Improving Transitions of Care for Hospitalized Patients on Warfarin.

BACKGROUND: Transitions in care create challenges for warfarin management, including dosing errors, medication nonadherence, and/or insufficient monitoring. Adverse drug events from warfarin following transitions have been found to have serious consequences. Before the intervention, at the time of hospital discharge, individual physicians identified warfarin management plans on paper forms on the basis of their personal practice preferences. With the implementation of a computerized physician order entry in the electronic health record (EHR) in November 2010, the paper form became obsolete. A modification to the EHR created an order prompting physicians to include five key elements for warfarin management on discharge. A study was conducted to assess the impact of this intervention as a communication tool for patients and health care providers. METHODS: Discharge documentation was retrospectively reviewed for warfarin patients discharged from University of Missouri (MU) Health Care (Columbia). Frequencies of documentation in the EHR of five key elements of warfarin management were calculated (indication for anticoagulation, target International Normalized Ratio (INR) range, anticipated duration of therapy, date of next INR, and posthospital provider to manage warfarin therapy) pre- and post-EHR modification. RESULTS: All five key elements were included in the discharge documents for 268 (42%) of the charts for 633 patients in the preintevention (baseline) period, for 297 (78%) of the 382 charts in the first postintervention period (September 15, 2013-March 15, 2014) and for 574 (61%) of the 943 charts in the second postintervention period (March 16, 2014-August 5, 2015). CONCLUSIONS: Although limited to one health care system's experience, this study demonstrates the EHR's potential value in assisting with anticoagulation therapy between outpatient and inpatient settings and across multiple providers.

Common Skin Rashes in Children.

Because childhood rashes may be difficult to differentiate by appearance alone, it is important to consider the entire clinical presentation to help make the appropriate diagnosis. Considerations include the appearance and location of the rash; the clinical course; and associated symptoms, such as pruritus or fever. A fever is likely to occur with roseola, erythema infectiosum (fifth disease), and scarlet fever. Pruritus sometimes occurs with atopic dermatitis, pityriasis rosea, erythema infectiosum, molluscum contagiosum, and tinea infection. The key feature of roseola is a rash presenting after resolution of a high fever, whereas the distinguishing features in pityriasis rosea are a herald patch and a bilateral and symmetric rash in a Christmas tree pattern. The rash associated with scarlet fever usually develops on the upper trunk, then spreads throughout the body, sparing the palms and soles. Impetigo is a superficial bacterial infection that most commonly affects the face and extremities of children. Erythema infectiosum is characterized by a viral prodrome followed by the "slapped cheek" facial rash. Flesh-colored or pearly white papules with central umbilication occur with molluscum contagiosum, a highly contagious viral infection that usually resolves without intervention. Tinea is a common fungal skin infection in children that affects the scalp, body, groin, feet, hands, or nails. Atopic dermatitis is a chronic, relapsing inflammatory skin condition that may present with a variety of skin changes.

Linking health professional learners and health care workers on action-based improvement teams.

BACKGROUND AND METHODS: Medical students, nursing students, and other health care professionals in training were integrated with health care workers on interprofessional quality improvement (QI) teams at our academic health center. Teams received training in QI, accompanied by expert QI mentoring, with dual goals of increasing expertise in improvement while improving care. RESULTS: Eighty-six learners and health system workers participated in 12 improvement teams in 2 years. Upon completion of the training, participants expressed that the program enhanced QI and teamwork skills and increased understanding of other health care professions. At the end of the program, fourth-year medical students showed greater ability to apply QI skills, as measured by the QI Knowledge Assessment Tool than did control students who did not participate in the program (P < .0001 in 2006-2007 and P < .0005 in 2007-2008). Many teams were successful in improving care processes. CONCLUSION: The design of "learning QI by doing," accompanied by just-in-time training and ongoing expert mentoring in QI, was identified by faculty as the most important factor contributing to success. This model successfully improved application of QI skills by learners while improving care within our academic health center. Testing of the model at other academic health centers and in other training environments is warranted.

The family medicine chief resident: a national survey of leadership development.

BACKGROUND AND OBJECTIVES: The chief resident position is a potential incubator for future leaders in family medicine. This national survey of family medicine residency programs shows that 97% of programs have a chief resident, and 84% of these are in their third year of training. However, the responsibilities, preparation, and selection for this role vary widely. At the University of Missouri (MU), we developed a unique leadership curriculum to enhance training for this role that includes attendance at leadership conferences, acquisition of specific skills such as time management and communication, defined responsibilities, and administrative time to complete duties. A survey of former MU chief residents found that aspects of the position such as leadership training and increased exposure to faculty were most valued while schedule tasks were seen as least desirable. Former chief residents were more likely to teach medical students or residents in their current practice compared to those who had not been a chief resident.

PURLS: A-fib and rate control: don't go too low.

For patients with atrial fibrillation, more relaxed heart rate control is as effective as stricter control but, with fewer adverse effects.

Help smokers quit: tell them their "lung age".

Perform spirometry on patients who smoke-even if they're asymptomatic-and show them their lung age-that is, the average age of a nonsmoker with a forced expiratory volume at 1 second (FEV1) equal to theirs. Doing so can help patients kick the habit.