Initial evidence of reliability and validity of an implicit association test assessing attitudes toward individuals who use substances.

Background: Substance use disorders (SUDs) are stigmatized conditions, with individual biases driving poor health outcomes. There are surprisingly few validated measures of bias or stigma toward individuals who use substances. Bias can be classified as explicit (self-report) or implicit (behaviorally based).Objectives: The goal of the present study was to establish preliminary indices of reliability and validity of an implicit association test (IAT) designed to measure implicit bias toward individuals who use substances.Methods: A large United States-based, crowd-sourced sample (n = 394, 51.5% male, 45.4% female, 2.5% nonbinary) completed the IAT and a small battery of survey instruments that assessed social distance to mental illness (including heroin use), attitude toward and perceived controllability of injection drug use, perception of public stigma, and social desirability.Results: Nearly all (92%; n = 363) scores on the IAT indicated greater negative than positive attitudes toward those who use substances. Spearman-Brown corrected split-half reliability on the IAT scores was excellent, r = .953. Controlling for social desirability, IAT scores positively correlated with all included measures pertaining to substance use as well as social distance for heroin and schizophrenia (but not diabetes). A principal component analysis resulted in two interpretable components representing disapproval (perceived controllability and negative attitudes) and perceived stigma (social stigma and social distance). Scores on the IAT positively correlated to scores on both components, again, controlling for social desirability.Conclusion: These results provide compelling preliminary evidence of validity of an IAT designed to measure bias toward individuals who use substances.

Hawks and Doves: Perceptions and Reality of Faculty Evaluations.

OBJECTIVES: Internal medicine clerkship grades are important for residency selection, but inconsistencies between evaluator ratings threaten their ability to accurately represent student performance and perceived fairness. Clerkship grading committees are recommended as best practice, but the mechanisms by which they promote accuracy and fairness are not certain. The ability of a committee to reliably assess and account for grading stringency of individual evaluators has not been previously studied. METHODS: This is a retrospective analysis of evaluations completed by faculty considered to be stringent, lenient, or neutral graders by members of a grading committee of a single medical college. Faculty evaluations were assessed for differences in ratings on individual skills and recommendations for final grade between perceived stringency categories. Logistic regression was used to determine if actual assigned ratings varied based on perceived faculty's grading stringency category. RESULTS: "Easy graders" consistently had the highest probability of awarding an above-average rating, and "hard graders" consistently had the lowest probability of awarding an above-average rating, though this finding only reached statistical significance only for 2 of 8 questions on the evaluation form (P = .033 and P = .001). Odds ratios of assigning a higher final suggested grade followed the expected pattern (higher for "easy" and "neutral" compared to "hard," higher for "easy" compared to "neutral") but did not reach statistical significance. CONCLUSIONS: Perceived differences in faculty grading stringency have basis in reality for clerkship evaluation elements. However, final grades recommended by faculty perceived as "stringent" or "lenient" did not differ. Perceptions of "hawks" and "doves" are not just lore but may not have implications for students' final grades. Continued research to describe the "hawk and dove effect" will be crucial to enable assessment of local grading variation and empower local educational leadership to correct, but not overcorrect, for this effect to maintain fairness in student evaluations.

A Qualitative Analysis of Hospitalist Perceptions of Self-Directed Discharge Among Inpatients with Opioid Use Disorder.

Background: People with opioid use disorder (OUD) have high rates of hospital admissions and high rates of patient-directed discharge, leading to significant morbidity and mortality. In this study, we aimed to understand hospitalist attitudes toward patients with OUD leaving before treatment completion and their willingness to collaborate with patients in future initiatives focused on improving the experience of hospital-based care for patients with OUD. Methods: We conducted semi-structured interviews with hospitalists at two hospitals in Philadelphia, PA to explore their perspectives on social and structural factors that contribute to patients with OUD leaving the hospital before treatment completion. Interviews were recorded, transcribed, and coded with NVivo using conventional content analysis. Results: Twenty-two hospitalists (64% female, 72.7% White, mean age 37) were interviewed between February and April 2021. Hospitalists listed the following as reasons for patients with OUD leaving before treatment completion: untimely and inadequate pain/withdrawal treatment, limited prescribing options in medications for OUD, restrictive visitor and smoking policies, and patient social and other obligations. Twenty out of 22 hospitalists were willing to engage in collaborative patient-centered care but noted institutional barriers. Conclusion: Hospitalists stated willingness to collaborate with patients on identifying and developing systems-level solutions that would allow for patient-centered care. In-hospital access to addiction consult service, staff with lived experience, and other culturally competent resources are key to reducing self-directed discharge, as is training to address stigma and reframe perceptions of appropriate dosing for pain and withdrawal. Hospitalists note a need for transitions to outpatient care after hospital discharge.

Medication Initiation, Patient-directed Discharges, and Hospital Readmissions Before and After Implementing Guidelines for Opioid Withdrawal Management.

OBJECTIVES: Rising rates of hospitalization for patients with opioid use disorder (OUD) result in high rates of patient-directed discharge (PDD, also called "discharge against medical advice") and 30-day readmissions. Interdisciplinary addiction consult services are an emerging criterion standard to improve care for these patients, but these services are resource- and expertise-intensive. A set of withdrawal guidelines was developed to guide generalists in caring for patients with opioid withdrawal at a hospital without an addiction consult service. METHODS: Retrospective chart review was performed to determine PDD, 30-day readmission, and psychiatry consult rates for hospitalized patients with OUD during periods before (July 1, 2017, to March 31, 2018) and after (January 1, 2019, to July 31, 2019) the withdrawal guidelines were implemented. Information on the provision of opioid agonist therapy (OAT) was also obtained. RESULTS: Use of OAT in patients with OUD increased significantly after guideline introduction, from 23.3% to 64.8% ( P < 0.001). Patient-directed discharge did not change, remaining at 14% before and after. Thirty-day readmissions increased 12.4% to 15.7% ( P = 0.05065). Receiving any OAT was associated with increased PDD and readmission, but only within the postintervention cohort. CONCLUSIONS: A guideline to facilitate generalist management of opioid withdrawal in hospitalized patients improved the process of care, increasing the use of OAT and decreasing workload on the psychiatry consult services. Although increased inpatient OAT has been previously shown to decrease PDD, in this study PDD and readmission rates did not improve. Guidelines may be insufficient to impact these outcomes.

Patient Safety Escape Room: A Team Simulation in Recognizing and Reporting Patient Safety Hazards.

Medical errors harm patients and increase costs. Engaging early clinicians in patient safety (PS) is critical but challenging. We evaluated the impact of a Patient Safety Escape Room (PSER) simulation on intern engagement in PS. During the PSER, learner teams identified PS hazards in a simulated hospital room, revealing clues that allow "escape" via event report entry. One-hundred twenty interns from 14 training programs completed 2 PSERs each. Before the PSER, 5% reported experience entering an event report. Following the PSER, all interns had participated in entering an event report. Mean learner-reported comfort in identifying PS hazards improved significantly (6.3 ± 1.57 to 8.0 ± 1.2; P < 0.001). Individual safety hazards were identified by between 6% and 100% of teams. Mean observer-rated teamwork was lower than learner-rated teamwork (41.5 ± 5.18 versus 45.92 ± 3.87; P = 0.01). Subsequent resident reporting rates did not increase compared with historic controls. The PSER engaged early learners, however, translating improvements into the clinical environment remains challenging.

"1,000 conversations I'd rather have than that one:" A qualitative study of prescriber experiences with opioids and the impact of a prescription drug monitoring program.

BACKGROUND: Prescription Drug Monitoring Programs (PDMPs) have shown impacts on a number of opioid-related outcomes but their role in clinician emotional experience of opioid prescribing has not been studied. OBJECTIVES: This study explores the impact of PDMPs on clinician attitudes toward and comfort with opioid prescribing, their satisfaction with patient interactions involving discussion of opioid prescriptions, and their recognition of opioid use disorder (OUD) and ability to refer patients to treatment. METHODS: Researchers conducted semi-structured interviews with five physicians and two nurse practitioners from a variety of specialties and practice environments. RESULTS: Many participants reported negative emotions surrounding opioid-related patient encounters, with decreased anxiety related to PDMP availability. These effects were less pronounced with clinicians who had greater opioid prescribing experience (either longer careers or higher-volume pain practices). Many participants felt uncomfortable around opioid prescribing. Data from the PDMP often changed prescribing practices, sometimes leading to greater comfort writing a prescription that might have felt riskier without PDMP data. Clinicians easily recognized patient behaviors, symptoms, and prescription requests suggesting that opioid-related adverse events were accumulating, but did not usually apply a label of OUD to these situations. PDMP findings occasionally contributed to a diagnosis and treatment referral for OUD. CONCLUSIONS: PDMP data is part of a nuanced approach to prescribing opioids. The objectivity of the data may be helpful in mitigating clinician negative emotions that are common around opioid therapy.

Hospitalist perspectives on buprenorphine treatment for inpatients with opioid use disorder.

Background: Patients with opioid use disorder (OUD) have high hospital admission rates. Hospitalists, clinicians that work in inpatient medical settings, may have a unique opportunity to intervene on behalf of these patients, yet their experience with and attitudes towards treating patients with OUD need further exploration. Methods: We conducted qualitative analysis of 22 semi-structured interviews with hospitalists between January and April 2021 in Philadelphia, PA. Participants were hospitalists in one major metropolitan university hospital and one urban community hospital in a city with a high prevalence of OUD and overdose deaths. Participants were asked about their experiences, successes, and difficulties in treating hospitalized patients with OUD. Results: Twenty-two hospitalists were interviewed. Participants were majority female (14, 64%) and White (16, 73%). We identified the following common themes: lack of training/experience with OUD, a lack of community OUD treatment infrastructure, a lack of inpatient OUD/withdrawal treatment resources, the "X-waiver" as a barrier to prescribing buprenorphine, the "ideal" patient to start on buprenorphine, and the hospital as an ideal intervention setting. Conclusions: Hospitalization due to acute illness or complication of drug use represents a potential intervention point to initiate treatment for patients with OUD. While hospitalists exhibit willingness to prescribe medications, provide harm reduction education, and link patients to outpatient addiction treatment, they identify training and infrastructure barriers that must first be addressed.

Use of a structured approach and virtual simulation practice to improve diagnostic reasoning.

OBJECTIVES: In 2015, the National Academy of Medicine IOM estimated that 12 million patients were misdiagnosed annually. This suggests that despite prolonged training in medical school and residency there remains a need to improve diagnostic reasoning education. This study evaluates a new approach. METHODS: A total of 285 medical students were enrolled in this 8 center, IRB approved trial. Students were randomized to receive training in either abdominal pain (AP) or loss of consciousness (LOC). Baseline diagnostic accuracy of the two different symptoms was assessed by completing a multiple-choice question (MCQ) examination and virtual patient encounters. Following a structured educational intervention, including a lecture on the diagnostic approach to that symptom and three virtual patient practice cases, each student was re-assessed. RESULTS: The change in diagnostic accuracy on virtual patient encounters was compared between (1) baseline and post intervention and (2) post intervention students trained in the prescribed symptom vs. the alternate symptom (controls). The completeness of the student's differential diagnosis was also compared. Comparison of proportions were conducted using χ2-tests. Mixed-effects regressions were used to examine differences accounting for case and repeated measures. Compared with baseline, both the AP and LOC groups had marked post-intervention improvements in obtaining a correct final diagnosis; a 27% absolute improvement in the AP group (p<0.001) and a 32% absolute improvement in the LOC group (p<0.001). Compared with controls (the groups trained in the alternate symptoms), the rate of correct diagnoses increased by 13% but was not statistically significant (p=0.132). The completeness and efficiency of the differential diagnoses increased by 16% (ß=0.37, p<0.001) and 17% respectively (ß=0.45, p<0.001). CONCLUSIONS: The study showed that a virtual patient platform combined with a diagnostic reasoning framework could be used for education and diagnostic assessment and improved correct diagnosis compared with baseline performance in a simulated platform.

How I Do It: PureWick female external catheter: a non-invasive urine management system for incontinent women.

Catheter associated urinary tract infections (CAUTIs) are common hospital-acquired infections and remain a significant medical and financial challenge to the healthcare system. Despite this risk, incontinent women may require prolonged catheterization to accurately monitor urine output and prevent skin breakdown. The PureWick Female External Urinary Catheter is a promising non-invasive urine collection system for use in incontinent women that may help reduce CAUTI rates, maintain skin integrity, accurately quantify urine output, and avoid extra healthcare costs.

Making Room at the Bedside: Improving Communication Alongside Medical Education Through Interdisciplinary Rounds.

Interdisciplinary rounding has been shown to improve patient safety and provider engagement. Many models for interdisciplinary rounding have been proposed but few focus on preserving bedside medical education. The authors changed the interdisciplinary bedside rounding model to accommodate more time for medical education. The objective was to assess perceptions of communication, care coordination, and teamwork surrounding this change. Resident and attending physicians and unit-based nursing staff completed an anonymous online survey prior to and following the rounding intervention. Length of stay on medical units also was monitored prior to and following the rounding intervention. Following the intervention, there were perceived improvements in interdisciplinary communication, care coordination, and teamwork, and there were no significant changes in length of stay.

Development and Validation of a Web-Based Prediction Model for AKI after Surgery.

Background: AKI after surgery is associated with high mortality and morbidity. The purpose of this study is to develop and validate a risk prediction tool for the occurrence of postoperative AKI requiring RRT (AKI-dialysis). Methods: This retrospective cohort study had 2,299,502 surgical patients over 2015-2017 from the American College of Surgeons National Surgical Quality Improvement Program Database (ACS NSQIP). Eleven predictors were selected for the predictive model: age, history of congestive heart failure, diabetes, ascites, emergency surgery, hypertension requiring medication, preoperative serum creatinine, hematocrit, sodium, preoperative sepsis, and surgery type. The predictive model was trained using 2015-2016 data (n=1,487,724) and further tested using 2017 data (n=811,778). A risk model was developed using multivariable logistic regression. Results: AKI-dialysis occurred in 0.3% (n=6853) of patients. The unadjusted 30-day postoperative mortality rate associated with AKI-dialysis was 37.5%. The AKI risk prediction model had high area under the receiver operating characteristic curve (AUC; training cohort: 0.89, test cohort: 0.90) for postoperative AKI-dialysis. Conclusions: This model provides a clinically useful bedside predictive tool for postoperative AKI requiring dialysis.

Effect of a Female External Urinary Catheter on Incidence of Catheter-Associated Urinary Tract Infection.

Background Catheter-associated urinary tract infections (CAUTIs) can be fatal, and are a source of avoidable expense for patients and hospitals. Prolonged catheterization increases infection risk, and avoiding catheters is crucial for infection prevention. Male external urinary catheters are recommended as a tool to prevent the need for indwelling catheterization. Female external urinary catheters (FEUCs) have intermittently been marketed without wide adoption; one has recently become available but published data is limited. Objective This retrospective observational study was conducted to investigate the effect of FEUCs on indwelling catheter use and female CAUTIs. Methods FEUCs were introduced to intensive care units. CAUTI rates and indwelling catheter days were obtained before and after the introduction of the devices. Results  CAUTI rates decreased from 3.14 per 1000 catheter days to 1.42 per 1000 catheter days (p=0.013). Female indwelling catheter days decreased, while overall intensive care patient days increased. Conclusions Introduction of a FEUC was associated with a statistically significant decrease in CAUTI rate among female intensive care patients. The FEUC may prevent the need for indwelling catheters in some situations.

Patient Safety Escape Room: A Graduate Medical Education Simulation for Event Reporting.

Introduction: Although residents are on the front lines of patient care, they enter few formal patient safety reports on the adverse events and near misses they witness. Demonstrating the rationale and mechanics of reporting may improve this. Methods: We designed and implemented an escape room patient safety simulation to incorporate active learning, gamification, and adult learning theory into intern patient safety onboarding. Interns from all sponsoring institution programs participated, identifying, mitigating, and reporting a range of patient safety hazards. Props and faculty time were the major resources required. Results: One hundred twenty interns participated in this simulation in June 2018. Forty-one percent reported previous training on reporting errors, and only 5% had previously entered an event report. Average confidence in ability to identify patient safety hazards improved after the simulation from 6.35 to 8.00 on a 10-point rating scale. The simulation was rated as relevant or highly relevant to practice by 96% of interns. Discussion: Several factors contribute to a low error-reporting rate among house staff. We developed a simulation modeled on popular escape room activities to increase awareness of safety hazards and ensure familiarity with the actual online reporting system our interns will use in the clinical environment.

Electronic Health Record Skills Workshop for Medical Students.

Introduction: The adoption of electronic health records (EHRs) presents new challenges for information gathering, documentation, and patient care. Medical students spend a significant amount of time using the EHR during their clerkship experiences and will continue to do so as they progress to residency. However, formal training varies between institutions and leaves gaps in data-gathering skills, documentation skills, and order entry-these three skills formed the basis for our learning objectives. We designed a workshop using a simulated EHR to teach these skills. Methods: We offered the workshop during a class-wide transition-to-internship course for senior medical students. After a brief didactic, students worked in small groups using a simulated EHR to complete cases addressing each of the three learning objectives. Faculty facilitators assisted groups and then guided a large-group discussion of the challenges encountered during the cases. Results: Twenty-five senior medical students attended the first optional workshop. Of these students, 66.7% recommended that the workshop continue to be included in the curriculum. Comments from those who recommended otherwise suggested that many of them would recommend the workshop if it used our local EHR (Epic). Correct answers to the factual questions increased for most questions between the pretest and the posttest. Confidence to perform all skills targeted in the learning objectives increased between the pretest and the posttest. Discussion: This EHR workshop was well received by senior medical students and increased confidence in EHR skills, including data gathering, documentation, and handling unsolicited information with a plan including order entry.

Leveraging Structural Changes in an Electronic Health Record Tool to Standardize Written Handoff.

Miscommunications during patient handoff can lead to harm. The I-PASS bundle has been shown to improve safety outcomes. Although effective training reliably improves verbal handoffs, research has demonstrated a lack of effect on written handoffs. The objective was to compare written handoff before and after integration of a standardized electronic health record (EHR) tool. Interns at a large urban academic medical center underwent I-PASS handoff training. The EHR handoff tool was then revised to prompt the I-PASS components. Handoff documents were obtained before and after the intervention. More handoffs included Illness Severity (33% to 59%, P < .001) and Action List (65% to 83%, P = .005) after the intervention. There was no change in handoffs with miscommunications (12.5% to 10%, P = .566) or omissions (8% to 11%, P = .447). Handoffs including tangential or unrelated information decreased (20% to 4%, P = .001). A written handoff tool can reinforce the effect of training and increase adherence to I-PASS.

Effectiveness of 17-α-hydroxyprogesterone caproate on preterm birth prevention in women with history-indicated cerclage.

OBJECTIVE: To determine whether 17-α-hydroxyprogesterone caproate (17P) reduces the incidence of preterm birth in women with a history-indicated cerclage. STUDY DESIGN: Retrospective cohort study of women who received a cerclage for a prior preterm birth, analyzed based on exposure to 17P. The primary outcome variable was delivery < 35 weeks. Secondary outcomes were preterm birth < 37, 32, 28, and 24 weeks; interval between cerclage placement and delivery; gestational age at delivery; and infant birth weight. RESULTS: Fourteen women received 17P and 80 did not. Baseline characteristics did not differ between these two groups. Preterm delivery at < 35 weeks did not differ between those who received 17P and those who did not (29% versus 15%, p = 0.46). There were no significant differences between the groups for any other outcome. CONCLUSION: 17P does not appear to have an effect on preterm birth < 35 weeks in women with a history-indicated cerclage.