MedIntegrate: Incorporating provincially funded community pharmacist services into an ambulatory internal medicine clinic to enhance medication reconciliation.

BACKGROUND: Medication reconciliation (MR) is associated with reduced discrepancies and adverse events within institutions. In ambulatory care, MR is often considered more challenging due to periodic, brief patient encounters and the involvement of multiple prescribers who lack shared records. MedsCheck, a community pharmacy program in Ontario for patients with diabetes or those taking 3 or more medications, generates a best possible medication history (BPMH) that can serve as a starting point for MR. Our objectives were to develop and evaluate a program to integrate MedsCheck into the workflow of an ambulatory clinic. METHODS: An initiative was implemented within the Complex Care Clinic (CCC), an academic internal medicine clinic at Women's College Hospital (WCH). During booking of their first appointment, patients were encouraged to receive a MedsCheck. A letter was faxed to the patient's preferred community pharmacy with a request to conduct a MedsCheck and send documentation to the clinic. Evaluation included patient and health care provider questionnaires and chart review. RESULTS: Fifty-five of 86 new patients referred to the CCC were eligible for a MedsCheck. Fifty-four patients consented to having their community pharmacy contacted, and documentation was received for 21 (39%) of these reviews. Chart review was conducted for patients who completed the patient feedback questionnaire (n = 32). Community pharmacists reported at least 1 drug therapy problem for 12 (57%) patients with a mean of 2.6 (SD 1.5) per patient. Medical residents reported an estimated mean appointment time savings of 7.9 minutes (SD 2.4). CONCLUSION: The program was feasibly integrated into clinic workflow and shortened the time spent creating BPMHs. This approach could be adopted by other ambulatory care clinics.

A scoping review of undergraduate ambulatory care education.

BACKGROUND: Since a disproportionate amount of medical education still occurs in hospitals, there are concerns that medical school graduates are not fully prepared to deliver efficient and effective care in ambulatory settings to increasingly complex patients. AIMS: To understand the current extent of scholarship in this area. METHOD: A scoping review was conducted by searching electronic databases and grey literature sources for articles published between 2001 and 2011 that identified key challenges and models of practice for undergraduate teaching of ambulatory care. Relevant articles were charted and assigned key descriptors, which were mapped onto Canadian recommendations for the future of undergraduate medical education. RESULTS: Most of the relevant articles originated in the United States, Australia, or the United Kingdom. Recommendations related to faculty development, learning contexts and addressing community needs had numerous areas of scholarly activity while scholarly activity was lacking for recommendations related to inter-professional practice, the use of technology, preventive medicine, and medical leadership. CONCLUSIONS: Systems should be established to support education and research collaboration between medical schools to develop best practices and build capacity for change. This method of scoping the field can be applied using best practices and recommendations in other countries.

Exploring Integration in Action: Competencies as Building Blocks of Expertise.

PURPOSE: Competency frameworks such as the CanMEDS roles and the ACGME core competencies may lead to the implicit assumption that physicians can learn and practice individual competencies in isolation. In contrast, models of adaptive expertise suggest that the integration of competencies reflects the capabilities of an expert physician. Thus, educational programming aimed at teaching discrete roles or competencies might overlook expert physician capabilities that are central to patient care. To develop expertise, learning opportunities must reflect expert capabilities. To better understand the relationship between competency-based medical education and expert development, the authors sought to explore how integrated competencies are enacted during patient care by postgraduate medical trainees. METHOD: Using a cognitive ethnographic approach, in 2014-2015 the authors conducted observations and-to refine and elaborate these observations-ad hoc informal interviews with 13 postgraduate trainee participants. Data collection resulted in 92 hours of observation, 26 patient case portraits, and a total of 220 pages of field notes for analysis. Through analysis, the authors identified and examined moments when postgraduate trainees appeared to be simultaneously enacting multiple competencies. RESULTS: The authors identified two key expert capabilities in moments of integrated competence: finding complexity and being patient-centered. They described two mechanisms for these forms of integration: valuing the patient's narrative of their illness, and integrated understanding. CONCLUSIONS: Understanding integrated competencies as the building blocks of expert capabilities, along with recognizing the importance of mechanisms that support integration, offers an opportunity to use existing competency-based frameworks to understand and teach adaptive expertise.

Are antiseptic-coated central venous catheters effective in a real-world setting?

BACKGROUND: Catheter-related bloodstream infections are common, costly, and morbid. Randomized controlled trials indicate that antiseptic-coated central venous catheters reduce infection rates. OBJECTIVE: To assess the clinical and economic effectiveness of antiseptic-coated catheters for critically ill patients in a real-world setting. METHODS: Central venous catheters coated with chlorhexidine/silver-sulfadiazene were introduced in all patients requiring central venous access in adult intensive care units at the University of Michigan Health System, a large, tertiary care teaching hospital. A pretest-posttest cohort design measured the primary outcome of catheter-related bloodstream infection rate, comparing the 2 years prior to the intervention with the 2 years following the intervention. We also evaluated cost-effectiveness and changes in vancomycin use. RESULTS: The intervention was associated with a 4% per month relative reduction in the incidence of catheter-related bloodstream infection, after controlling for the effects of time. Overall, a 35% relative risk reduction (P < .0003) in the catheter-related bloodstream infection rate occurred in the posttest phase. The use of antiseptic-coated catheters reduced costs more than $100,000 annually. Vancomycin use was less in units in which antiseptic catheters were used compared with wards in which these catheters were not used. CONCLUSION: Antiseptic-coated catheters appear to be clinically effective and economically efficient in a real-world setting.