Epistaxis Rates and Health Care Utilization in Patients With a Ventricular Assist Device.

Objective: Identify baseline epistaxis rates and epistaxis-related health care utilization trends in the ventricular assist device (VAD) population. Methods: Single center, retrospective cohort study consisting of chart review of adult VAD patients. Analysis of descriptive statistics was assessed using χ 2 tests, independent sample t tests, or Fisher's exact when expected counts were low. Logistic regression was used to assess associations between epistaxis and variables of interest. Results: Two hundred ninety patients were included in the analysis. Ninety-eight (33.8%) patients developed epistaxis and 84 (29.0%) received medical attention. Patients with gastrointestinal (GI) bleeding had increased rates of epistaxis (42.4% vs 29.0%). Logistic regression analysis found GI bleeding to have an adjusted odds of developing epistaxis of 1.94 (95% confidence interval [CI]: 1.12-3.37) and kidney disease to have an adjusted odds of 1.83 (95% CI: 1.06, 3.13). Discussion: VAD implantation improves survival and quality of life but also carries significant bleeding risks. At our institution, 29% of VAD patients received medical attention for epistaxis. GI bleeding and kidney disease were found to have increased adjusted odds of developing epistaxis. Fifty-nine percent of epistaxis events occurred while inpatient and 32.8% of events were seen in the emergency department. Implications for Practice: VAD patients are an at-risk group that could potentially benefit from preventative nasal hydration regimen.

Listening campaigns: engaging clinicians to assess system factors contributing to burnout.

BACKGROUND: Even prior to the pandemic, many US physicians experienced burnout affecting patient care quality, safety and experience. Institutions often focus on personal resilience instead of system-level issues. Our leaders developed a novel process to identify and prioritise key system-related solutions and work to mitigate factors that negatively impact clinician well-being through a structured listening campaign. METHODS: The listening campaign consists of meeting with each clinician group leader, a group listening session, a follow-up meeting with the leader, a final report and a follow-up session. During the listening session, clinicians engage in open discussion about what is going well, complete individual reflection worksheets and identify one 'wish' to improve their professional satisfaction. Participants rate these wishes to assist with prioritisation. RESULTS: As of January 2020, over 200 clinicians participated in 20 listening sessions. One hundred and twenty-two participants completed a survey; 80% stated they benefited from participation and 83% would recommend it to others. CONCLUSION: Collecting feedback from clinicians on their experience provides guidance for leaders in prioritising initiatives and opportunities to connect clinicians to organisational resources. A listening campaign is a tool recommended for healthcare systems to elicit clinician perspectives and communicate efforts to address systemic factors.

Rural-urban otolaryngologic observational workforce analysis: The state of Nebraska.

Objective: To analyze the rural-urban access to otolaryngology (OHNS) care within the state of Nebraska. Design: Cross-sectional study. Methods: Counties in Nebraska were categorized into rural versus urban status based upon the 2013 National Center for Health Statistics urban-rural classification scheme with I indicating most urban and VI indicating most rural. The information on otolaryngologists was gathered utilizing the Health Professions Tracking System. Otolaryngologists were categorized based on the county of their primary and outreach clinic location(s). Travel burden was estimated using census tract centroid distance to the nearest clinic location, aggregated to county using weighted population means to determine the average county distance to the nearest otolaryngologist. Results: Nebraska is a state with a population of 1.8 million people unequally distributed across 76,824 square miles, with rural counties covering 2/3 of the land area. Nebraska has 78 primary OHNS clinics and 70 outreach OHNS clinics distributed across 93 counties. More than half (54.8%) of the counties in Nebraska lacked any OHNS clinic. Overall, a statistically significant difference was found when comparing mean primary OHNS per 100,000 population and mean miles to a primary OHNS clinic with Level III counties being 5.17 linear miles from primary OHNS compared to Level V counties being 29.94 linear miles. Conclusion: Overall, a clear discrepancy between rural and urban primary OHNS clinics in Nebraska can be seen visually and statistically with rural Nebraskans having to travel at least 5.5 times farther to primary OHNS clinics when compared to urban Nebraskans.

Quality Versus Quantity: Using Scholarly Activity to Assess Otolaryngology Residency Candidates.

Selecting qualified candidates each year for residency positions has become more difficult in recent years, due to the sharp increase in Otolaryngology applicants. Although there are objective measures that can be used to directly compare medical students during the initial screening process, most information in the application is highly subjective and/or variable across institutions. Many programs count the total posters/presentations and publications to gauge scholarship. This measure of quantity may lead to negative bias toward those who have no home program, limited time outside of academics, and/or inadequate resources to engage in volunteer research. Evaluating the quality of research may be superior to quantity. A first-author publication is a viable proxy that demonstrates applicants have developed skills that set them apart from their peers. They likely possess non-clinical, translatable skills including internal motivation, self-regulation, curation of information, and task completion that map closely with qualities that make for excellent residents.

A Retrospective Study of Anticholinergic Use and Later Mobilization as Risk Factors for Urinary Retention After Major Lower Extremity Joint Arthroplasty.

BACKGROUND: Postoperative urinary retention (POUR) is a common surgical complication of major joint arthroplasty and is associated with increased lengths of stay and urinary tract infections. Studies have found that certain anticholinergic medications and reduced mobility are associated with POUR. This study assessed the effect of anticholinergic burden and later postoperative ambulation on POUR. METHODS: In this retrospective cohort study, we included subjects who had undergone elective primary or revision hip or knee arthroplasty (total hip arthroplasty [THA] or total knee arthroplasty [TKA]) between March 2015 and December 2017 in a single health system. Anticholinergic burden was measured using the Anticholinergic Drug Scale (ADS). We performed bivariate and multivariable logistic regression with POUR as the dependent variable. Of the 1,397 study subjects, 622 (45%) underwent THA and 775 (55%) underwent TKA. Their mean age was 65 years (range, 21 to 98), and 841 (60%) were women. POUR developed in 183 (13%) subjects. RESULTS: In multivariable analyses, ADS was associated with POUR after THA (P < .05), but not TKA (P = .08), while later ambulation was not associated with POUR after either procedure (P > .3 for both). CONCLUSION: Anticholinergic burden after THA was independently associated with POUR. Strategies to reduce anticholinergic burden may help reduce POUR after THA.

The effect of geographic rounding on hospitalist work experience: a mixed-methods study.

OBJECTIVES: To describe the structure and implementation of a model in which hospitalists focus on a particular hospital unit or area, referred to as 'geographic rounding,' and to analyze its effect on hospitalist efficiency, interruptions, after-hours work, and satisfaction. METHODS: The leadership of our academic hospital medicine group designed a geographic rounding intervention with the goal of improving provider satisfaction and mitigating burnout. Our quantitative analysis compared the pre-intervention and post-intervention time periods with regard to progress note completion time, after-hours progress note completion, secure messaging communication volume, and Mini-Z survey results. A post-intervention qualitative analysis was performed to further explore the relationship between geographic rounding and the drivers of burnout. RESULTS: Following the intervention, 97% of geographic rounders were localized to one or two geographic areas and 77% were localized to a single geographic area. Following the implementation of geographic rounding, progress notes were completed an average of 29 minutes earlier (p < 0.001). The proportion of progress notes completed after-hours decreased from 25.1% to 20% (p < 0.001). The volume of secure messages received by hospitalists decreased from 1.95 to 1.8 per patient per day (p < 0.001). The proportion of hospitalists reporting no burnout increased from 77.8% to 93% after implementing geographic rounding, a change that did not reach statistical significance (p = 0.1). Qualitative analysis revealed mixed effects on work environment but improvements in efficiency, patient-centeredness, communication with nurses, and job satisfaction. CONCLUSION: Geographic rounding represents an organization-level change that has the potential to improve hospitalist career satisfaction.

Providers at a Midwestern Academic System Report a Positive Experience with Telehealth During the COVID-19 Pandemic.

Introduction: Since the onset of the COVID-19 pandemic, there has been rapid expansion in the use of telehealth. As a result, many providers who had no prior experience using telehealth are now using it to provide patient care. The goal of this study was to survey health care providers on a wide range of telehealth topics including their experiences examining and connecting with patients digitally, identifying which types of patients may be best suited to telehealth, and identifying technical and logistical areas for improvement when using telehealth. Methods: Physicians and advanced practice providers (n = 944) at a large midwestern academic system were invited to complete an anonymous online survey during a 2-week period in October 2020. Results: Surveys, completed and analyzed (n = 178), indicated 86.6% of respondents felt confident in their clinical assessment, and 86.1% felt they formed an adequate personal connection with the patient in the majority of telehealth visits. A majority (58.5%) of providers felt telehealth was not effective for new patients, but 83% of providers felt it was effective for providing care to established patients. Respondents identified several areas for technological improvement including issues with video (27.5%) and audio (16.8%) quality. In 24.4% of visits, these technology issues were severe enough providers needed to convert an audiovisual appointment to telephone. Conclusions: Provider experience with telehealth has largely been positive at our institution. Although telehealth may not be appropriate for new patients, providers did feel it was an effective means of providing care for established patients. To continue improving the quality of telehealth, a multiteam approach should be considered, including members of technology and clinical operations teams working closely with those providers experienced in telehealth.

Perceptions of older adults? Measuring positive, negative, and physical descriptors using the stereotype content and strength survey.

The COVID-19 pandemic has disproportionately impacted the health of older adults. In addition to a higher risk for serious illness and death, the societal value of senescent adults was challenged. There have been conflicting results reported in the research literature regarding positive and negative stereotypes of older adults, and areliable and valid assessment tool to measure content (existence of astereotype) and strength (intensity of astereotype) is unavailable. To address issues with instruments employed to measure ageist stereotypes, researchers developed the Stereotypes Content and Strength Survey. University students (n=483) were directed to "think about their perceptions of older adults" and indicate how many they believed could be described using the terms listed on a5-point Likert-type scale from none-all. Response categories for each descriptive item were dichotomized into 1 = "some, most or all" and 0 = "none or few." Based on an odds analyses of 117 items, 84 met the content criteria to be considered astereotype regarding older adults. Using the criteria for strength, items were categorized into 36 "strong," 25 "moderate," and 23 "weak" stereotypes. Assessing the content and strength of stereotypic beliefs using this procedure may contribute to major bias influencing ageist perceptions.

Just-In-Time Simulation Training for Nasopharyngeal Specimen Collection During the SARS-CoV-2 Pandemic.

INTRODUCTION: Rapid and accurate detection of the novel coronavirus using a nasopharyngeal specimen requires training for professionals who may have limited experience. To respond to the urgent need, an interprofessional team created a just-in-time (JIT) module to provide only what was needed, precisely when needed, and rapidly deployed training sessions to a large group of health professionals. METHODS: In April and May 2020, health professionals from the hospital, ambulatory clinics, and public health attended training. Procedural comfort/knowledge and perception of the training were assessed with pre-survey and post-survey. RESULTS: Comfort level in collecting a nasopharyngeal specimen among participating health professionals increased from 2.89 (n = 338) on the pre-survey to 4.51 (n = 300) on the postsurvey on a 5-point scale. Results revealed a significant difference (P < .01) between pre-post knowledge questions regarding the correct angle and depth of the swab to obtain an adequate sample from the nasopharynx. DISCUSSION: This study demonstrates that a JIT intervention can improve knowledge and comfort regarding the nasopharyngeal swab procedure. In preparation for the prevention and mitigation of future viral outbreaks (ie, coronavirus and influenza), educators should consider creating JIT skills training for health care professionals who may be deployed to assist in mass testing efforts.

A Novel Just-In-Time-Online-Training for Nasopharyngeal Swab Specimen Collection During the COVID-19 Pandemic.

INTRODUCTION:  The spread of coronavirus disease 2019 (COVID-19) is controlled by timely detection of infected patients using a nasopharyngeal (NP) swab test, followed by isolation and treatment. One challenge encountered with NP swab collection was to train healthcare providers (HCPs) with different training backgrounds and experience for collecting NP swab specimens across Nebraska, including a sizeable rural area. In-person training for NP swab collection skills was challenging due to social distancing. We developed a Just-In-Time-Online Training (JITOT) and delivered it using Facebook Live (TM) to meet our HCPs' training needs. METHODS:  Online training was held on April 21, 2020, and attended by 453 HCPs. A quasi-experimental study based on a survey and a multiple choice questionnaire (MCQ) was conducted to evaluate its effectiveness in improving the participants' knowledge and attitudes. RESULTS:  Group mean knowledge score increased from a pre-test score of 57%-95% in the post-test showing a large effect size (Hedges' g = 0.976877). On a five-point Likert scale, the majority (86.21%) of the survey respondents agreed/strongly agreed that this training increased their overall comfort for nasal swab specimen collection as compared to their pre-training comfort (37.93%) with this procedure. The majority of respondents (96.55%) in the post-training evaluation agreed/strongly agreed that "the delivery method was appropriate." CONCLUSION:  A JITOT session is helpful to teach, demonstrate, clarify doubts, and improve the knowledge and comfort of the participants. It can be quickly delivered using a free social media platform for broader outreach during public health emergencies.

Integrated Comprehensive Care for Transcare and Gender Diverse Clinic Patients: An Assessment of Physical, Mental, and Social Needs.

Introduction There is a large body of research reporting the healthcare needs of groups identifying as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ); however, a gap exists in the research literature because many epidemiological studies focus on sexual orientation rather than gender identify/incongruence. To address the lack of specific data from transgender and gender diverse (TGD) individuals, our organization designed and deployed a survey to assess the gender-affirming physical, mental, and social care needs of current patients. Methods A group of subspecialty physicians currently working with TGD patients created a list of questions and requested feedback from medical professionals familiar with the healthcare needs of this population. In addition, patients reviewed the survey for content and clarity. The final 68-item survey was distributed in April 2020 to patients or patients' representatives with an email address on file at the Nebraska Medicine Transgender Care Clinic (NMTCC). Participants were asked to respond to questions regarding their gender identity, their transition-related medical decisions, and their interest in services. Results Invitations were sent to 690 patients and 168 surveys were completed (response rate: 24.3%). Over 90% (n = 153) of the participants were patients and 9% (n = 15) answered survey questions on the patient's behalf. A majority (77.2%) had started the medical transition (hormones or puberty blockers) in the past four years. Nearly half (46.4%) identified as trans women, 43.4% identified as trans men, and 10.2% indicated they were nonbinary or gender expansive. Participants' sex assigned at birth was 50.9% female and 46.1% male. Most patients (n = 149; 92%) reported currently receiving hormone treatment within the Nebraska Medicine healthcare system. Results indicated the highest level of clinical services interest was primary care (38.4%), gender-affirming surgery (73.5%), voice therapy (49.0%), and hair removal (37.5%). In addition, participants were very likely to participate in support groups with "people of similar gender identity" (32.9%), with "others around my age" (28.6%), and "including a mix of ages and identities" (26.9%). Discussion This study suggests that our TGD patients would utilize integrated services to access a variety of clinical and non-clinical services. Ongoing community engagement and direct feedback from patients are critical to the success and growth of our gender-affirming care clinic. The results of this study will inform the planning and further evolution of a program designed to build trust and address health inequities for TGD individuals throughout the region.

Perception versus reality: Does provider documentation behavior change when clinic notes are shared electronically with patients?

INTRODUCTION: Secure patient portals have improved patient access to information, including provider notes. Although there is evidence suggesting that electronic note sharing improves communication and care quality, some studies have reported provider concerns regarding note sharing. MATERIAL AND METHODS: This mixed-methods single site study utilized survey questions from a previously published landmark study to assess provider perceptions of electronic note sharing as well as objective EHR data. Surveys were sent to 628 providers in 34 primary and specialty care clinics approximately 12 weeks after the implementation of phase 1 (April 1, 2018) and phase 2 (July 1, 2018). EHR data were extracted from three months pre- and three months post-implementation of note sharing to determine whether or not note authoring times were affected. RESULTS: Nearly one-quarter (n = 150) of the responses sent to 628 providers were retained for analysis (23.9 % response rate). A majority (84.7 %) of respondents believed notes were useful vehicles for communication and 73.3 % agreed that making notes available to patients was a good idea. Additionally, 16.0 % of respondents (14.0 % for primary care and 17.0 % for specialists) believed they "spent more time writing/dictating/editing their notes." A comparison of pre-post note authoring time revealed the aggregated primary care median increased 0.14 min (7.93-8.07 min) while aggregated specialty care median was identical (11.6 min). DISCUSSION: The EHR comparison of note authoring time pre-post did not reflect provider concerns identified in the survey regarding electronic note sharing.

A Mixed-Methods Evaluation of Medical Residents' Attitudes Towards Interprofessional Learning and Stereotypes Following Sonography Student-Led Point-of-Care Ultrasound Training.

BACKGROUND: Point-of-care ultrasound (POCUS) training is growing across internal medicine graduate medical education, but lack of trained faculty is a barrier to many programs. Interprofessional education (IPE) may offer a solution but must overcome potential biases of trainees. AIM: To evaluate the impact of an interprofessional POCUS training on residents' attitudes towards interprofessional learning and stereotypes. SETTING: Midwestern health sciences university. PARTICIPANTS: Diagnostic medical sonography (DMS) students (n = 13) served as teachers for first-year internal medicine residents (IMR) (n = 49). PROGRAM DESCRIPTION: DMS students participated in a train-the-trainer session to learn teaching strategies via case-based simulation, then coached IMR to acquire images of the kidneys, bladder, and aorta on live models. PROGRAM EVALUATION: Mixed-methods evaluation, including pre-/post-surveys and focus group interviews. The survey response rate was 100% (49/49 IMR). Composite survey scores evaluating residents' attitudes towards IPE and stereotyping of sonographers improved significantly following the intervention. Qualitative analysis of focus group interviews yielded four themes: enhanced respect for other disciplines, implications for future practice, increased confidence of DMS students, and interest in future IPE opportunities. DISCUSSION: Interprofessional POCUS education can improve residents' perceptions towards IPE, increase their level of respect for sonographers, and motivate interest in future interprofessional collaboration.

Peer Coaching as a Faculty Development Tool: A Mixed Methods Evaluation.

BACKGROUND: In the era of competency-based assessment, medical education faculty are frequently challenged to develop unique teaching approaches. One method to address faculty development needs in a real-time clinical learning environment is peer coaching. OBJECTIVE: We implemented and evaluated a faculty development program involving peer observation and feedback for attending physicians. METHODS: Hospital internal medicine faculty assigned to a teaching service were recruited for the study. Participants voluntarily agreed to observe and be observed by a peer attending physician during a 2-week block of teaching rounds. When serving in the coaching role, faculty were asked to observe 4 separate occasions using an observation tool based on the Stanford Faculty Development Program framework to guide feedback. An outside consultant facilitated a focus group and completed a qualitative content analysis to categorize all participants' experiences during the faculty development activity. RESULTS: Of the 22 eligible faculty, 14 (64%) agreed to participate by committing to 6 to 8 hours observing another faculty member during rounds, 2 feedback sessions, and 90 minutes to provide program feedback during a focus group. The analysis of the focus group revealed favorable reactions to the faculty development program, including (1) observed attending awareness of unrecognized habits; (2) personalized teaching tips for the observed attending to improve teaching quality based on individual style/preferences; and (3) exposure to new teaching techniques. CONCLUSIONS: An inpatient-based peer-coaching faculty development program was acceptable and feasible for a majority of faculty and may improve individual teaching effectiveness among conventionally trained physicians.

Stereotypes of Older Adults: Development and Evaluation of an Updated Stereotype Content and Strength Survey.

BACKGROUND AND OBJECTIVES: Stereotypes are beliefs about a particular group often adopted to bypass complex information processing. Like racism and other forms of discrimination, ageism affects individuals and society as a whole. The purpose of the study was to analyze the Stereotype Content and Strength Survey (SCSS) designed to update assessment tools commonly used to measure stereotypes of older adults. RESEARCH DESIGN AND METHODS: An updated survey was developed including aging-related descriptive items from previously published studies. Students enrolled at two Midwestern universities (n = 491) were directed to think about their perceptions of "older adults" and select the proportion they believed could be described by the items used in the tool. Response categories for each descriptive item were dichotomized and operationalized to be a strong stereotype if the collapsed response percentage was significantly ≥80%. RESULTS: A Principal Axis Factor analysis and Direct Oblim rotation was computed on 117 descriptive items representing positive, negative, and physical characteristics, resulting in a 3-factor model with acceptable psychometric properties. Cronbach alpha analyses revealed reliable scales for negative (α = .92), positive (α = .88), and physical (α = .81) stereotypes. Of 117 descriptive items, 33 emerged as strong stereotypes including 30 positive, 2 physical, and 1 negative item. DISCUSSION AND IMPLICATIONS: This updated assessment has the potential to contribute to an understanding of the existence of age-related stereotypes as well as the strength, or the proportion of older adults who could be described by each of the items used in the SCSS.

Building a bigger tent in point-of-care ultrasound education: a mixed-methods evaluation of interprofessional, near-peer teaching of internal medicine residents by sonography students.

BACKGROUND: Point-of-care-ultrasound (POCUS) training is expanding in undergraduate and graduate medical education, but lack of trained faculty is a major barrier. Two strategies that may help mitigate this obstacle are interprofessional education (IPE) and near-peer teaching. The objective of this study was to evaluate a POCUS course in which diagnostic medical sonography (DMS) students served as near-peer teachers for internal medicine residents (IMR) learning to perform abdominal sonography. METHODS: Prior to the IPE workshop, DMS students participated in a train-the-trainer session to practice teaching and communication skills via case-based simulation. DMS students then coached first-year IMR to perform POCUS examinations of the kidney, bladder, and gallbladder on live models. A mixed-methods evaluation of the interprofessional workshop included an objective structured clinical exam (OSCE), course evaluation, and qualitative analysis of focus group interviews. RESULTS: Twenty-four of 24 (100%) IMR completed the OSCE, averaging 97.7/107 points (91.3%) (SD 5.2). Course evaluations from IMR and DMS students were globally positive. Twenty three of 24 residents (96%) and 6/6 DMS students (100%) participated in focus group interviews. Qualitative analysis identified themes related to the learning environment, scanning technique, and suggestions for improvement. IMR felt the interprofessional training fostered a positive learning environment and that the experience complimented traditional faculty-led workshops. Both groups noted the importance of establishing mutual understanding of expectations and suggested future workshops have more dedicated time for DMS student demonstration of scanning technique. CONCLUSION: An interprofessional, near-peer workshop was an effective strategy for teaching POCUS to IMR. This approach may allow broader adoption of POCUS in medical education, especially when faculty expertise is limited.