Preoperative Cognitive Assessment Recommendations for the Older Adult.

PURPOSE: The purpose of this project was to identify the need for and to improve the preoperative cognitive assessment of the older adult. DESIGN: A retrospective chart review was used to explore the incidence of postoperative delirium (PD) and characteristics associated with it. METHODS: A retrospective chart review was used to identify the incidence of PD in a community hospital. The data were analyzed using descriptive statistics for trends in demographic and physiological characteristics of older adults undergoing elective hip or knee surgery. FINDINGS: The incidence of PD was found to be 11%. Older adults with PD had an increased mean age and comorbid conditions. PD was associated with a mean increase in hospital stay, postoperative complications, and 30-day readmission. CONCLUSIONS: Preoperative cognitive assessment can identify high-risk patients, stratify care, medically optimize the older adult before surgery, and improve perioperative outcomes.

Preoperative Risk Assessment to Guide Prophylaxis and Reduce the Incidence of Postoperative Nausea and Vomiting.

PURPOSE: This article describes the implementation of a postoperative nausea and vomiting (PONV) risk prediction and prophylaxis protocol. DESIGN: This is a retrospective pre/post implementation quality improvement project. METHODS: This project used chart reviews to assess the impact of the implemented PONV assessment and prophylaxis in a sample population of adult females undergoing gynecologic surgical procedures. FINDINGS: The mean number of prophylactic antiemetics administered significantly increased during the postimplementation period from 3.64 (SD, 0.878) in the preimplementation period to 4.07 (SD, 1.021) in the postimplementation period (P < .001). The greatest increase in antiemetic administration occurred in the moderate-risk (risk score, 4) and the high-risk (risk score, 5 to 6) groups. The incidence of PONV decreased from 32.3% in the preimplementation period to 28.9% in the postimplementation period; however, this reduction did not meet statistical significance. Antiemetic administration compliance increased from 37% in the preimplementation group to 61% in the postimplementation group (P < .001). CONCLUSIONS: The results of this project suggest that a risk-tailored approach to PONV prophylaxis using a risk assessment tool along with treatment recommendations is effective at reducing the incidence of PONV. The effectiveness of this approach is limited by the involvement of the anesthesia providers responsible for completing the assessments and administering PONV prophylaxis.

Suicide Prevention: A Healer Education and Referral Program for Nurses.

OBJECTIVE: The aim of this study was to describe the pilot expansion of a proactive suicide risk-screening program, initially designed for physicians, to nurses. BACKGROUND: The Healer Education, Assessment and Referral (HEAR) program detects at-risk physicians and facilitates referral to mental healthcare. Nothing similar has been available for at-risk nurses. Local nurse suicides served as the catalyst to extend the HEAR program to nurses. METHODS: Education, outreach, and an encrypted, online, anonymous, proactive risk screening were conducted to identify and refer nurses with depression and suicide risk. RESULTS: During the 1st 6 months of the program, 172 of 2475 (7%) nurses completed questionnaires; 74 (43%) were rated as high risk, and another 98 (55%) as moderate risk; 12 (7%) reported current active thoughts or actions of self-harm, and 19 (11%) reported previous suicide attempts. Forty-four (26%) received in-person or verbal counseling, and 17 accepted referral for continued treatment. CONCLUSIONS: An encrypted, anonymous, proactive risk screening is effective at identifying nurses at risk and referring them to mental healthcare.

Alcohol use in an academic medical school environment: A UC San Diego Healer Education Assessment and Referral (HEAR) Report.

BACKGROUND: Medical students and physicians in training and in practice are at risk for excessive alcohol use and abuse, potentially impacting the affected individuals as well as their family members, trainees, and patients. However, several roadblocks to care, including stigma, often keep them from seeking treatment. METHODS: We analyzed data from anonymous questionnaires completed by medical students, house staff, and faculty from 2009 to 2014 as part of a depression awareness and suicide prevention program at a state-supported medical school in the United States. The authors explored associations between self-reported "drinking too much" and depression, suicidal ideation, substance use, intense affective states, and mental health treatment. RESULTS: Approximately one-fifth of the respondents reported "drinking too much." "Drinking too much" was associated with more severe depression and impairment, past suicide attempts and current suicidal ideation, intense affective states, and other substance use. Those who were "drinking too much" were more likely than others to accept referrals for mental health treatment through the anonymous interactive screening program, suggesting that this program may be effective in skirting the stigma barrier for accessing mental health care for this at-risk population. CONCLUSIONS: The self-reported prevalence of "drinking too much" among medical students, house staff, and faculty is high and associated with negative mental health outcomes. Targeted, anonymous screenings may identify at-risk individuals and provide mental health care referrals to those in need.

Listening to depression and suicide risk in medical students: the Healer Education Assessment and Referral (HEAR) Program.

OBJECTIVE: A growing body of literature documents high rates of burnout, depression, and suicidal ideation among physicians and medical students. Barriers to seeking mental health treatment in this group include concerns about time, stigma, confidentiality, and potential career impact. The authors describe a 4-year trial of the Healer Education Assessment and Referral (HEAR) program, designed to increase mental health services utilization (MHSU) and decrease suicide risk (SR) as assessed by an Interactive Screening Program (ISP)at one US medical school. METHODS: Over a 4-year period, medical students were engaged in face-to-face, campus-wide, educational group programs and were invited to complete an individual, online, and anonymous survey. This survey contained the 9-item Patient Health Questionnaire (PHQ-9) scale to assess depression and items to identify suicidal thoughts and behaviors, substance use, distressing emotional states, and the use of mental health treatment. Students who engaged in this ISP by corresponding electronically with a counselor after completing the survey were assessed and when indicated, referred to further treatment. RESULTS: The HEAR program was delivered to 1,008 medical students. Thirty-four percent (343/1,008) completed the online screening portion. Almost 8 % of respondents met the criteria for high/significant SR upon analysis of the completed screens. Ten out of 13 of the students with SR who dialogued with a counselor were not already receiving mental health treatment, indicating that this anonymous ISP identified a high proportion of an untreated, at risk, and potentially suicidal population. MHSU among medical students who completed the survey was 11.5 % in year 1 and 15.0 % by year 4. SR among medical students was 8.8 % in year 1 and 6.2 % in year 4 as assessed by the ISP. CONCLUSIONS: This novel interventional program identified at risk, potentially suicidal medical students at one institution. Based on this single-site experience, we suggest that future multisite studies incorporate a comparison group, acquire baseline (prematriculation) data regarding MHSU and SR, and use an individualized yet anonymous identification system to measure changes in individual participants' mental health status over time.

What Can State Medical Boards Do to Effectively Address Serious Ethical Violations?

State Medical Boards (SMBs) can take severe disciplinary actions (e.g., license revocation or suspension) against physicians who commit egregious wrongdoing in order to protect the public. However, there is noteworthy variability in the extent to which SMBs impose severe disciplinary action. In this manuscript, we present and synthesize a subset of 11 recommendations based on findings from our team's larger consensus-building project that identified a list of 56 policies and legal provisions SMBs can use to better protect patients from egregious wrongdoing by physicians.

The Impact of Early Epidural Discontinuation on Pain, Opioid Usage, and Length of Stay After Periacetabular Osteotomy.

BACKGROUND: Periacetabular osteotomy (PAO) is the standard of care for treatment of symptomatic acetabular dysplasia. Patients undergoing PAO for acetabular dysplasia have postoperative pain that can be managed with epidural analgesia. The purpose of this study was to evaluate the impact of the timing of the discontinuation of epidural analgesia on pain, opioid usage, and hospital length of stay (LOS). The study hypothesis was that removal of the epidural catheter on postoperative day 1 (POD1) would lead to reduced overall opioid usage and LOS compared with removal on POD2. METHODS: This is a retrospective before-and-after observational review of the impact of discontinuing epidural analgesia on POD1 versus POD2 in terms of in-hospital pain, opioid usage, and LOS. Baseline patient factors such as age, sex, and body mass index (BMI) as well as outcomes including mean and median of daily pain, total oral morphine milligram equivalents (MMEs) used per day, and LOS were recorded. Descriptive and comparative statistical analyses including multivariable main-effects linear regression modeling were performed to evaluate the impact of the timing of epidural removal on outcomes. RESULTS: Directly comparing outcomes for the day of epidural removal, patients with removal on POD1 had significantly less pain (mean of 4.6 versus 5.1 on the numeric rating scale [NRS], p = 0.033) and opioid usage (130.7 versus 200.4 MMEs, p < 0.001) than patients with removal on POD2. Additionally, LOS (3.3 versus 4.6 days, p < 0.001) and total opioid usage (333.0 versus 674.8 MMEs, p < 0.001) were significantly reduced in patients with epidural removal on POD1. These results persisted in multivariable analyses that were adjusted for age, sex, and BMI. CONCLUSIONS: This study demonstrated that patients with epidural removal on POD1 have significantly lower pain and an overall decrease in opioid usage on the date of epidural removal compared with patients undergoing epidural removal on POD2. Additionally, they have a shorter LOS as well as lower total opioid usage. Decreasing the duration of epidural usage may reduce pain, opioid usage, and LOS in patients undergoing PAO. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Implementation of a Successful Enhanced Recovery after Surgery Program in a Community Hospital.

Background Enhanced recovery after surgery (ERAS) protocols have been shown to be effective at accelerating return to functioning, reducing length of stay, and reducing cost per encounter at major medical centers and health systems across the United States and Europe. Implementation in the community hospital setting has been considered more challenging due to a wide range of factors. This study demonstrates the successful creation of such a program in a community hospital in central North Carolina. Methods Starting in the spring of 2016, an anesthesiology-led, multidisciplinary ERAS team was formed with the purpose of developing an enhanced recovery after major urologic surgery program. A clinical protocol was developed by the team that met quarterly to review metrics. Outcome data were collected by chart review and compared to pre-ERAS values in a retrospective, nonrandomized, consecutive fashion and underwent statistical analysis. Results Overall, a reduction in both average and median length of stay (37% reduction) was observed in the post-ERAS group along with a reduction in 90-day readmission. Statistical analysis confirmed a very strong likelihood (p<.0001) that the ERAS protocol resulted in the observed reduction in the length of stay. Discussion This study demonstrated the feasibility of starting an ERAS program in a community hospital as well as the critical role that anesthesiology leadership can provide. An anesthesiology-led ERAS program offers a solution to some of the challenges faced by community hospitals regarding variable and silo-based care. ERAS pathways aim to implement standardized and coordinated evidence-based care protocols through multidisciplinary teams representing the entirety of the surgical encounter, leading to more consistent and favorable outcomes for patients and hospitals. This model can be applied to many other services in addition to the major urology effort described here.

Preemptive Oral Acetaminophen for Women Undergoing Total Laparoscopic Hysterectomy.

OBJECTIVE: To decrease hospital expenses by administering oral acetaminophen rather than intravenous (IV) acetaminophen to women who undergo laparoscopic hysterectomy. DESIGN: A quality improvement project using a between-groups, pre-/postimplementation design for women undergoing total laparoscopic hysterectomy. Retrospective chart review was used to compare data of women who received intraoperative IV acetaminophen before implementation versus women who received oral acetaminophen after implementation. Pain scores and opioid consumption in morphine equivalents were recorded at four time points. SETTING/LOCAL PROBLEM: A 369-bed hospital in the southeastern United States, where, in 2016, nearly $260,000 was spent on perioperative IV acetaminophen for all operating room cases. PARTICIPANTS: Women between the ages of 18 and 55 years scheduled to have total laparoscopic hysterectomy were included. Excluded were women with a history of chronic pain, opioid use, or liver pathology; women with a contraindication to nonsteroidal anti-inflammatory drugs; and women whose procedures were converted from laparoscopic to open. INTERVENTION/MEASUREMENTS: Women were instructed to take oral acetaminophen the day before surgery in divided doses, with 1 g every 6 hours, for a total dose of 3 g. On the day of surgery, women received the final 1-g dose of oral acetaminophen. RESULTS: There were no significant differences between groups for pain scores or total opioids received before implementation (mean = 3.28, standard deviation = 2.05) compared with after implementation (mean = 3.65, standard deviation = 1.63; t [18] = -.043, p = .674). The preimplementation cost per individual was $30.03 for 1 g of IV acetaminophen, and the postimplementation cost was $0.36 for 2 500-mg oral acetaminophen tablets, a 98.8% relative cost decrease per woman. CONCLUSION: Replacing IV acetaminophen with preemptive oral acetaminophen has the potential to save money without compromising care.

Improving Charting Skills of Physicians in Monitored Practice.

INTRODUCTION: The Physician Enhancement Program (PEP) is an in-practice monitoring program for physicians with potential dyscompetency issues. One component of PEP is a monthly chart audit. The purpose of our study was to determine if physicians' charting skills improve through their participation in PEP. METHODS: The sample included physicians who participated in PEP for at least 6 months regardless of specialization, age, or gender (n = 77). PEP chart audits evaluate seven different aspects of chart and care quality, including legibility, organization, history, assessment/formulation, treatment, physical examination, and overall chart quality. Each aspect of charting is scored on a Likert-type scale from a score of 1 to 9. We conducted pair-matched t tests of the mean item scores for the 1st versus 6th, 12th, 18th, and 24th month in PEP for all chart elements except legibility. We also compared the size of the paired differences by month 1 scores for overall chart quality mean score to determine if the magnitude of change varied by starting point. RESULTS: There was significant improvement (P < .002) across the 6 chart quality elements per physician at months 6, 12, 18, and 24. Physicians who started below Q1 for overall chart quality mean showed most improvement, whereas those who started above Q3 had insignificant change as they had little room to improve. DISCUSSION: PEP participants demonstrated improved charting skills for each chart quality element evaluated. PEP is an effective form of physician education resulting in physician behavior changes, especially for those physicians who need it the most.

Preventing Egregious Ethical Violations in Medical Practice: Evidence-Informed Recommendations from a Multidisciplinary Working Group.

This article reports the consensus recommendations of a working group that was convened at the end of a 4-year research project funded by the National Institutes of Health that examined 280 cases of egregious ethical violations in medical practice. The group reviewed data from the parent project, as well as other research on sexual abuse of patients, criminal prescribing of controlled substances, and unnecessary invasive procedures that were prosecuted as fraud. The working group embraced the goals of making such violations significantly less frequent and, when they do occur, identifying them sooner and taking necessary steps to ensure they are not repeated. Following review of data and previously published recommendations, the working group developed 10 recommendations that provide a starting point to meet these goals. Recommendations address leadership, oversight, tracking, disciplinary actions, education of patients, partnerships with law enforcement, further research and related matters. The working group recognized the need for further refinement of the recommendations to ensure feasibility and appropriate balance between protection of patients and fairness to physicians. While full implementation of appropriate measures will require time and study, we believe it is urgent to take visible actions to acknowledge and address the problem at hand.

Code Lavender: Cultivating Intentional Acts of Kindness in Response to Stressful Work Situations.

CONTEXT: Providing healthcare can be stressful. Gone unchecked, clinicians may experience decreased compassion, and increased burnout or secondary traumatic stress. Code Lavender is designed to increase acts of kindness after stressful workplace events occur. OBJECTIVE/INTERVENTION: To test the feasibility of providing Code Lavender. HYPOTHESES: After stressful events in the workplace, staff will provide, receive, and recommend Code Lavender to others. The provision of Code Lavender will improve Professional Quality of Life Scale (ProQoL) scores, general job satisfaction, and feeling cared for in the workplace. METHOD/SAMPLE: Pilot program testing and evaluation. Staff and physicians on four hospital units were informed of the Code Lavender kit availability, which includes words of comfort, chocolate, lavender essential oil, and employee health referral information. Feasibility data and ProQoL scores were collected at baseline and three months. RESULTS: At baseline, 48% (n = 164) reported a stressful event at work in the last three months. Post-intervention, 51% reported experiencing a stressful workplace event, with 32% receiving a Code Lavender kit from their co-workers as a result (n = 83). Of those who received the Code Lavender intervention; 100% found it helpful, and 84% would recommend it to others. No significant changes were demonstrated before and after the intervention in ProQoL scores or job satisfaction, however the emotion of feeling cared-for improved. CONCLUSIONS: Results warrant continuation and further dissemination of Code Lavender. Investigators have received requests to expand the program implying positive reception of the intervention. Additional interventions are needed to overcome workplace stressors. A more intense peer support program is being tested.

Value of General Medical Knowledge Examinations in Performance Assessment of Practicing Physicians With Potential Competence and Performance Deficiencies.

INTRODUCTION: Problems with a physician's performance may arise at any point during their career. As such, there is a need for effective, valid tools and processes to accurately assess and identify deficiencies in competence or performance. Although scores on multiple-choice questions have been shown to be predictive of some aspects of physician performance in practicing physicians, their relationship to overall clinical competence is somewhat uncertain particularly after the first 10 years of practice. As such, the purpose of this study was to examine how a general medical knowledge multiple-choice question examination is associated with a comprehensive assessment of competence and performance in experienced practicing physicians with potential competence and performance deficiencies. METHODS: The study included 233 physicians, of varying specialties, assessed by the University of California, San Diego Physician Assessment and Clinical Education Program (PACE), between 2008 and 2012, who completed the Post-Licensure Assessment System Mechanisms of Disease (MoD) examination. Logistic regression determined if the examination score significantly predicted passing assessment outcome after correcting for gender, international medical graduate status, certification status, and age. RESULTS: Most physicians (89.7%) received an overall passing assessment outcome on the PACE assessment. The mean MoD score was 66.9% correct, with a median of 68.0%. Logistic regression (P = .038) was significant in indicating that physicians with higher MoD examination scores had an increased likelihood of achieving a passing assessment outcome (odds ratio = 1.057). DISCUSSION: Physician MoD scores are significant predictors of overall physician competence and performance as evaluated by PACE assessment.

The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine.

To address physician depression and suicide at one U.S. medical school, a faculty committee launched a Suicide Prevention and Depression Awareness Program in 2009 whose focus is medical students', residents', and faculty physicians' mental health. The program consists of a two-pronged approach: (1) screening, assessment, and referral and (2) education. The screening process is anonymous, confidential, and Web based, using customized software created by the American Foundation for Suicide Prevention. The educational component consists of a medical-school-wide campaign including Grand Rounds on physician burnout, depression, and suicide as well as similar sessions geared toward trainees. The authors document the process of developing and implementing the program, including the program's origins and goals, their critical decision-making processes, and successes and challenges of the program's first year.Of the 2,860 medical students, housestaff, and faculty who received the e-mail invitation in the first year, 374 individuals (13%) completed screens, 101/374 (27%) met criteria for significant risk for depression or suicide, and 48/374 (13%) received referrals for mental health evaluation and treatment. The program provided 29 Grand Rounds and other presentations during the first year.This may be the first program that aims to increase awareness of depression and to destigmatize help-seeking in order to prevent suicide and whose target population includes the full panoply of medical school constituents: students, residents, and faculty physicians. The program was well received in its first year, and while demonstrating the prevention of suicides is difficult, the authors are encouraged by the program's results thus far.

Assessment and remedial clinical education of surgeons in California.

HYPOTHESIS: Assessment and remedial clinical education of practicing surgeons is feasible and possibly beneficial. DESIGN: Retrospective series. SETTING: Urban academic medical center. PARTICIPANTS: Licensed surgeons. INTERVENTIONS: Structured assessment and remedial clinical education based on resident-education models. MAIN OUTCOME MEASURES: Assessment and clinical education results. RESULTS: Forty-seven general, general/vascular, and colorectal surgeons were assessed by the University of California, San Diego, Physician Assessment and Clinical Education program in 2000 to 2010. Forty-six (98%) were male (mean [SD] age, 54 [11] years; range, 34-80 years). Thirty-three (70%) came from state medical board actions: 25 from California's disciplinary division, 2 from California's licensing division, 3 from other state boards, and 3 self-referred during other state board actions. Fourteen (30%) came from health care organizations: 8 from California hospitals, 3 from hospitals in other states, 2 self-referred during hospital proceedings, and 1 self-referred during a medical group investigation. Twenty-three (49%) underwent a 2-day assessment only, including a 1-hour mock oral board examination: 8 "passed" with no recommendations; 6, with minor recommendations; 6 had major recommendations; and 3 "failed." Twenty-four surgeons (51%) also completed 26 five-day clinical education programs, with 20 "passes," 1 minor recommendation, 3 major recommendations, and 2 "fails." CONCLUSION: A program of assessment and remedial clinical education of surgeons designed to meet the needs of one medical board is being used by nongovernmental organizations as well, and it seems to meet the needs of some individual surgeons. This type of program may play a role in the profession's self-regulation.

Toward meeting the challenge of physician competence assessment: the University of California, San Diego Physician Assessment and Clinical Education (PACE) Program.

Physician competence and performance problems contribute to medical errors and substandard health care quality. Assessment of the clinical competence of practicing physicians, however, is challenging. Although physician competence assessment undoubtedly does take place at the local level (e.g., hospital, medical group), it is difficult to objectively assess a partner, colleague, or friend. Moreover, the methodologies used and the outcomes are necessarily veiled by peer review statutes. Consequently, there is a need for regional or national assessment centers with the knowledge, skill, and experience to perform clinical competence assessments on individual physicians and provide or direct remediation, when appropriate. The University of California, San Diego (UCSD) Physician Assessment and Clinical Education (PACE) Program was founded at the UCSD School of Medicine in 1996 for this purpose. From inception in 1996 through the first quarter of 2009, 867 physicians have participated in the UCSD PACE Program. The PACE Program is divided into two components. Phase I includes two days of multilevel, multimodal testing, and Phase II is a five-day, preceptor-based formative assessment program taking place in the residency program of the physician's specialty. From July 2002 through December 2005, a study of 298 physician participants of the UCSD PACE Program was conducted.The future of the comprehensive assessment of practicing physicians depends on (1) development and standardization of instruments, techniques, and procedures for measuring competence and performance, including in-practice measures, (2) collaborative networking of assessment programs, (3) cost control, and (4) continued development of remedial measures that correspond to assessment findings.

Remediation of the deficiencies of physicians across the continuum from medical school to practice: a thematic review of the literature.

Despite widespread endorsement of competency-based assessment of medical trainees and practicing physicians, methods for identifying those who are not competent and strategies for remediation of their deficits are not standardized. This literature review describes the published studies of deficit remediation at the undergraduate, graduate, and continuing medical education levels. Thirteen studies primarily describe small, single-institution efforts to remediate deficient knowledge or clinical skills of trainees or below-standard-practice performance of practicing physicians. Working from these studies and research from the learning sciences, the authors propose a model that includes multiple assessment tools for identifying deficiencies, individualized instruction, deliberate practice followed by feedback and reflection, and reassessment. The findings of the study reveal a paucity of evidence to guide best practices of remediation in medical education at all levels. There is an urgent need for multiinstitutional, outcomes-based research on strategies for remediation of less than fully competent trainees and physicians with the use of long-term follow-up to determine the impact on future performance.

Diagnosis of acute coronary syndrome.

The term "acute coronary syndrome" encompasses a range of thrombotic coronary artery diseases, including unstable angina and both ST-segment elevation and non-ST-segment elevation myocardial infarction. Diagnosis requires an electrocardiogram and a careful review for signs and symptoms of cardiac ischemia. In acute coronary syndrome, common electrocardiographic abnormalities include T-wave tenting or inversion, ST-segment elevation or depression (including J-point elevation in multiple leads), and pathologic Q waves. Risk stratification allows appropriate referral of patients to a chest pain center or emergency department, where cardiac enzyme levels can be assessed. Most high-risk patients should be hospitalized. Intermediate-risk patients should undergo a structured evaluation, often in a chest pain unit. Many low-risk patients can be discharged with appropriate follow-up. Troponin T or I generally is the most sensitive determinant of acute coronary syndrome, although the MB isoenzyme of creatine kinase also is used. Early markers of acute ischemia include myoglobin and creatine kinase-MB subforms (or isoforms), when available. In the future, advanced diagnostic modalities, such as myocardial perfusion imaging, may have a role in reducing unnecessary hospitalizations.