Utility of a Diabetes Medication Poster in a Primary Care Clinic.

BACKGROUND: Diabetes with related complications is a common disease state seen in primary care and available therapies have increased exponentially. It is difficult for a busy primary clinician to know and utilize these options efficiently. OBJECTIVE: The objective was to determine whether creating a diabetes medication poster that included costs, drug classification, adverse effects, and clinical outcomes/contraindications/cautions for use in an internal medicine/medicine-pediatric clinic improves resident and faculty knowledge, comfort, and awareness of those medications. METHODS: This quality improvement prospective study was designed to evaluate the utility of a diabetes medication poster in a medicine/medicine-pediatric clinic over a 2-month period. A pre and post survey was electronically sent to all residents and faculty to assess their level of confidence and knowledge of diabetes medication treatment before and after the poster was distributed. This study was classified as exempt by the Institutional Review Board. RESULTS: There were 40 physicians that responded to the pre survey and 31 to the post survey. Both surveys revealed >90% agreed or strongly agreed that the poster would decrease risk of adverse reactions, help control cost, and increase confidence to providers about diabetic medications. The knowledge score increased pre vs post survey (P = .0398). CONCLUSION: There are a myriad of tools that can be utilized to help navigate complex diseases. Posters have rarely been evaluated. Physicians viewed the diabetes medication poster as favorable to help decrease adverse effects and cost while increasing knowledge. Areas where visual aids could be effective without overwhelming the providers should be explored.

Evaluation of a Pharmacist-Driven Protocol to Reduce Inappropriate Use of Acid-Suppressive Medications In the Non-ICU Setting.

PURPOSE: Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2 blockers) continue to be over utilized for stress ulcer prophylaxis (SUP). Our study aims to evaluate the effectiveness and feasibility of a pharmacist-driven termination protocol in a community teaching hospital to limit the inappropriate use of acid-suppressive medications in the non-intensive care unit (ICU) setting. METHODS: Patient charts were evaluated for the appropriate use of PPIs or H2 blockers. A centralized pharmacist contacted healthcare providers for medication discontinuation if the acid suppressant use was deemed inappropriate. The primary outcome of the study was the number of patients who had acid-suppressive medication discontinued after the implementation of the pharmacist-driven termination protocol. RESULTS: Acid-suppressive medication was inappropriately prescribed for nine patients. It was discontinued for eight of those patients based on the pharmacist-driven termination protocol; this was a statistically significant decrease (P < 0.001). The pharmacist spent, on average, less than one minute on each patient's chart. CONCLUSION: Our study revealed that a pharmacist-driven termination protocol resulted in a 6% overall reduction rate in inappropriately used acid-suppressive medications, with little impact on pharmacist workflow. Implementing such a termination protocol could help to decrease the inappropriate use of acid-suppressive medications in an inpatient hospital service.

Rare Red Rashes: A Case Report of Levetiracetam-Induced Cutaneous Reaction and Review of the Literature.

Cutaneous reactions secondary to medications are rare but can be serious events resulting in morbidity and mortality and can be caused by anticonvulsant medications. Levetiracetam has been considered relatively safe compared with other antiepileptics with regard to skin eruptions. We report a case of a cutaneous reaction secondary to levetiracetam. A 64-year-old man presented to the hospital with an altered mental status and aphasia. Imaging revealed a left basal ganglia mass. A biopsy of the lesion was obtained, and levetiracetam was started at 500 mg intravenously twice a day for seizure prophylaxis. After 13 doses, the patient developed a diffuse, erythematous, warm, blanching, morbilliform rash. Levetiracetam was discontinued, and methylprednisolone was started. After 4 days, the rash dissipated. Levetiracetam is an antiepileptic medication that has an unknown mechanism of action. To date, there are only 4 cases reported involving skin reactions from levetiracetam. Two of the cases were classified as Stevens-Johnson Syndrome: 1 as toxic epidermal necrolysis and 1 as erythema multiforme. Our case was classified as a morbilliform rash. A Naranjo score of 7 suggested a probable cause for a levetiracetam-induced skin reaction. Antiepileptic medications are used in certain cases to prevent seizures in patients with central nervous system tumors. Although levetiracetam seems to have fewer side effects than the traditional antiepileptic medications, it is important for the healthcare provider to continuously evaluate the need for all medications and discontinue unneeded ones to help avoid potential medication adverse effects.

Are students ready for meaningful use?

BACKGROUND: The meaningful use (MU) of electronic medical records (EMRs) is being implemented in three stages. Key objectives of stage one include electronic analysis of data entered into structured fields, using decision-support tools (e.g., checking drug-drug interactions [DDI]) and electronic information exchange. OBJECTIVE: The authors assessed the performance of medical students on 10 stage-one MU tasks and measured the correlation between students' MU performance and subsequent end-of-clerkship professionalism assessments and their grades on an end-of-year objective structured clinical examination. PARTICIPANTS: Two-hundred and twenty-two third-year medical students on the internal medicine (IM) clerkship. DESIGN/MAIN MEASURES: From July 2010 to February 2012, all students viewed 15 online tutorials covering MU competencies. The authors measured student MU documentation and performance in the chart of a virtual patient using a fully functional training EMR. Specific MU measurements included, adding: a new problem, a new medication, an advanced directive, smoking status, the results of screening tests; and performing a DDI (in which a major interaction was probable), and communicating a plan for this interaction. KEY RESULTS: A total of 130 MU errors were identified. Sixty-eight (30.6%) students had at least one error, and 30 (13.5%) had more than one (range 2-6). Of the 130 errors, 90 (69.2%) were errors in structured data entry. Errors occurred in medication dosing and instructions (18%), DDI identification (12%), documenting smoking status (15%), and colonoscopy results (23%). Students with MU errors demonstrated poorer performance on end-of-clerkship professionalism assessments (r =-0.112, p=0.048) and lower observed structured clinical examination (OSCE) history-taking skills (r =-0.165, p=0.008) and communication scores (r= - 0.173, p=0.006). CONCLUSIONS: MU errors among medical students are common and correlate with subsequent poor performance in multiple educational domains. These results indicate that without assessment and feedback, a substantial minority of students may not be ready to progress to more advanced MU tasks.

Mobile technology for the facilitation of direct observation and assessment of student performance.

BACKGROUND: We developed, implemented, and assessed a web-based clinical evaluation application (i.e., CEX app) for Internet-enabled mobile devices, including mobile phones. The app displays problem-specific checklists that correspond to training problems created by the Clerkship Directors in Internal Medicine. PURPOSE: We hypothesized that use of the CEX app for directly observing students' clinical skills would be feasible and acceptable, and would demonstrate adequate reliability and validity. METHODS: Between July 2010 and February 2012, 266 third-year medical students completed 5 to 10 formative CEXs during their internal medicine clerkship. The observers (attendings and residents), who performed the CEX, used the app to guide and document their observations, record their time observing and giving feedback to the students, and their overall satisfaction with the CEX app. Interrater reliability and validity were assessed with 17 observers who viewed 6 videotaped student-patient encounters, and by measuring the correlation between student CEX scores and their scores on subsequent standardized-patient Objective Structured Clinical Examination (OSCE) exams. RESULTS: A total of 2,523 CEXs were completed by 411 observers. The average number of evaluations per student was 9.8 (± 1.8 SD), and the average number of CEXs completed per observer was 6 (± 11.8 SD). Observers spent less than 10 min on 45.3% of the CEXs and 68.6% of the feedback sessions. An overwhelming majority of observers (90.6%) reported satisfaction with the CEX. Interrater reliability was measured at 0.69 among the observers viewing the videotapes, and their ratings discriminated between competent and noncompetent performances. Student CEX grades, however, did not correlate with their end of 3rd-year OSCE scores. CONCLUSIONS: The use of this CEX app is feasible and it captures students' clinical performance data with a high rate of user satisfaction. Our embedded checklists had adequate interrater reliability and concurrent validity. The grades measured on this app, however, were not predictive of subsequent student performance.

The implementation of a mobile problem-specific electronic CEX for assessing directly observed student-patient encounters.

BACKGROUND: Facilitating direct observation of medical students' clinical competencies is a pressing need. METHODS: We developed an electronic problem-specific Clinical Evaluation Exercise (eCEX) based on a national curriculum. We assessed its feasibility in monitoring and recording students' competencies and the impact of a grading incentive on the frequency of direct observations in an internal medicine clerkship. Students (n = 56) at three clinical sites used the eCEX and comparison students (n = 56) at three other clinical sites did not. Students in the eCEX group were required to arrange 10 evaluations with faculty preceptors. Students in the second group were required to document a single, faculty observed 'Full History and Physical' encounter with a patient. Students and preceptors were surveyed at the end of each rotation. RESULTS: eCEX increased students' and evaluators' understanding of direct-observation objectives and had a positive impact on the evaluators' ability to provide feedback and assessments. The grading incentive increased the number of times a student reported direct observation by a resident preceptor. CONCLUSIONS: eCEX appears to be an effective means of enhancing student evaluation.

A randomized trial comparing digital and live lecture formats [ISRCTN40455708.

BACKGROUND: Medical education is increasingly being conducted in community-based teaching sites at diverse locations, making it difficult to provide a consistent curriculum. We conducted a randomized trial to assess whether students who viewed digital lectures would perform as well on a measure of cognitive knowledge as students who viewed live lectures. Students' perceptions of the digital lecture format and their opinion as whether a digital lecture format could serve as an adequate replacement for live lectures was also assessed. METHODS: Students were randomized to either attend a lecture series at our main campus or view digital versions of the same lectures at community-based teaching sites. Both groups completed the same examination based on the lectures, and the group viewing the digital lectures completed a feedback form on the digital format. RESULTS: There were no differences in performance as measured by means or average rank. Despite technical problems, the students who viewed the digital lectures overwhelmingly felt the digital lectures could replace live lectures. CONCLUSIONS: This study provides preliminary evidence digital lectures can be a viable alternative to live lectures as a means of delivering didactic presentations in a community-based setting.