Implementing a Longitudinal Adolescent Transition of Care Curriculum: Identifying Comfort and Barriers Among Residents.

Amid growing recognition of the importance of transitioning adolescents and young adults (AYA) from pediatric- to adult-oriented health care systems, residency programs are being tasked with educating residents on best transition practices. However, consensus on how to approach training residents in transition of care (TOC) is limited. Our academic residency program therefore created and implemented a TOC of AYA curriculum for pediatric residents in an effort to increase provider knowledge and comfort with this topic. Three classes of post-graduate year one (PGY1) pediatric residents participated in this curriculum from 2017-2019 (n=35) and subsequently completed a problem-based learning (PBL) exercise in a primary care clinic with adolescent patients based on core goals in transitioning AYA. Residents completed pre-PBL and post-PBL surveys quantifying provider comfort in several aspects of the transition process. The majority of residents (94%) identified the PBL exercise as being useful, with no significant difference between classes. Eighty-nine percent (n=31) identified 1) earlier introduction of TOC and/or 2) incorporation of TOC discussions during AYA well visits as intended areas of future practice change. Overall provider comfort in transitioning AYA increased significantly from matched pre-PBL to post-PBL surveys (p=0.004). Paired mean differences also showed a significant increase in provider comfort based on several identifiable skillsets in transitioning AYA. This study suggests that a formal curriculum for pediatric residents significantly increases resident comfort in transitioning AYA and encourages change in future clinical practice. Future directions include evaluating the implementation of a formal longitudinal curriculum across several PGY levels and expansion of the curriculum to include internal medicine residents. Standardized curricula on this topic may improve resident comfort on a national level.

Advance Care Planning and Communication Skills Improve after an Interprofessional Team Simulation with Standardized Patients.

Background: Improving rates of advance care planning (ACP) and advance directive completion is a recognized goal of health care in the United States. No prior study has examined the efficacy of standardized patient (SP)-based student interprofessional ACP trainings. Objectives: The present study aims to evaluate an interprofessional approach to ACP education using SP encounters. Design: We designed a pre-post evaluation of an innovative interprofessional ACP training curriculum using multimodal adult learning techniques to test the effects of completing ACP discussions with SPs. Three surveys (pre-training T1, post-training T2, and post-clinical encounter T3) evaluated student knowledge, Communication Self-Efficacy (CSES), ACP self-efficacy, and interprofessional teamwork (using SPICE-R2). Setting/Subjects: Students from the schools of medicine, nursing, and social work attended three training modules and two SP encounters focused on ACP. Measurements/Results: During academic year 2018-2019, 36 students participated in the training at University of Maryland. Results demonstrated statistically significant improvements in ACP self-efficacy, M T1 = 2.9 (standard deviation [SD]T1 = 0.61) compared with M T3 = 3.9 (SDT3 = 0.51), p < 0.001, and CSES, M T1 = 4.6 (SDT1 = 1.35) versus M T3 = 7.3 (SDT3 = 0.51), p < 0.001, from T1 to T3. There was a medium-to-large improvement in knowledge from an average score of 4.3 (SD = 1.0) at T1 to an average score of 5.5 (SD = 1.4) at T2, p = 0.005, d = 0.67. Conclusions: Our interprofessional training module and SP encounter was successful in improving medical, social work, and nursing students' self-reported communication skills and knowledge regarding ACP.

Continuation of Opioid Therapy at Transitions of Care in Critically Ill Patients.

PURPOSE: Opioids are one of the high-risk medication classes that are administered to critically ill patients during their intensive care unit (ICU) stay. However, little attention has been given to inpatient opioid prescribing practices, especially in critically ill patients. The purpose of our study was to characterize opioid prescribing practices across 2 transitions of care during an inpatient hospital stay: medical ICU (MICU)/intermediate care unit (IMC) to floor and floor to hospital discharge and identify potential patient-specific factors that impact opioid continuation. METHODS: This is a retrospective cohort study evaluating opioid-naive adult patients with new opioid therapy initiated in MICU/IMC at a tertiary care academic medical center from December 1, 2016, to November 30, 2017. Opioid continuation rate was assessed twice: transition 1 (MICU/IMC to floor) and transition 2 (floor to hospital discharge). RESULTS: In total, 112 opioid-naive patients with initial opioid administration in the MICU/IMC were included. Opioid therapy was continued in 56.1% (37/66) at transition 1 and 56.8% of patients (21/37) at transition 2. Patients with opioids continued at transition 1 had a longer hospital length of stay compared to those not continued on opioids, 22 (interquartile range [IQR] 11-36) vs 8 (IQR 6-14; P = .0004). Among the patients continued on opioids at hospital discharge, intubation during hospital stay and cumulative opioid dosage were greater than those not continued on opioids (17 [80.9%] vs 7 [43.8%], P = .019; and 3482 mcg [IQR 1690-9530] vs 732.5 mcg [IQR 187.5-1360.9], P = .0018, respectively). CONCLUSIONS: Opioid-naive patients receiving opioid therapy in the MICU/IMC had a continuation rate of >56% during transitions of care, including hospital discharge. Factors that contributed to the continuation of opioids at transitions of care included longer hospital length of stay, intubation, and cumulative hospital opioid dosage. These findings may help to provide health systems with guidance on targeted opioid stewardship programs.

Moxifloxacin-Induced Thrombocytopenia Mediated by Moxifloxacin-Dependent IgM and IgG Antiplatelet Antibodies: A Case Report.

Moxifloxacin is a rare but important cause of drug-induced immune thrombocytopenia (DIT). We describe a patient who presented with an acute onset of severe thrombocytopenia complicated by petechial rash, epistaxis, and melena. Recent new drug exposures included moxifloxacin and two proton pump inhibitors. On presentation to the hospital, all recently initiated medications were discontinued and the patient's thrombocytopenia was treated with platelet transfusions, intravenous immunoglobulin, and high-dose corticosteroids. Her thrombocytopenia improved over the next seven days and she was discharged on hospital day 8. Serologic testing revealed strongly positive moxifloxacin-dependent IgM and IgG antiplatelet antibodies, confirming a diagnosis of moxifloxacin-induced immune thrombocytopenia. DIT has been reported with other fluoroquinolone antibiotics, especially ciprofloxacin. This case documents a rare but potentially fatal complication of exposure to moxifloxacin and is the first to demonstrate objective evidence of acute sensitization with IgM antibody positivity. It highlights the need to consider this potential reaction when choosing antibiotic therapy, particularly in patients who are at high risk for bleeding, have hematologic disorders, or are receiving myelosuppressive therapies, and perhaps in those with a history of multiple drug allergies.

Acute Severe Hyponatremia Induced by a Duloxetine Overdose in an Elderly Woman.

We report a case of acute severe hyponatremia within 24 hours after a duloxetine overdose. An 82-year-old woman presented to the ED after ingesting duloxetine and diltiazem. She became hemodynamically unstable due to the diltiazem overdose and was appropriately resuscitated. During hospitalization she experienced hyponatremia consistent with syndrome of inappropriate antidiuretic hormone (SIADH). Based on the observations we concluded there was a probable relationship between the hyponatremia and the duloxetine overdose. Clinicians should monitor patients' electrolytes for acute disturbances after an overdose of duloxetine.

An interprofessional training to improve advance care planning skills among medicine, nursing, and social work students.

Suboptimal training for healthcare students is a recognized barrier to successful completion of advance care planning (ACP) with patients and families. Our study sought to enhance ACP knowledge and communication skills for interprofessional healthcare students. During academic year 2017-2018, 46 students (19-medicine, 16-nursing, and 11-social work), received three training modules delivered by interprofessional faculty. Students subsequently observed a clinical ACP encounter attended by a patient and their family, a clinical social worker, and an internal medicine resident. Three surveys (pre-training T1, post-training T2, and post-clinical encounter T3) evaluated change in student knowledge, communication self-efficacy, ACP self-efficacy, and interprofessional teamwork (using SPICE-R). A randomized waitlist approach was used to test the effects of the clinical ACP training. Student attendance and engagement were high. Relative to baseline, all outcomes differed at all data collection intervals (p < 0.05), except for the SPICE-R from T2 to T3 (p > 0.05). ACP self-efficacy scores declined at T2 before improving at T3. Communication self-efficacy was lower at T2 but improved at T3. Teamwork improved with a medium-large effect (ES = 0.75) at T2 and a large effect (ES = 1.00) at T3. Participant knowledge of ACP improved overall (p < 0.001) as well as for each discipline (p < 0.05). Preliminary findings indicate the interprofessional training experience enhanced student communication skills, ACP knowledge, and appreciation for team-based care. T2 findings demonstrate decrease in communication and ACP self-efficacy, perhaps suggesting students initially underestimated ACP complexity and overestimated their ability to communicate about ACP. T3 findings further suggest that students ultimately benefited from the training experience with meaningful improvements on all key outcomes.

Impact of an Antipsychotic Discontinuation Bundle During Transitions of Care in Critically Ill Patients.

INTRODUCTION:: Delirium affects a large proportion of patients admitted to the intensive care unit (ICU) and is associated with increased morbidity and mortality. Antipsychotics have become frequently used agents for the treatment of delirium; however, they are often continued at transitions of care. This has potential negative short- and long-term health consequences that are preventable. We investigated the antipsychotic tapering bundle's impact on the rate of antipsychotic continuation at transitions from the medical intensive care unit (MICU). METHODS:: This was a preretrospective and postretrospective chart review that included adult patients in the MICU initiated on antipsychotic therapy for ICU delirium. A bundled multidisciplinary education program and antipsychotic discontinuation algorithm were implemented in the MICU to provide recommendations for safe and effective use of antipsychotics for ICU delirium and minimize continuation of therapy at transitions of care. Rates of antipsychotic continuation at transition from the MICU were compared between the preintervention and postintervention groups with the χ2 test. RESULTS:: A total of 140 patients in the prebundle group and 141 patients in the postbundle group were enrolled. Overall, baseline characteristics were similar. After implementation of the discontinuation bundle, antipsychotic continuation at MICU discharge decreased (27.9% in the prebundle group vs 17.7% in the postbundle group; P < .05). In the multivariate analysis, patients were less likely to be continued on antipsychotic therapy at MICU discharge after implementation of the bundle (odds ratio [OR]: 0.47; 95% confidence interval [CI]: 0.26-0.86). There were also lower rates of overall antipsychotic continuation at hospital discharge (OR: 0.4; 95% CI: 0.18-0.89). CONCLUSION:: This is the first study to demonstrate a reduction in antipsychotic continuation at transition from the MICU after implementation of an antipsychotic discontinuation bundle in ICU patients. We believe this bundle allows for safer transitions of care from the MICU and decreases unnecessary antipsychotic therapy.

Hospital delirium treatment: Continuation of antipsychotic therapy from the intensive care unit to discharge.

PURPOSE: The rate of continuation of antipsychotics for the management of delirium during hospital transitions of care in a tertiary care medical center was investigated. METHODS: A retrospective chart review was conducted for adult patients admitted to the medical intensive care unit (MICU) between June 1, 2011, and May 31, 2012, who were initiated on antipsychotic therapy at least 24 hours before transfer out of the MICU. The primary outcome evaluated was the percentage of patients initiated on an antipsychotic in the MICU who were continued on therapy after transfer to a medical ward. Secondary outcomes included the appropriateness of continuing antipsychotic therapy during transitions of care and the percentage of patients continued on an antipsychotic after hospital discharge. RESULTS: Of the 87 patients who met the study inclusion criteria, 23 (26%) were continued on antipsychotic therapy after their transfer from the MICU to the medical ward. Of the 23 patients continued on antipsychotic therapy, 9 (39%) were discharged from the hospital with an antipsychotic. Fourteen of the 23 patients were eligible for assessment of inappropriate antipsychotic continuation upon transfer from the MICU. Of these 14 patients, 9 (64%) were inappropriately continued on an antipsychotic. Patients continued on antipsychotic therapy at hospital discharge were more likely to be discharged to a facility (rehabilitation, skilled nursing facility, or healthcare institution) (p = 0.049).Future areas for study should include (1) prospective analysis to understand the clinical decision-making of providers when treating delirium, (2) evaluation of the long-term impact of continuing antipsychotic therapy for delirium, and (3) ways to improve communication of medication regimens during transitions of care. Plans to reduce antipsychotic continuation could involve reassessing patients on the medical wards, improving documentation of the indication for use in the medical record, or developing protocols to taper off antipsychotics before patients are discharged from the hospital. CONCLUSION: The continuation of antipsychotics for the management of delirium during transitions of care was a common practice at a tertiary care medical center. Patients receiving antipsychotics for treatment of delirium in the MICU were inappropriately continued on these agents when transferred from the MICU to the medical floor or discharged from the hospital.