A systematic review of evidence-based practices for clinical education and health care delivery in the clinical teaching unit.

BACKGROUND: The clinical teaching unit is a widespread clinical training model that requires reform to prepare physicians for practice in the 21st century. In this systematic review, we aimed to identify evidence-based practices in internal medicine clinical teaching units that contribute to improved clinical education and health care delivery. METHODS: We searched several databases from 1993 until Apr. 5, 2021, to identify published studies in inpatient clinical teaching units that involved medical trainees and reported outcomes related to trainee education or health care delivery. We identified emergent themes using a narrative approach and determined confidence in review findings using the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) methodology. RESULTS: We included 107 studies of internal medicine clinical teaching units, of which 93 (87%) were conducted in North America. Surveys (n = 31, 29%), trials (n = 17, 16%) and narrative studies (n = 15, 14%) were the most prevalent study designs. Practices identified as contributing to improved clinical education or health care delivery included purposeful rounding (high confidence), bedside rounding (moderate confidence), resource stewardship interventions (high confidence), interprofessional rounds (moderate confidence), geographic wards (moderate confidence), allocating more trainee time to patient care or educational activities (moderate confidence), "drip" continuous models of admission (moderate confidence), limiting duty hours (moderate confidence) and limiting clinical workload (moderate confidence). INTERPRETATION: In this review, we identified several evidence-based practices that may contribute to improved educational and health care outcomes in clinical teaching unit settings. These findings may offer guidance for policies, resource allocation and staffing of teaching hospitals.

Moxifloxacin Use and Its Association on the Diagnosis of Pulmonary Tuberculosis in An Inner City Emergency Department.

BACKGROUND: Moxifloxacin can be used in the treatment of tuberculosis, its effect on the diagnosis and treatment of pulmonary tuberculosis is not well characterized. OBJECTIVE: To identify patients from the St. Paul's Hospital emergency department (ED) treated with moxifloxacin who also had sputum sent for investigation of possible tuberculosis and the impact on sensitivity of acid-fast bacilli (AFB) smears and time to initiation of tuberculosis treatment. METHODS: We conducted a retrospective single-center cohort study on patients that were prescribed moxifloxacin in the ED during a 5-year period and had samples collected for pulmonary tuberculosis. All AFB samples obtained throughout the hospital in patients not exposed to moxifloxacin during the same time period were also examined. RESULTS: Two-thousand six hundred and seventy-three patients who were admitted to St. Paul's Hospital through the ED received moxifloxacin during the study period. 273 (10.2%) of these patients were subsequently investigated for tuberculosis, with 9 positive cases of Mycobacterium tuberculosis (3.3%). One-thousand three hundred and sixty-nine patients not exposed to moxifloxacin were screened for tuberculosis with 33 active cases (2.4%). The false-negative rate for AFB smears in the exposed group was 85.2% vs. 53.8% in the unexposed group (relative risk of false-negative AFB = 1.55; 95% CI 1.24-2.03). Time to initiation of anti-tuberculosis therapy was significantly delayed in the exposed group, with median time to initiation of 14 days vs. 2 days (p = 0.013). CONCLUSIONS: Exposure to moxifloxacin is associated with significantly increased rates of false-negative AFB smears and was associated with a significant delay in the initiation of anti-tuberculosis therapy.

Population-Based Trends in Complexity of Hospital Inpatients.

Importance: Clinical experience suggests that hospital inpatients have become more complex over time, but few studies have evaluated this impression. Objective: To assess whether there has been an increase in measures of hospital inpatient complexity over a 15-year period. Design, Setting and Participants: This cohort study used population-based administrative health data from nonelective hospitalizations from April 1, 2002, to January 31, 2017, to describe trends in the complexity of inpatients in British Columbia, Canada. Hospitalizations were included for individuals 18 years and older and for which the most responsible diagnosis did not correspond to pregnancy, childbirth, the puerperal period, or the perinatal period. Data analysis was performed from July to November 2023. Exposure: The passage of time (15-year study interval). Main Outcomes and Measures: Measures of complexity included patient characteristics at the time of admission (eg, advanced age, multimorbidity, polypharmacy, recent hospitalization), features of the index hospitalization (eg, admission via the emergency department, multiple acute medical problems, use of intensive care, prolonged length of stay, in-hospital adverse events, in-hospital death), and 30-day outcomes after hospital discharge (eg, unplanned readmission, all-cause mortality). Logistic regression was used to estimate the relative change in each measure of complexity over the entire 15-year study interval. Results: The final study cohort included 3 367 463 nonelective acute care hospital admissions occurring among 1 272 444 unique individuals (median [IQR] age, 66 [48-79] years; 49.1% female and 50.8% male individuals). Relative to the beginning of the study interval, inpatients at the end of the study interval were more likely to have been admitted via the emergency department (odds ratio [OR], 2.74; 95% CI, 2.71-2.77), to have multimorbidity (OR, 1.50; 95% CI, 1.47-1.53) and polypharmacy (OR, 1.82; 95% CI, 1.78-1.85) at presentation, to receive treatment for 5 or more acute medical issues (OR, 2.06; 95% CI, 2.02-2.09), and to experience an in-hospital adverse event (OR, 1.20; 95% CI, 1.19-1.22). The likelihood of an intensive care unit stay and of in-hospital death declined over the study interval (OR, 0.96; 95% CI, 0.95-0.97, and OR, 0.81; 95% CI, 0.80-0.83, respectively), but the risks of unplanned readmission and death in the 30 days after discharge increased (OR, 1.14; 95% CI, 1.12-1.16, and OR, 1.28; 95% CI, 1.25-1.31, respectively). Conclusions and Relevance: By most measures, hospital inpatients have become more complex over time. Health system planning should account for these trends.

Clinical teaching unit design: a realist systematic review protocol of evidence-based practices for clinical education and health service delivery.

INTRODUCTION: The clinical teaching unit (CTU) has emerged as a near-ubiquitous model of clinical education across Canadian and international medical schools since it was first proposed over 50 years ago. However, while healthcare has changed dramatically over this period, the CTU model has remained largely unchanged. We thus aimed to systematically review principles of CTU design that contribute to improved outcomes in clinical education and health service delivery. METHODS AND ANALYSIS: We will perform a realist systematic review in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) II protocol for realist reviews. Databases, including MEDLINE, Embase, Cochrane Database of Systematic Reviews and Cumulative Index of Nursing and Allied Health Literature (CINAHL), were searched to find primary research articles published from 1993 to 2019 involving CTUs or other teaching wards, and outcomes related to either trainee education or health service delivery. Two reviewers will independently screen studies in a two-stage process. Retrieved titles and/or abstracts of studies will be screened in the first stage, with full texts reviewed in the second stage. Selected articles meeting inclusion criteria will undergo data abstraction using a standardised, pre-piloted form for assessment of study quality and knowledge synthesis. ETHICS AND DISSEMINATION: This review will generate higher quality evidence on the design of CTUs as a model for both clinical education and health service delivery. In addition, further knowledge translation efforts may be necessary to ensure that known best practices in CTU design become common practice.

Assessing cardiac physical examination skills using simulation technology and real patients: a comparison study.

OBJECTIVE: High-stakes assessments of doctors' physical examination skills often employ standardised patients (SPs) who lack physical abnormalities. Simulation technology provides additional opportunities to assess these skills by mimicking physical abnormalities. The current study examined the relationship between internists' cardiac physical examination competence as assessed with simulation technology compared with that assessed with real patients (RPs). METHODS: The cardiac physical examination skills and bedside diagnostic accuracy of 28 internists were assessed during an objective structured clinical examination (OSCE). The OSCE included 3 modalities of cardiac patients: RPs with cardiac abnormalities; SPs combined with computer-based, audio-video simulations of auscultatory abnormalities, and a cardiac patient simulator (CPS) manikin. Four cardiac diagnoses and their associated cardiac findings were matched across modalities. At each station, 2 examiners independently rated a participant's physical examination technique and global clinical competence. Two investigators separately scored diagnostic accuracy. RESULTS: Inter-rater reliability between examiners for global ratings (GRs) ranged from 0.75-0.78 for the different modalities. Although there was no significant difference between participants' mean GRs for each modality, the correlations between participants' performances on each modality were low to modest: RP versus SP, r = 0.19; RP versus CPS, r = 0.22; SP versus CPS, r = 0.57 (P < 0.01). CONCLUSIONS: Methodological limitations included variability between modalities in the components contributing to examiners' GRs, a paucity of objective outcome measures and restricted case sampling. No modality provided a clear 'gold standard' for the assessment of cardiac physical examination competence. These limitations need to be addressed before determining the optimal patient modality for high-stakes assessment purposes.

Assessing the relationship between cardiac physical examination technique and accurate bedside diagnosis during an objective structured clinical examination (OSCE).

BACKGROUND: Many standardized patient (SP) encounters employ SPs without physical findings and, thus, assess physical examination technique. The relationship between technique, accurate bedside diagnosis, and global competence in physical examination remains unclear. METHOD: Twenty-eight internists undertook a cardiac physical examination objective structured clinical examination, using three modalities: real cardiac patients (RP), "normal" SPs combined with related cardiac audio-video simulations, and a cardiology patient simulator (CPS). Two examiners assessed physical examination technique and global bedside competence. Accuracy of cardiac diagnosis was scored separately. RESULTS: The correlation coefficients between participants' physical examination technique and diagnostic accuracy were 0.39 for RP (P < .05), 0.29 for SP, and 0.30 for CPS. Patient modality impacted the relative weighting of technique and diagnostic accuracy in the determination of global competence. CONCLUSIONS: Assessments of physical examination competence should evaluate both technique and diagnostic accuracy. Patient modality affects the relative contributions of each outcome towards a global rating.

Does physical examination competence correlate with bedside diagnostic acumen? An observational study.

AIM: To examine the relationship between a physician's ability to examine a standardized patient (SP) and their ability to correctly identify related clinical findings created with simulation technology. METHOD: The authors conducted an observational study of 347 candidates during a Canadian national specialty examination at the end of post-graduate internal medicine training. Stations were created that combined physical examination of an SP with evaluation of a related audio-video simulation of a patient abnormality, in the domains of cardiology and neurology. Examiners evaluated a candidate's competence at performing a physical examination of an SP and their accuracy in diagnosing a related audio-video simulation. RESULTS: For the cardiology stations, the correlation between the physical examination scores and recognition of simulation abnormalities was 0.31 (p < 0.01). For the neurology stations, the correlation was 0.27 (p < 0.01). Addition of the simulations identified 18% of 197 passing candidates on the cardiology stations and 17% of 240 passing candidates on the neurology stations who were competent in their physical examination technique but did not achieve the passing score for diagnostic skills. CONCLUSIONS: Assessments incorporating SPs without physical findings may need to include other methodologies to assess bedside diagnostic acumen.

Incorporating simulation technology in a canadian internal medicine specialty examination: a descriptive report.

High-stakes assessment of clinical performance through the use of standardized patients (SPs) is limited by the SP's lack of real physical abnormalities. The authors report on the development and implementation of physical examination stations that combine simulation technology in the form of digitized cardiac auscultation videos with an SP assessment for the 2003 Royal College of Physicians and Surgeons of Canada's Comprehensive Objective Examination in Internal Medicine. The authors assessed candidates on both the traditional stations and the stations that combined the traditional SP examination with the digitized cardiac auscultation video. For the combined stations, candidates first completed a physical examination of the SP, watched and listened to a computer simulation, and then described their auscultatory findings. The candidates' mean scores for both types of stations were similar, as were the mean discrimination indices for both types of stations, suggesting that the combined stations were of a testing standard similar to the traditional stations. Combining an SP with simulation technology may be one approach to the assessment of clinical competence in high-stakes testing situations.

Clostridium difficile-associated diarrhea: predictors of severity in patients presenting to the emergency department.

OBJECTIVE: Experiences with Clostridium difficile-associated diarrhea (CDAD) were reviewed to determine predictors of severity in patients presenting from the community. METHODS: All patients admitted to two hospitals over 4.5 years with a primary diagnosis of CDAD were reviewed. Patients requiring a hospital stay of greater than 14 days, colectomy, intensive care unit admission or who died were classified as 'severe CDAD' and compared with the remainder of the patients (termed 'mild CDAD'). RESULTS: One hundred fifty-three patients (mean age 63.4+/-20.5 years, range 21 to 93, 64.7% female) were reviewed. Forty-four per cent of the patients had community-acquired CDAD, and the remainder had hospital-acquired disease. There were 44/153 (28.8%) patients with severe CDAD, of which 10/153 (6.5%) died. The severe group had more patients over 70 years old (75% versus 43% in the mild group, OR 3.09, CI 1.81-8.63, P<0.001) and had more comorbid disease (median two major organ systems affected [range zero to five] versus one [range zero to four] in the mild group, OR 1.52, CI 1.27-2.65, P<0.05). Patients with recurrent CDAD were more likely to have severe CDAD (12/44 versus 10/109 in the mild group, OR 4.10, CI 1.47-9.40, P<0.01). CONCLUSION: Age over 70 years, comorbid illness and CDAD recurrence are significant risk factors for severe disease and a poor outcome in patients admitted to hospital for CDAD.

Hypertension and nephritic urine sediment following retroperitoneal lymph node dissection.

Retroperitonela lymph node dissection (RPLND), cisplatin-based chemotherapy, and tumor surveillance has dramatically improved survival of patients with non-seminomatous germ cell tumors. Complications, including renal vascular injuries, have been encountered with post-chemotherapy RPLND. We report on a patient with delayed renovascular hypertension and nephritic sediment following RPLND. A thirty year old man presented with well-controlled hypertension following treatment of a left testicular non-seminomatous germ cell tumor 11 years earlier. Post-orchiectomy investigation revealed retroperitoneal lymphadenopathy which was treated with cispaltin-based chemotherapy. A residual mass was managed surgically and during perihilar dissection, the left renal vein was injured and repaired. Current investigation revealed hypertension and a nephritic urine sediment, both of which resolved with left simple nephrectomy. We believe that inadvertent renal artery injury was responsible for this late complication.

Development and validation of a cardiac findings checklist for use with simulator-based assessments of cardiac physical examination competence.

INTRODUCTION: Objective outcome measures for use with simulator-based assessments of cardiac physical examination competence are lacking. The current study describes the development and validation of an approach to scoring performance using a cardiac findings checklist. METHODS: A cardiac findings checklist was developed and implemented for use with a simulator-based assessment of cardiac physical examination competence at a Canadian national specialty examination in internal medicine. Candidate performance as measured using the checklist was compared with global ratings of clinical performance on the cardiac patient simulator and with overall examination performance. RESULTS: Interrater reliability for scoring the checklist ranged from 0.95 for scoring correct findings to 0.72 for scoring incorrect findings. A summary checklist score had a Pearson correlation of 0.60 with overall candidate performance on the simulator-based station. CONCLUSION: Use of a cardiac findings checklist provides one objective measure of cardiac physical examination competence that may be used with simulator-based assessments.

Improving internal medicine residents' performance, knowledge, and confidence in central venous catheterization using simulators.

BACKGROUND: Efficacy of simulators in teaching central venous catheterization (CVC) in an internal medicine residency program is unknown. OBJECTIVE: To determine whether or not learning CVC on simulators is associated with improvement in performance of CVC, knowledge about the procedure, and self-reported confidence. METHODS: All consenting first-year internal medicine residents who completed training in CVC on simulators were included. Participants were evaluated pre- and post-training by video-recorded CVC insertion and multiple-choice knowledge assessments. Procedural technique was rated in a blinded fashion by two independent adjudicators. Knowledge retention and self-reported confidence were reassessed at 18 months. MEASUREMENTS: Primary outcome of CVC performance was assessed based on global rating score (minimum 1, maximum 5). Secondary measures include checklist score (out of ten), knowledge score and self-reported confidence (6-point Likert scale ranging from "none" to "complete"). RESULTS: Median global rating scores in 30 participants increased from 3.5 (IQR = 3-4) to 4.5 (IQR = 4-4.5) (P < 0.001). Checklist score increased from 9 (IQR = 6-9.5) to 9.5 (IQR = 9-9.5) (P < 0.001). Knowledge score increased from 65.7 +/- 11.9% to 81.2 +/- 10.7% (P < 0.001). Confidence increased from 3 ("moderate", IQR = 2-3) to 4 ("good", IQR=3-4) (P < 0.001). Sixteen participants completed the retention tests. Improvement in knowledge score and confidence at 18 months was retained compared with baseline (P = 0.002 and P < 0.0001 respectively). CONCLUSIONS: Use of simulators in teaching CVC in an internal medicine residency program results in improved procedural performance, knowledge, and self-reported confidence. Improvement in knowledge and confidence was retained at 18 months.

Assessing the mini-Clinical Evaluation Exercise in comparison to a national specialty examination.

PURPOSE: To evaluate the reliability and validity of the Mini-Clinical Evaluation Exercise (mini-CEX) for postgraduate year 4 (PGY-4) internal medicine trainees compared to a high-stakes assessment of clinical competence, the Royal College of Physicians and Surgeons of Canada Comprehensive Examination in Internal Medicine (RCPSC IM examination). METHODS: Twenty-two PGY-4 residents at the University of British Columbia and the University of Calgary were evaluated, during the 6 months preceding their 2004 RCPSC IM examination, with a mean of 5.5 mini-CEX encounters (range 3-6). Experienced Royal College examiners from each site travelled to the alternate university to assess the encounters. RESULTS: The mini-CEX encounters assessed a broad range of internal medicine patient problems. The inter-encounter reliability for the residents' mean mini-CEX overall clinical competence score was 0.74. The attenuated correlation between residents' mini-CEX overall clinical competence score and their 2004 RCPSC IM oral examination score was 0.59 (P = 0.01). CONCLUSION: By examining multiple sources of validity evidence, this study suggests that the mini-CEX provides a reliable and valid assessment of clinical competence for PGY-4 trainees in internal medicine.