Evaluation of an Interprofessional Team Training Program to Improve the Use of Patient Safety Strategies Among Healthcare Professions Students.

PURPOSE: To assess whether our introductory TeamSAFE (Team Simulation and Fearlessness in Education) program improved student knowledge of effective teamwork skills; impacted their perception of their own teamwork skills and preparedness for teamwork in clinical practice; and augmented their understanding of the roles and responsibilities of different healthcare team members. METHODS: Students completed an online learning module, then attended a simulation-based workshop to practice patient safety and teamwork skills. A pre-post-test design was used to assess knowledge of TeamSTEPPS® concepts and perception of teamwork skills among 959 students from 7 health professions. We conducted a qualitative analysis of student responses to open-ended questions about their perceptions of teamwork skills. RESULTS: Qualitative analysis revealed three themes: 1) put patients first; 2) recognize that the whole is greater than the sum of its parts; and 3) embrace the unknown. Quantitative analysis suggested that students gained knowledge from the workshop. Item analysis using item response theory showed that items have difficulty and discrimination in the lower range. CONCLUSION: Findings suggest that the workshop was effective in improving knowledge of teamwork skills, improving student self-perception of teamwork skills and practice readiness, increasing understanding of the roles and responsibilities of students from different health professions, and understanding the importance of patient safety.

Intravenous Fluid Management in Critically Ill Adults: A Review.

TOPIC: This article reviews the management of intravenous fluids and the evaluation of volume status in critically ill adults. CLINICAL RELEVANCE: Intravenous fluid administration is one of the most common interventions in the intensive care unit. Critically ill patients have dynamic fluid requirements, making the management of fluid therapy challenging. New literature suggests that balanced salt solutions may be preferred in some patient populations. PURPOSE OF PAPER: The bedside critical care nurse must understand the properties of various intravenous fluids and their corresponding impact on human physiology. The nurse's clinical and laboratory assessments of each patient help define the goals of fluid therapy, which will in turn be used to determine the optimal patient-specific selection and dose of fluid for administration. Nurses serve a vital role in monitoring the safety and efficacy of intravenous fluid therapy. Although this intervention can be lifesaving, inappropriate use of fluids has the potential to yield detrimental effects. CONTENT COVERED: This article discusses fluid physiology and the goals of intravenous fluid therapy, compares the types of intravenous fluids (isotonic crystalloids, including 0.9% sodium chloride and balanced salt solutions; hypotonic and hypertonic crystalloids; and colloids) and their adverse effects and impact on hemodynamics, and describes the critical care nurse's essential role in selecting and monitoring intravenous fluid therapy.

Management of Clostridioides difficile Infection.

CLINICAL RELEVANCE: Clostridioides (formerly Clostridium) difficile infection is among the most identified causes of health care-associated infections in US hospitals and remains a major public health problem. The incidence and severity of C difficile infection are high among critically ill patients. Treating critically ill patients is challenging; treatment failure is especially common because of comorbidities and the continued need for antibiotic therapy for other infections. Because of the high risk of C difficile infection recurrence and high mortality rate associated with the disease, intensive research has taken place over the last decade to improve patient outcomes. This research has resulted in new drugs indicated for C difficile infection and new information on existing drugs. The 2010 clinical practice guidelines for C difficile infections have been updated on the basis of this new information. PURPOSE OF PAPER: To review the 2017 update of the clinical practice guidelines from the Society for Health-care Epidemiology of America and the Infectious Diseases Society of America. CONTENT COVERED: The updated recommendations for the treatment of C difficile infection, the clinical pharmacology of old and new drugs for treating the infection, and the role of critical care nurses in mini-mizing the risk of C difficile infection for their patients.

Osteonecrosis of the jaw in patients receiving intravenous or oral bisphosphonates.

To identify potential risk factors for the development of osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonates, we conducted a MEDLINE search. We identified 44 English-language published case reports and case series describing 481 patients with bisphosphonate-related ONJ. Our review of these reports indicated that ONJ occurs more frequently in patients receiving intravenous bisphosphonates (453 patients [94.2%]) than in patients receiving oral bisphosphonates (28 patients [5.8%]). Most patients who developed ONJ had cancer (451 patients [93.8%]), with multiple myeloma being the most common diagnosis, followed by breast, prostate, and lung cancers. Nearly one third of patients had a history of glucocorticoid use. The inciting event (reported in 449 patients) preceding the diagnosis of ONJ was a tooth extraction or other surgical or invasive dental procedure in 309 patients (68.8%), whereas 93 patients (20.7%) developed ONJ spontaneously. Guidelines for the prevention and treatment of bisphosphonate-associated ONJ have been developed but are largely based on anecdotal evidence. Patients receiving bisphosphonates must be counseled on the risks and benefits of therapy. Further studies will help to elucidate the pathophysiology, frequency, and risk factors for development of bisphosphonate-associated ONJ.

Student perceptions of the impact and value of incorporation of reflective writing across a pharmacy curriculum.

INTRODUCTION: To assess student perceptions regarding the impact and value of incorporating written reflection across a pharmacy curriculum. METHODS: Throughout the first three years of the pharmacy curriculum, students use the "What, So What, Now What" format to write 18 reflections within five didactic and six experiential courses. For the 93 students in the class of 2015, individual course evaluation questions measuring perceptions of the impact of reflective writing on their achievement of curricular outcomes were analyzed. Student perceptions of reflective writing's value and impact on their professional development were obtained via a survey administered to the class of 2015 after their third professional year. RESULTS: Students identified reflection (100%) and written reflection (98%) as having some degree of importance to their professional development. However, only 42% of students felt that reflective writing had an appreciable or significant impact on their professional development. Most students indicated that reflective writing had a positive impact on their sensitivity to specific patient populations, ethical behavior, interpersonal skills, and ability to provide patient-centered, interprofessional care. CONCLUSION: This study found that most students found some value in reflective writing, felt that reflective writing positively impacted their self-awareness and professional behaviors, and were able to identify benefits of the reflective writing program.

Probable Interaction Between Warfarin and Banana Flakes Supplement.

PURPOSE: To describe a case of subtherapeutic international normalized ratio (INR) associated with concomitant use of warfarin and banana flakes in a patient with diarrhea. SUMMARY: A man in his 30s was hospitalized for an elective procedure, but his stay was complicated by cerebral venous thrombosis requiring intravenous infusion of unfractionated heparin, ventilator-associated pneumonia, bacteremia requiring broad-spectrum antimicrobials and percutaneous endoscopic gastrostomy tube placement, and diarrhea. Eventually, the heparin was transitioned to warfarin. After several days of therapeutic INR, the INR became subtherapeutic and remained so for 3 days. The decreased INR correlated temporally with initiation of consistent administration of dried banana flakes to treat diarrhea and the subsequent decrease in the rate and extent of diarrhea. Diarrhea decreases the amount and activity of vitamin K-producing intestinal flora and dietary vitamin K absorption, resulting in increased INR. Resolution of diarrhea secondary to banana flakes administration in this patient may have contributed to the decreased INR by causing a relative increase in vitamin K-producing flora and vitamin K absorption. A probability score of 5 was obtained upon applying the Drug Interaction Probability Scale modified to address interactions between warfarin and dietary supplements, indicating a probable interaction between warfarin and banana flakes. CONCLUSION: Concomitant use of warfarin and banana flakes supplements may result in a reduced rate and extent of diarrhea and may be associated with subtherapeutic INR and decreased warfarin efficacy. Practitioners must be aware of this potential interaction and closely monitor INR and adjust warfarin doses accordingly.

A Required Online Course with a Public Health Focus for Third Professional Year Pharmacy Students.

OBJECTIVE: To design, deliver, and evaluate the impact of a required course on student knowledge acquisition and ability to evaluate contemporary public health issues. DESIGN: A 2-credit course was implemented using asynchronous, online delivery. Learning activities included literature retrieval and assessment, analytic writing, quizzes, and creation of a group wiki evaluating a current public health issue. Course topics included health care reform, social determinants of health, health disparities, evidence-based medicine, end-of-life care, patient safety, and research ethics. ASSESSMENT: Strong student performance on assessments indicated an ability to use higher-order cognitive domains. Online delivery provided students with the flexibility to complete assignments at their convenience, allowed participation by all students, and encouraged self-directed learning. CONCLUSION: Completion of a required, online, asynchronous course with a public health focus allowed pharmacy students to increase their knowledge of and ability to evaluate contemporary ethical, social, cultural, and governmental issues affecting pharmacy practice.

Dabigatran-Associated Intracranial Hemorrhage: Literature Review and Institutional Experience.

Dabigatran etexilate is an oral direct thrombin inhibitor approved for prevention of stroke and systemic embolization in patients with nonvalvular atrial fibrillation and for the treatment of venous thromboembolism. Although dabigatran has a favorable safety profile, predictable pharmacokinetics, fewer drug interactions than warfarin, and does not require monitoring, clinical data regarding dabigatran reversal are limited. In addition, currently available laboratory assays allow measurement of the presence, but not extent, of dabigatran-associated anticoagulation. Patient age, renal function, weight, concurrent drug therapy, adherence, and concomitant disease states can affect dabigatran's efficacy and safety. Management of dabigatran-related intracranial hemorrhage must be approached on a case-by-case basis and include assessment of degree of anticoagulation, severity of hemorrhage, renal function, timing of last dabigatran dose, and risk of thromboembolic events. Initial management includes dabigatran discontinuation and general supportive measures. Oral activated charcoal should be administered in those who ingested dabigatran within 2 hours. Four-factor prothrombin complex concentrates (4PCCs), activated PCC, or recombinant activated factor VII use may be reasonable but is not evidence based. Reserve fresh frozen plasma for patients with dilutional coagulopathy. If readily available, hemodialysis should be considered, particularly in patients with advanced kidney injury or excessive risk of thromboembolic events. More clinical studies are needed to determine a standardized approach to treating dabigatran-associated intracranial hemorrhage. Institutional protocol development will facilitate safe, efficacious, and timely use of the limited management options.