Interprofessional Medication Error Disclosure Training Using a Telehealth Consultation Simulation.

Objective. Health professions students must develop collaborative skills to disclose errors effectively and improve patient safety. We proposed that an interprofessional simulation using telehealth technology would provide medical and pharmacy students the opportunity to practice, develop, and grow in their confidence and skills of working collaboratively and disclosing medication errors.Methods. A three-phase interprofessional student simulation was developed. Phase 1 included individual student preparation. An interprofessional telehealth consultation encounter occurred in phase 2 for the error disclosure between the pharmacy and medical students. Phase 3 included faculty-led interprofessional debrief sessions. A pre- and postsimulation survey assessed students' experiences regarding their confidence in error disclosure, use of telehealth technology, and the role of the community pharmacist. Faculty evaluated pharmacy student performance using a 12-point rubric.Results. Presimulation survey responses (n=173) were compared to postsimulation survey responses (n=140). Significant changes were seen for all students' confidence in error disclosure and use of telehealth technology. No significant change was noted in the students' understanding of the community pharmacists' role on the interprofessional team. Pharmacy student performance-based rubric data (n=148) revealed a median score of seven out of 12 for error disclosure and interprofessional communication items.Conclusion. Medical and pharmacy students perceived their confidence improved in interprofessional error disclosure and use of telehealth consultation technology through this interprofessional simulation. Pharmacy students' error disclosure and interprofessional communication skill development were assessed through this simulation.

Determining the impact of an interprofessional learning in practice model on learners and patients.

The Institute of Medicine recently expressed a need to measure the impact of interprofessional education (IPE) on health professions collaborative behavior in practice environments and patient outcomes, and the National Center for Interprofessional Practice and Education has focused research efforts to connect interprofessional practice and education. We describe a model intentionally designed to link interprofessional practice experience in ambulatory care setting and an IPE curriculum for students, called the Interprofessional Learning in Practice (ILIP) model. The study objective was to determine the impact of the ILIP model on student and patient outcomes during a 24-month intervention period. Student satisfaction was collected through a brief survey administered post-ILIP model. Patient outcomes were collected from before and after the intervention period through a retrospective chart review of patients who received care through the ILIP model. For the study, disease indicators for the top three chronic diagnoses of depression, hypertension, and type 2 diabetes mellitus were chosen as the patient outcomes. Student outcomes were analyzed using descriptive statistics and the Mann-Whitney U test. Patient outcomes were analyzed using McNemar's test and paired t-tests. Of the 382 students who participated in the ILIP model during the study period, 179 completed surveys, indicating that they valued the experience, valued learning from interprofessional preceptors, and gained interprofessional skills to use in their future practice. During the 24-month intervention, 401 patients were evaluated post-ILIP model, statistically significant results demonstrated HbA1c values for patients with diabetes were reduced by 0.5% and depression screening improved from 9% to 91%. Additionally, patients' hypertension control was similar to baseline and diabetes control (as defined as HbA1c ≤8%) was improved compared to baseline but did not reach statistical significance. By aligning interprofessional practice and education in the ILIP model, students had a positive experience, gained interprofessional collaboration skills, and provided value-added benefits to improve patient outcomes.

The SPEER: An interprofessional team behavior rubric to optimize geriatric clinical care.

Geriatric patients with complex health care needs can benefit from interprofessional (IP) care; however, a major gap in health professional education is determining how to prepare future providers for IP collaboration. Effective IP team behavior assessment tools are needed to teach, implement, and evaluate IP practice skills. After review of IP evaluation tools, the Standardized Patient Encounter Evaluation Rubric (SPEER) was created to evaluate team dynamics in IP practice sites.Independent sample t-tests between faculty and learner SPEER scores showed learners scored themselves 15 points higher than their faculty scores (p < .001). Cronbach's α showed high internal consistency (α = 0.91). Paired t-tests found that learners identified improvements in the team's ability to address the patient's education needs and to allow the patients to voice their expectations. Faculty identified improvements in the teams' ability to make recommendations. Faculty evaluations of learner teams showed improvements in raw ratings on all but two items. Qualitative data analysis for emergent themes showed learners desired team functioning feedback and how teamwork could improve to provide optimal IP care.In conclusion, the SPEER can help faculty and learners identify growth in their teams' ability to perform key IP skills in clinical sites.

Preparing a healthcare workforce for geriatrics care: an Interprofessional team based learning program.

BACKGROUND: Improving the care of older adults in our healthcare system involves teams working together. As the geriatrics population rises globally, health science learners need to be prepared to work collaboratively to recognize and treat common conditions in geriatrics. To enable workforce preparation, the Institute of Medicine and the National League for Nursing emphasize the need to implement interprofessional active learning activities for undergraduate healthcare learners at academic medical centers. METHODS: The Geriatrics Champions Program was a team-based learning activity created to meet this task. It was a 24-month program, repeated twice, that impacted 768 learners and 151 faculty from medicine, occupational therapy, physical therapy, nursing, social welfare, psychology, pharmacy and dietetics. Each class was intentionally divided into 20 interprofessional teams that met four times annually. Each session focused on one geriatrics domain. The objectives were centered around the specific geriatrics competencies for each health profession, divided into the eight domains written in the "American Geriatrics Society IM-FM Residency Competencies". Evaluation consisted of individual and team Readiness Assessment Tests (iRAT and tRAT). Surveys were also used to collect feedback using a Likert scale. Wilcoxon signed rank tests were used to compare iRAT and tRAT scores. Other analyses identified characteristics associated with tRAT performance group (Unpaired t-tests) and tRAT performance on the raw scale (Pearson correlation). Paired t-tests using a 7-level Likert Scale measured pre-post change in learner knowledge. RESULTS: Student tRAT scores were 30% higher than iRAT scores (p < 0.001). Teams were more likely to score 100% on the initial tRAT attempt if more team members attended the current session (p < 0.001), more health professions were represented by team members in attendance (p = 0.053), and the team had a better track record of past attendance (p < 0.01). In the post-program evaluation, learners felt this program was helpful for their career preparation in interprofessional geriatrics care. CONCLUSIONS: Learners understood that teams performed better than individuals in the care of older adults. Feedback from the learners and faculty was consistently positive and learners felt better prepared for geriatrics care. The program's benefits may extend beyond individual sessions.

A Subgroup of Chronic Low Back Pain Patients With Central Sensitization.

BACKGROUND: Our knowledge of central sensitization (CS) in chronic low back pain (CLBP) is limited. 2011 fibromyalgia criteria and severity scales (2011 FM survey) have been used to determine FM positive as a surrogate of CS. The major features of CS including widespread hyperalgesia and dysfunction of the descending inhibitory pathways can be identified by pressure pain threshold (PPT) and conditioned pain modulation (CPM) tests. The purpose of the study was to examine neurophysiological characteristics and psychosocial symptoms in a subgroup of FM-positive CLBP compared with FM-negative CLBP patients. METHODS: A total of 46 participants with CLBP and 22 pain-free controls completed outcome measures of the 2011 FM survey, PPT and CPM tests, and psychosocial questionnaires. Differences between FM-positive and FM-negative CLBP participants on these measures and correlations were analyzed. RESULTS: The 2011 FM survey identified 22 (48%) participants with CLBP as FM positive. FM-positive CLBP participants showed lower PPT values of the thumbnail (P=0.011) and lower back (P=0.003), lower CPM values of the thumbnail (P=0.002), and more severe pain catastrophizing, anxiety, and depression symptoms (P<0.05) than FM-negative CLBP participants. The 2011 FM scores were significantly correlated with the PPT and CPM values of the thumbnail and with psychosocial symptoms (P<0.001). DISCUSSION: Our findings suggest a subgroup of CLBP patients exhibiting with signs and symptoms of CS. Associations between subjective and objective CS measures indicate that the 2011 FM survey can be utilized to identify the presence of CS in CLBP in clinical practice.

Teaching for Practice: The Impact of a Large-Scale Interprofessional Foundational Program.

PURPOSE: The University of Kansas Medical Center has developed an interprofessional education (IPE) foundational program using TeamSTEPPS, a curriculum designed to improve patient care through effective communication and teamwork. The purpose of this study was to understand the impact of the Level 1 program on learners as they develop the attitudes, knowledge, and skills related to interprofessional collaborative practice. METHODS: Learners (n=715) representing 15 professions participated in the Level 1 program. A mixed-methods approach was used to assess achievement of learning objectives, learner reactions, modifications of perceptions and attitudes, acquisition of knowledge and skills, and anticipated behaviors. RESULTS: Learners (n=585, 81.8%) agreed that the program was valuable. Positive changes in attitudes were significant pre-post (p<0.001). An average of 80.3% of learners who responded (n=196, 27.4%) correctly answered knowledge survey questions. Furthermore, analysis of open-ended questions suggested that learners gained an increased appreciation for interprofessional communication and better understanding of the roles of other healthcare professions. CONCLUSIONS: Based on positive learner reactions, changes in attitudes and knowledge, and anticipated behaviors associated with this program, similar approaches that incorporate TeamSTEPPS early in professional curricula may be useful for foundational IPE programming due to the intentional alignment with collaborative practice and orientation towards the Quadruple Aim.

An interprofessional objective structured teaching experience (iOSTE): An interprofessional preceptor professional development activity.

There has been a recent shift to develop and implement interprofessional education for learners during their "clinical" years. With this shift comes a specific need to develop preceptors in the area of interprofessional precepting. The interprofessional objective structured teaching experience (iOSTE) is one method for developing preceptors. The iOSTE was developed from experience with an interprofessional teaching clinic. Full and short versions of the iOSTE were implemented across multiple universities. The iOSTE gives preceptors an opportunity to gain experience with key skills associated with precepting interprofessional learners in clinical settings. Participants evaluated the iOSTE after the session using Likert scale ratings and open-ended questions. Descriptive statistics, independent samples T-tests, and content analysis were used to analyse the data. A total of 96 individuals from 15 different professions and three different universities participated in the iOSTE, with 59.4% (n = 57) completing the iOSTE evaluation. The iOSTE was highly rated with significant differences between the full and short versions of the iOSTE for three evaluation items. Content analysis revealed common themes that preceptors took away from the experience were of "all voices included" and "interprofessional precepting skills". Overall, the iOSTE appears to a feasible and effective method for developing interprofessional preceptors.

Interprofessional Education and Practice Guide No. 7: Development, implementation, and evaluation of a large-scale required interprofessional education foundational programme.

Health profession educators and administrators are interested in how to develop an effective and sustainable interprofessional education (IPE) programme. We describe the approach used at the University of Kansas Medical Centre, Kansas City, United States. This approach is a foundational programme with multiple large-scale, half-day events each year. The programme is threaded with common curricular components that build in complexity over time and assures that each learner is exposed to IPE. In this guide, lessons learned and general principles related to the development of IPE programming are discussed. Important areas that educators should consider include curriculum development, engaging leadership, overcoming scheduling barriers, providing faculty development, piloting the programming, planning for logistical coordination, intentionally pairing IP facilitators, anticipating IP conflict, setting clear expectations for learners, publicising the programme, debriefing with faculty, planning for programme evaluation, and developing a scholarship and dissemination plan.

Student Outcomes Associated with an Interprofessional Program Incorporating TeamSTEPPS®.

BACKGROUND: Interprofessional education (IPE) of health professions students is a starting point for developing collaborative-practice-ready healthcare professionals, ultimately leading to improved patient care. The purpose of this study was to develop and evaluate a novel, foundational, IPE pilot program that incorporates TeamSTEPPS® for health professions students. METHODS: Students representing 13 different health professions programs participated in successive Level 1 and Level 2 "Foundations of Interprofessional Collaboration: Introduction to TeamSTEPPS®" half-day activities (n = 241). Students' satisfaction with the pilot program, changes in attitudes toward teamwork from before to after participation, TeamSTEPPS® knowledge acquisition, and anticipated future interprofessional collaboration-oriented behavior change were assessed through online surveys. RESULTS: Overall, students were highly satisfied with the pilot program and reported that learning from other professions was valuable. Statistically significant positive changes were noted in attitudes toward teamwork, most notably with the Level 1 pilot. Greater than 80% of students who completed the surveys demonstrated acquisition of TeamSTEPPS® knowledge. Students also reported feeling more prepared to collaborate interprofessionally in their future practice. CONCLUSION: This study demonstrated that the two-level foundational pilot program is feasible and had the intended effects with regards to moving health professions students toward becoming collaborative-practice-ready healthcare professionals.

Adults with diabetic peripheral neuropathy exhibit impairments in multitasking and other executive functions.

BACKGROUND AND PURPOSE: Diabetic peripheral neuropathy (DPN) contributes to functional impairment, and there is growing evidence that neuropsychological factors also influence physical function. We compared cognitive and executive function in adults with DPN with an age-matched comparison group, and examined the relationships between DPN, executive function, and physical function. METHODS: Twenty subjects with DPN and 20 comparison subjects were assessed. Diabetic peripheral neuropathy was quantified via the Michigan Neuropathy Screening Instrument and nerve conduction velocity testing. Subjects were administered Beck's Depression Inventory, the Mini-Mental Status Examination, and the Timed Up and Go (TUG) test. Each participant also completed a battery of 7 executive function tasks, including the Cognitive Timed Up and Go (cTUG) test, in which a concurrent mental subtraction task was added to the standard TUG test. RESULTS: The DPN group demonstrated poorer letter fluency (34.2 ± 11.6 words vs 46.2 ± 12.2 words; P = 0.001), category fluency (47.0 ± 8.1 words vs 56.3 ± 8.5 words; P = 0.003), and Rey-Osterrieth scores (25.9 ± 4.3 points vs 31.7 ± 2.4 points; P < 0.001), and took longer to complete both the TUG (10.3 ± 2.8 seconds vs 5.9 ± 1.0 seconds; P < 0.001) and cTUG (13.0 ± 5.8 seconds vs 6.9 ± 1.6 seconds; P < 0.001). Poorer global cognitive performance and greater depression symptoms were significantly related to each other (r = -0.46; P = 0.04) and to slower TUG times (r = -0.53; P = 0.02; and r = 0.54; P = 0.02, respectively). DISCUSSION AND CONCLUSIONS: Verbal, visuospatial, and multitasking measures of executive function may be impaired in adults with DPN. Future research should examine how these and other cognitive and psychological factors, such as depression, affect physical function in this population.

Diagnostic accuracy of fall risk assessment tools in people with diabetic peripheral neuropathy.

BACKGROUND: Diabetic peripheral neuropathy affects nearly half of individuals with diabetes and leads to increased fall risk. Evidence addressing fall risk assessment for these individuals is lacking. OBJECTIVE: The purpose of this study was to identify which of 4 functional mobility fall risk assessment tools best discriminates, in people with diabetic peripheral neuropathy, between recurrent "fallers" and those who are not recurrent fallers. DESIGN: A cross-sectional study was conducted. SETTING: The study was conducted in a medical research university setting. PARTICIPANTS: The participants were a convenience sample of 36 individuals between 40 and 65 years of age with diabetic peripheral neuropathy. MEASUREMENTS: Fall history was assessed retrospectively and was the criterion standard. Fall risk was assessed using the Functional Reach Test, the Timed "Up & Go" Test, the Berg Balance Scale, and the Dynamic Gait Index. Sensitivity, specificity, positive and negative likelihood ratios, and overall diagnostic accuracy were calculated for each fall risk assessment tool. Receiver operating characteristic curves were used to estimate modified cutoff scores for each fall risk assessment tool; indexes then were recalculated. RESULTS: Ten of the 36 participants were classified as recurrent fallers. When traditional cutoff scores were used, the Dynamic Gait Index and Functional Reach Test demonstrated the highest sensitivity at only 30%; the Dynamic Gait Index also demonstrated the highest overall diagnostic accuracy. When modified cutoff scores were used, all tools demonstrated improved sensitivity (80% or 90%). Overall diagnostic accuracy improved for all tests except the Functional Reach Test; the Timed "Up & Go" Test demonstrated the highest diagnostic accuracy at 88.9%. LIMITATIONS: The small sample size and retrospective fall history assessment were limitations of the study. CONCLUSIONS: Modified cutoff scores improved diagnostic accuracy for 3 of 4 fall risk assessment tools when testing people with diabetic peripheral neuropathy.

The effect of exercise on neuropathic symptoms, nerve function, and cutaneous innervation in people with diabetic peripheral neuropathy.

UNLABELLED: Although exercise can significantly reduce the prevalence and severity of diabetic complications, no studies have evaluated the impact of exercise on nerve function in people with diagnosed diabetic peripheral neuropathy (DPN). The purpose of this pilot study was to examine feasibility and effectiveness of a supervised, moderately intense aerobic and resistance exercise program in people with DPN. We hypothesized that the exercise intervention can improve neuropathic symptoms, nerve function, and cutaneous innervation. METHODS: A pre-test post-test design was used to assess change in outcome measures following participation in a 10-week aerobic and strengthening exercise program. Seventeen subjects with diagnosed DPN (8 males/9 females; age 58.4±5.98; duration of diabetes 12.4±12.2 years) completed the study. Outcome measures included pain measures (visual analog scale), Michigan Neuropathy Screening Instrument (MNSI) questionnaire of neuropathic symptoms, nerve function measures, and intraepidermal nerve fiber (IENF) density and branching in distal and proximal lower extremity skin biopsies. RESULTS: Significant reductions in pain (-18.1±35.5 mm on a 100 mm scale, P=.05), neuropathic symptoms (-1.24±1.8 on MNSI, P=.01), and increased intraepidermal nerve fiber branching (+0.11±0.15 branch nodes/fiber, P=.008) from a proximal skin biopsy were noted following the intervention. CONCLUSIONS: This is the first study to describe improvements in neuropathic and cutaneous nerve fiber branching following supervised exercise in people with diabetic peripheral neuropathy. These findings are particularly promising given the short duration of the intervention, but need to be validated by comparison with a control group in future studies.

Effects of age and localized muscle fatigue on ankle plantar flexor torque development.

BACKGROUND AND PURPOSE: Older adults often experience age-related declines in strength, which contribute to fall risk. Such age-related levels of fall risk may be compounded by further declines in strength caused by acute muscle fatigue. Both age- and fatigue-related strength reductions likely impact the ability to quickly develop joint torques needed to arrest falls. Therefore, the purpose of this study was to investigate the combined effects of age and localized muscle fatigue on lower extremity joint torque development. METHODS: Young (mean age, 26 (2.5) years) and older (mean age, 71 (2.8) years) healthy male adults performed an isometric ankle plantar flexion force control task before and after an ankle plantar flexor fatiguing exercise. Force control performance was quantified using onset time, settling time, and rate of torque development. RESULTS: Age-related increases and decreases were observed for onset time and rate of torque development, respectively. A fatigue-related decrease in rate of torque development was observed in young, but not older adults. DISCUSSION: The results suggest performance declines that may relate to older adults' reduced ability to prevent falls. A fatigue-related performance decline was observed among young adults, but not older, suggesting the presence of age-related factors such as motor unit remodeling and alterations in perceived exertion. CONCLUSIONS: Older adults demonstrated an overall reduction in the ability to quickly produce ankle torque, which may have implications for balance recovery and fall risk among older adults.

Early biomechanical markers of postural instability in Parkinson's disease.

Current clinical assessments do not adequately detect the onset of postural instability in the early stages of Parkinson's disease (PD). The aim of this study was to identify biomechanical variables that are sensitive to the effects of early Parkinson's disease on the ability to recovery from a balance disturbance. Ten adults diagnosed with idiopathic PD and no clinically detectable postural instability, and ten healthy age-range matched controls (HC) completed the study. The first step in the response to a backwards waist pull was quantified in terms of strategy, temporal, kinematic, kinetic, and center of pressure (COP) variables. People with PD, compared to HC, tended to be less consistent in the choice of stepping limb, utilized more time for weight shift, used a modified ankle joint motion prior to liftoff, and the COP was further posterior at landing. The study results demonstrate that PD changes the response to a balance disturbance which can be quantified using biomechanical variables even before the presence of clinically detectable postural instability. Further studies are required to determine if these variables are sensitive and specific to postural instability.