Severe anemia, anorexia, and uremia associated with diabetic foot infections: A case series.

Anemia of inflammation, as found in many chronic disease states, is common among persons with diabetic foot infections but is typically mild and self-limited. Herein we present four cases of patients with foot infections accompanied by severe anemia (nadir hemoglobin <8 gm/dL and resulting in transfusion of 4 + units of blood) as well as significant weight loss (30 + pounds), hyponatremia (<135 mmol/L), hypoalbuminemia (nadir <2 gm/dL), uremia and other metabolic derangements.

Inpatient Coding System and Opportunities for Documentation Optimization: An Interactive Session for Internal Medicine Residents.

Introduction: The Inpatient Prospective Payment System, the framework for categorization of admissions, is based upon physician documentation leading to International Classification of Diseases, Tenth Revision code generation and Medical Severity Diagnosis-Related Group (MS-DRG) assignment. In this curriculum, we introduced internal medicine residents to this inpatient coding framework and its effects on hospital quality metrics and reimbursement. We focused on educating learners about the importance of physicians being proficient in providing thorough and specific clinical documentation to produce appropriate DRG assignment. Methods: Internal medicine residents participated in a 90-minute session that introduced the basic framework of inpatient coding, discussed effects of physician documentation on hospital quality metrics and reimbursement, and provided tips on opportunities for documentation improvement. In an interactive learning activity, residents were presented with clinical vignettes and earned reimbursement based on their documentation of appropriate diagnoses. Each scenario was followed by clinical definitions and actionable documentation recommendations for common diagnoses. Materials included a PowerPoint presentation, clinical vignettes, sample teaching points, and a rubric to calculate estimated reimbursement. Results: Prior to the session, 38% of learners were confident in their understanding of how documentation affects hospital reimbursement, which improved to 90% postsession. Learners reported improvement in their knowledge of documentation requirements for all targeted diagnoses. Discussion: This interactive curriculum improved resident knowledge of the inpatient coding system and documentation requirements for common diagnoses and addressed a deficiency in residency education on a topic of significant importance for the success of hospital systems.

Implementation of a Hospital Medicine Rotation and Curriculum for Internal Medicine Residents.

Introduction: Hospital medicine is a growing field that focuses not only on expertise in inpatient medicine but also on knowledge of nonclinical health system topics. The traditional model for resident education does not lend itself to learning these topics. We developed a unique ward rotation with a dedicated curriculum called the Resident Inpatient Training Experience (RITE) to address this deficiency. Methods: The RITE rotation was initially implemented in the 2013-2014 academic year. The curriculum accompanying the rotation contained four case-based modules that included content on patient safety, quality improvement, cost-conscious care, hospital metrics/reimbursement, physician billing and coding, and transitions of care. Prior to RITE, residents received an email orientation to the service. To evaluate the rotation and curriculum, residents completed a pre- and postrotation online survey. Forty-six upper PGY 2 residents each rotated on the service for 1 month. An experienced hospitalist attended on the service and facilitated a weekly discussion on each module. This publication includes an updated version of the email orientation, the four modules, and the surveys. Results: There was a 72% response rate for completion of the pre- and postrotation survey. Confidence in managing hospitalized patients and knowledge of module content taught during the rotation improved. Discussion: We found that implementation of a hospital medicine rotation and curriculum improved resident independence and knowledge of the module topics and was a successful way to alleviate current deficiencies in resident education.

Efficacy of quality improvement and patient safety workshops for students: a pilot study.

BACKGROUND: While the Association of American Medical Colleges encourages medical schools to incorporate quality improvement and patient safety (QI/PS) into their curriculum, medical students continue to have limited QI/PS exposure. To prepare medical students for careers that involve QI/PS, the Institute for Healthcare Improvement chapter at an allopathic medical school and school of allied health professions initiated self-directed learning by offering student-led workshops to equip learners with skills to improve the quality and safety of healthcare processes. METHODS: In this prospective cohort study, workshops were hosted for medical students between 2015 and 2018 on five QI/PS topics: Process Mapping, Root-Cause Analysis (RCA), Plan-Do-Study-Act (PDSA) Cycles, Evidence Based Medicine (EBM), and Patient Handoffs. Each workshop included a hands-on component to engage learners in practical applications of QI/PS skills in their careers. Change in knowledge, attitudes, and behaviors was assessed via pre- and post-surveys using 5-point Likert scales, and analyzed using either the McNemar test or non-parametric Wilcoxon signed-rank test. Surveys also gathered qualitative feedback regarding strengths, future areas for improvement, and reasons for attending the workshops. RESULTS: Data was collected from 88.5% of learners (n = 185/209); 19.5% of learners reported prior formal instruction in these topics. Statistically significant improvements in learners' confidence were observed for each workshop. Additionally, after attending workshops, learners felt comfortable teaching the learned QI/PS skill to colleagues (mean pre/post difference 1.96, p < 0.0001, n = 139) and were more likely to pursue QI/PS projects in their careers (mean pre/post difference 0.45, p < 0.0001, n = 139). Lastly, learners demonstrated a statistically significant increase in knowledge in four out of five skills workshop topics. CONCLUSION: Few medical students have formal instruction in QI/PS tools. This pilot study highlights advantages of incorporating an innovative, student-directed modified 'flipped classroom' methodology, with a focus on active experiential learning and minimal didactic instruction.

Impact of a Resident-Centered Interprofessional Quality Improvement Intervention on Acute Care Length of Stay.

Competency in interprofessional quality improvement and performance measurement is required by the Accreditation Council for Graduate Medical Education. We implemented an interprofessional quality improvement project to support trainee involvement in systems-level improvement to reduce hospital length of stay and engage trainees in efforts to improve the validity and reliability of clinical documentation contributing to risk-adjusted performance measures. The intervention had three components: daily interprofessional disposition huddles to discuss discharge needs, medical documentation curriculum to improve clinical data accuracy, and scheduled coding huddles to provide real-time feedback on documentation. Outcome measures included an unadjusted and risk-adjusted measure of hospital length of stay. Case severity index (CSI) served as a process measure. Statistical process control charts were used to measure change over time. The mean unadjusted length of stay decreased from 5.84 to 4.98 days. Both the unadjusted and the risk-adjusted length of stay measures exceeded the lower control limit of the statistical control chart. The CSI increased and exceeded the upper control limit of the statistical control chart. Improvements were sustained in the year following implementation. The intervention offers a model for academic institutions to satisfy new Common Program Requirements by engaging trainees in performance measurement and interprofessional improvement efforts.