A Retrospective Cohort Study of the Impact of Nurse Practitioners on Hospitalized Patient Outcomes.

The role of advanced practice providers has expanded in the hospital setting. However, little data exist examining the impact of these providers. Our purpose was to determine the effect of adding nurse practitioners in a complementary role on the quality and efficiency of care of hospitalized patients. A retrospective cohort study evaluated adult patients admitted by private physicians (without house staff or non-physician providers) to a general medical-surgical unit in an academic medical center. The admissions department allocated patients as beds became available and nurse practitioners were assigned to patients until their caseload was reached. Outcomes included length of hospital stay, in-hospital mortality, admission costs, 30-day readmissions, transfer to a more intensive care level, and discharge order time. Of the 382 patients included in this study, 263 were assigned to the nurse practitioner group. Hospital mortality was lower in the nurse practitioner group [OR 0.11 (95% CI 0.02-0.51)] as was transfer to more intensive care level [OR 0.39 (95% CI 0.20-0.75)]; however, the nurse practitioner group had longer length of stay (geometric mean = 5.80 days for nurse practitioners, 3.63 days for no nurse practitioners; p < 0.0001) and higher cost per patient (geometric mean = USD 6631 vs. USD 5121; p = 0.005). The results were unchanged when models were adjusted for potential confounders. Adding nurse practitioners can yield improved clinical outcomes (lower hospital mortality and fewer transfers to intensive care), but with a potential economic expense (longer hospital stays and higher costs).

Plasma trial: Pilot randomized clinical trial to determine safety and efficacy of plasma transfusions.

BACKGROUND: Plasma is frequently administered to patients with prolonged INR prior to invasive procedures. However, there is limited evidence evaluating efficacy and safety. STUDY DESIGN AND METHODS: We performed a pilot trial in hospitalized patients with INR between 1.5 and 2.5 undergoing procedures conducted outside the operating room. We excluded patients undergoing procedures proximal to the central nervous system, platelet counts <40,000/µl, or congenital or acquired coagulation disorders unresponsive to plasma. We randomly allocated patients stratified by hospital and history of cirrhosis to receive plasma transfusion (10-15 cc/kg) or no transfusion. The primary outcome was change in hemoglobin concentration within 2 days of procedure. RESULTS: We enrolled 57 patients, mean age 56.0, 34 (59.6%) with cirrhosis, and mean INR 1.92 (SD = 0.27). In the intention to treat analysis, there were 10 of 27 (38.5%) participants in the plasma arm with a post procedure INR <1.5 and one of 30 (3.6%) in the no treatment arm (p < .01). The mean INR after receiving plasma transfusion was -0.24 (SD 0.26) lower than baseline. The change from pre-procedure hemoglobin level to lowest level within 2 days was -0.6 (SD = 1.0) in the plasma transfusion arm and -0.4 (SD = 0.6) in the no transfusion arm (p = .29). Adverse outcomes were uncommon. DISCUSSION: We found no differences in change in hemoglobin concentration in those treated with plasma compared to no treatment. The change in INR was small and corrected to less than 1.5 in minority of patients. Large trials are required to establish if plasma is safe and efficacious.

Simulation as a Platform for Development of Entrustable Professional Activities: A Modular, Longitudinal Approach.

Background The Association of American Medical Colleges (AAMC) has recently identified a list of integrated activities to be expected of all medical school graduates entering residency: the core Entrustable Professional Activities (EPAs). Direct observation and deliberate practice of individual EPA behaviors in the clinical setting has multiple challenges, and there is limited literature describing a comprehensive, longitudinal curriculum dedicated to formative EPA assessment.  Approach We present a model curriculum to develop and provide formative assessment of EPA skills longitudinally throughout the clinical years. Each EPA-focused training session includes a simulation case followed by several small group activities with content related to the clinical vignette in the initial simulation. We have designed this curriculum to be longitudinal and modular, and present the general framework here.  Outcomes Step-wise implementation began in 2013. Over 450 medical students have participated in the third year (MS3) clerkship sessions, 30 in the MS4 sub-internship sessions, and over 300 thus far in the fourth year (MS4) capstone course, including students from 10 different medical schools. MS3 sessions focused on EPAs 4, 7, 8, 9, 10, and MS4 sessions had an additional focus on EPA 8. The capstone course encompassed nearly all 13 EPAs in active simulation-based learning. Opportunities to provide formative assessment through on-the-spot feedback exist throughout the curriculum. Student feedback was overwhelmingly positive. Next steps We found that simulations are an effective method of providing formative assessment of EPAs that are exceptionally well-received by medical students. We have demonstrated that these can be implemented for medical students from multiple educational backgrounds. We believe that deliberate practice and longitudinal formative assessment is of utmost importance in effectively developing core EPAs prior to final entrustment decisions.

Searching for answers to clinical questions using google versus evidence-based summary resources: a randomized controlled crossover study.

PURPOSE: To compare the speed and accuracy of answering clinical questions using Google versus summary resources. METHOD: In 2011 and 2012, 48 internal medicine interns from two classes at Rutgers University Robert Wood Johnson Medical School, who had been trained to use three evidence-based summary resources, performed four-minute computer searches to answer 10 clinical questions. Half were randomized to initiate searches for answers to questions 1 to 5 using Google; the other half initiated searches using a summary resource. They then crossed over and used the other resource for questions 6 to 10. They documented the time spent searching and the resource where the answer was found. Time to correct response and percentage of correct responses were compared between groups using t test and general estimating equations. RESULTS: Of 480 questions administered, interns found answers for 393 (82%). Interns initiating searches in Google used a wider variety of resources than those starting with summary resources. No significant difference was found in mean time to correct response (138.5 seconds for Google versus 136.1 seconds for summary resource; P = .72). Mean correct response rate was 58.4% for Google versus 61.5% for summary resource (mean difference -3.1%; 95% CI -10.3% to 4.2%; P = .40). CONCLUSIONS: The authors found no significant differences in speed or accuracy between searches initiated using Google versus summary resources. Although summary resources are considered to provide the highest quality of evidence, improvements to allow for better speed and accuracy are needed.

Evidence review: periprocedural use of blood products.

Blood product transfusion has not been subject to rigorous clinical study, and great practice variations exist. Of particular concern to hospitalists is the use of red blood cells, plasma, and platelets prior to invasive procedures to correct anemia or perceived bleeding risk. We summarize the known risks associated with periprocedural anemia, prolonged international normalized ratio (INR), and thrombocytopenia, as well as the effects of blood product administration on clinical outcomes. Clinical trial evidence argues for a restrictive red blood cell transfusion threshold (a hemoglobin level of 7-8 g/dL or symptomatic anemia) for most perioperative patients. There are no high-quality data to guide plasma and platelet transfusions around the time of procedures. Available data do not support the use of prothrombin time/INR to guide prophylactic administration of plasma, and there are scarce data to guide platelet use around the time of an invasive procedure. Therefore, we rely on current consensus expert opinion, which recommends administration of plasma in moderate- to high-risk procedures when INR is >1.5. We recommend platelet transfusion in low-risk procedures when platelet count is <20,000/µL, for average-risk procedures when platelet count is <50,000/µL, and for procedures involving the central nervous system when the platelet count is <100,000/µL.

Red blood cell transfusion: what is the evidence when to transfuse?

PURPOSE OF REVIEW: This review provides a summary of the clinical trials evaluating transfusion thresholds and recommendations for red blood cell transfusion. We highlight the trial results in patients in the critical care setting, undergoing surgery, and patients with gastrointestinal bleed, acute coronary syndrome, and acute brain injury. RECENT FINDINGS: Clinical trials in hip fracture patients with underlying cardiovascular disease or risk factors, and in cardiac surgery, support the findings from prior studies in intensive care unit patients that restrictive transfusion (7-8 g/dl) is well tolerated even in elderly high-risk patients. Restrictive transfusion strategy (7 g/dl) was further supported by the statistically lower mortality in patients with gastrointestinal bleeding compared with liberal transfusion (10 g/dl) strategy. Pilot trials in acute coronary syndrome raise the possibility that liberal transfusion improves outcome, but large trials are needed. SUMMARY: A restrictive transfusion strategy of administering red blood cell transfusion in patients with hemoglobin concentration of 7-8 g/dl in most patients is supported by randomized clinical trials. Further randomized clinical trials are needed to establish the optimal transfusion threshold in patients with acute coronary syndrome and brain injury, and to elucidate physiological triggers.