction is needed and other nursing units should consider implementing Smartphones within their medical centers.

A novel virtual course to teach medical students high-value decision-making.

BACKGROUND: Although a clinician's ability to employ high-value decision-making is influenced by training, many undergraduate medical education programmes lack a formal curriculum in high-value, cost-conscious care. We present a curriculum developed through a cross-institutional collaboration that was used to teach students at two institutions about this topic and can serve as a framework for other institutions to develop similar curricula. APPROACH: The faculty from the University of Virginia and the Johns Hopkins University School of Medicine created a 2-week-long online course to teach medical students the fundamentals of high-value care. The course consisted of learning modules, clinical cases, textbook studies, journal clubs and a competitive 'Shark Tank' final project where students proposed a realistic intervention to promote high-value clinical care. EVALUATION: Over two-thirds of students rated the course's quality as excellent or very good. Most found the online modules (92%), assigned textbook readings (89%) and 'Shark Tank' competition (83%) useful. To evaluate the student's ability to apply the concepts learned during the course in clinical contexts, we developed a scoring rubric based on the New World Kirkpatrick Model to evaluate students' proposals. Groups chosen as finalists (as determined by faculty judges) were more likely to be fourth-year students (56%), achieved higher overall scores (p = 0.03), better incorporated cost impact at several levels (patient, hospital and national) (p = 0.001) and discussed both positive and negative impacts on patient safety (p = 0.04). IMPLICATIONS: This course provides a framework for medical schools to use in their teaching of high-value care. Cross-institutional collaboration and online content overcame local barriers such as contextual factors and lack of faculty expertise, allowed for greater flexibility, and enabled focused curricular time to be spent on a capstone project competition. Prior clinical experience amongst medical students may be an enabling factor in promoting application of learning related to high-value care.

Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.

BACKGROUND: Resident duty hour restrictions have resulted in more frequent patient care handoffs, increasing the need for improved quality of residents' sign-out process. OBJECTIVE: To characterize resident sign-out process and identify effective strategies for quality improvement. DESIGN: Mixed methods analysis of resident sign-out, including a survey of resident views, prospective observation and characterization of 64 consecutive sign-out sessions, and an appreciative-inquiry approach for quality improvement. PARTICIPANTS: Internal medicine residents (n = 89). INTERVENTIONS: An appreciative inquiry process identified five exemplar residents and their peers' effective sign-out strategies. MAIN MEASURES: Surveys were analyzed and observations of sign-out sessions were characterized for duration and content. Common effective strategies were identified from the five exemplar residents using an appreciative inquiry approach. KEY RESULTS: The survey identified wide variations in the methodology of sign-out. Few residents reported that laboratory tests (13%) or medications (16%) were frequently accurate. The duration of observed sign-outs averaged 134 ±73 s per patient for the day shift (6 p.m.) sign-out compared with 59 ± 41 s for the subsequent night shift (8 p.m.) sign-out for the same patients (p = 0.0002). Active problems (89% vs 98%, p = 0.013), treatment plans (52% vs 73%, p = 0.004), and laboratory test results (56% vs 80%, p = 0.002) were discussed less commonly during night compared with day sign-out. The five residents voted best at sign-out (mean vote 11 ± 1.6 vs 1.7 ± 2.3) identified strategies for sign-out: (1) discussing acutely ill patients first, (2) minimizing discussion on straightforward patients, (3) limiting plans to active issues, (4) using a systematic approach, and (5) limiting error-prone chart duplication. CONCLUSIONS: Resident views toward sign-out are diverse, and accuracy of written records may be limited. Consecutive sign-outs are associated with degradation of information. An appreciative-inquiry approach capitalizing on exemplar residents was effective at creating standards for sign-out.

What strategies are used by clinician champions to reduce low-value care?

Background: Clinician champions are front-line clinicians who advocate for and influence practice change in their local context. The strategies they use when leading efforts to reduce the use of low-value care have not been well described. The purpose of this study is to identify and describe strategies used by six clinician champions who led a low-value care initiative in their clinical setting. Methods: Qualitative data collected during an overuse reduction initiative led by clinician champions were used to identify strategies, guided by the Expert Recommendations for Implementing Change compilation of strategies. Clinician champions were asked to rank the importance of these activities and indicate which one of the six most important activities they would be willing to discuss in an interview. A 30-min semi-structured interview was conducted with each clinician about the activity they selected and thematically analyzed. Results: Twelve Expert Recommendations for Implementing Change strategies were identified. The top six strategies discussed during interviews were: build a coalition, conduct a local needs assessment, develop a formal implementation blueprint, conduct educational meetings, use facilitation, and develop clinical reminders. Common themes that emerged across all interviews were the use of data to engage clinicians in conversations, including the patient's perspective in designing the interventions, and investing the time upfront to plan and launch the initiative because of the inherent challenges of relinquishing a service. Conclusions: Clinician champions identified multiple strategies as important when de-implementing a low-value service. Many were used to engage in conversations with stakeholders, including leadership, providers, and patients, to increase buy-in and support, challenge beliefs, promote behavior change, and gather insights about next steps in their effort. Future work is needed to better understand how prepare clinicians for this role and to understand the mechanisms through which these strategies might be effective.

Considering Factors of and Knowledge About Patients in Handover Assessment.

The healthcare system is moving from one primary physician who assumes responsibility for each patient to a more team-based approach. Thus, assessing team communication is critical. This study characterizes and assesses the quality of hospitalist handover communications at shift change using the literature recommended content and language form elements. Quality handovers should contain the following content: patient identifiers, active issues, and care plans. Quality handovers also should include utterances in the following language forms: explanations, rationales, and directives. Interviews, observation, recording, and conversation analysis of hospitalist handover communications were used. Hospitalist handover utterances were assigned both content and language form codes. The proportion of quality element verbalization across all patient handovers was calculated. In addition, the impact of patient factors (new admission, new problem, acuity level) and handover receiver knowledge on the inclusion of quality elements was examined. The 106 individual patient handovers across 16 handover sessions were recorded. 39% contained all six quality elements. While the majority of handovers contained five out of six quality elements, only 48% included directives. There was also no difference in the inclusion of quality elements based on patient factors or handover receiver knowledge. Hospitalist handovers are lacking in directives. Efforts to improve handovers through enhanced electronic medical record systems and training may need to expand to hospitalists and other attending level physicians.