Design, Implementation, and Outcomes of an Interprofessional Mobile Web Application for Preceptors for Challenging Issues.

OBJECTIVE: The purpose of this study was to develop and assess an easily accessible interprofessional mobile web application to assist preceptors with challenging teaching and learning situations. METHODS: Phase 1 was a modified Delphi process of 48 advanced practice nursing, dentistry, medicine, and pharmacy preceptors to determine the content of the application. Phase 2 consisted of 12 preceptors from the 4 disciplines piloting a prototype to refine the tool using design-thinking principles. Feedback was analyzed using inductive coding and thematic analysis. Phase 3 evaluated the impact of the final tool on 80 preceptors' satisfaction, knowledge, self-efficacy, and perception of behavior change. RESULTS: Consensus on 10 topics was reached in the following 3 themes: feedback and communication, clinical and professional development of learners, and precepting efficiency. Preceptors rated the tool as efficient and applicable. Features perceived as useful included concise and applicable content that was easy to navigate with practical video examples. Features to improve included academic jargon, length of content, and lack of connectivity with other preceptors. Knowledge and self-efficacy improved after the use of the refined tool. Change in perceptions of behavior after 1 month was mixed, with a significant change in accessing resources to address challenging situations and regularly reflecting on challenging situations and no significant change in awareness, frequency, or success in managing challenging situations. CONCLUSION: An interprofessional mobile web application for challenging teaching and learning situations developed through a modified Delphi process was deemed efficient and relevant and demonstrated positive knowledge and self-efficacy change.

Teaching colleagues how to discuss prognosis as part of a hospital-wide quality improvement project: the positive impact of a 90-minute workshop.

BACKGROUND: Many physicians have difficulty with discussions about prognosis. The aims of this study were to evaluate why physicians struggle to discuss prognosis and to measure the effect of a 90-minute communication workshop on self-reported skill. MEASURES: An evaluation study was used with three measurement points: before the 90-minute communication workshop (e-mail survey); immediately after the workshop (paper survey); and one month after the workshop (e-mail survey). INTERVENTION: Physicians from diverse specialties at a single academic institution were paid to participate in a 90-minute communication workshop on discussing prognosis. OUTCOMES: Physicians identified several reasons why discussions of prognosis are hard: "I am not sure of the actual prognosis" (58.9%; 95% CI, 50.9, 66.5), "I worry I will take away hope (42.9%; 95% CI, 35.2, 50.9), and "I worry the patient is not ready to hear the information" (42.9%; 95% CI, 35.2, 50.9). Physicians who attended this short workshop reported that they could apply what was learned to their work immediately (4.6, range 1-5). One month after the workshop, 91% of respondents reported trying a skill learned in the workshop. The most frequently used skill was Ask/Tell/Ask (61.5%; 95% CI, 51.6, 70.6). CONCLUSIONS/LESSONS LEARNED: A short workshop on discussing prognosis was highly valued by physicians from diverse specialties and a majority reported using at least one of the communication skills learned.

Improving access to palliative care through an innovative quality improvement initiative: an opportunity for pay-for-performance.

BACKGROUND: Improving access to palliative care is an important priority for hospitals as they strive to provide the best care and quality of life for their patients. Even in hospitals with longstanding palliative care programs, only a small proportion of patients with life-threatening illnesses receive palliative care services. Our two well-established palliative care programs in large academic hospitals used an innovative quality improvement initiative to broaden access to palliative care services, particularly to noncancer patients. METHODS: The initiative utilized a combination of electronic and manual screening of medical records as well as intensive outreach efforts to identify two cohorts of patients with life-threatening illnesses who, according to University HealthSystems Consortium (UHC) benchmarking criteria, would likely benefit from palliative care consultation. Given the differing cultures and structure of the two institutions, each service developed a unique protocol for identifying and consulting on suitable patients. RESULTS: Consultation rates in the target populations tripled following the initiative: from 16% to 46% at one hospital and from 15% to 48% at the other. Although two different screening and identification processes were developed, both successfully increased palliative care consultations in the target cohorts. CONCLUSION: Quality improvement strategies that incorporate pay-for-performance incentives can be used effectively to expand palliative care services to underserved populations.

Is pacemaker deactivation at the end of life unique? A case study and ethical analysis.

Although there has been considerable controversy regarding the deactivation of pacemakers near the end of life, clinicians can expect to face more requests for pacemaker withdrawal as the number of implants grows. Despite a clear ethical and legal precedent, these requests may elicit significant psychological and moral distress on the part of the clinical team. We illustrate some of the difficulties clinicians may face by describing the case of a patient with end-stage heart failure who asked to have her pacemaker turned off near the end of life. We discuss the challenges in determining pacemaker dependency, differing attitudes toward deactivating pacemakers versus other cardiac devices, and how the issues of perceived burden and timing of death may contribute to a clinician's sense of moral distress.