Deficits in Identification of Goals and Goal-Concordant Care After Sepsis Hospitalization.

In a recent study, identifying and supporting patients' care goals was named the highest priority in hospital medicine. Although sepsis is one of the leading causes of death and postdischarge morbidity among hospitalized patients, little is known about how frequently care goals are assessed prior to discharge and adhered to in the 90 days after sepsis hospitalization. Evaluating a cohort of 679 high-risk sepsis survivors enrolled in a clinical trial, we found that care goals were documented explicitly in a standardized tool in 130 patients; an additional 139 patients were identified using all available clinical documentation, resulting in only 269 (40%) patients with goals that could be ascertained from the electronic health record (EHR). Among those categorized, goals were classified as prioritizing longevity (35%), function (52%), and comfort (12%). Based on expert review of the care provided during the 90 days subsequent to discharge, goal-concordant care was identified in 184 (68%) cases for which goals were specified. Documentation of goals in a standardized EHR tool was associated with increased likelihood of receiving goal-concordant care (odds ratio, 3.6; 95% CI, 2.4-5.5). Hospitalization and peridischarge time points represent important opportunities to address deficits in the documentation of goals and provision of goal-concordant care for sepsis survivors.

Peer chart audits: a tool to meet Accreditation Council on Graduate Medical Education (ACGME) competency in practice-based learning and improvement.

BACKGROUND: The Accreditation Council on Graduate Medical Education (ACGME) supports chart audit as a method to track competency in Practice-Based Learning and Improvement. We examined whether peer chart audits performed by internal medicine residents were associated with improved documentation of foot care in patients with diabetes mellitus. METHODS: A retrospective electronic chart review was performed on 347 patients with diabetes mellitus cared for by internal medicine residents in a university-based continuity clinic from May 2003 to September 2004. Residents abstracted information pertaining to documentation of foot examinations (neurological, vascular, and skin) from the charts of patients followed by their physician peers. No formal feedback or education was provided. RESULTS: Significant improvement in the documentation of foot exams was observed over the course of the study. The percentage of patients receiving neurological, vascular, and skin exams increased by 20% (from 13% to 33%) (p = 0.001), 26% (from 45% to 71%) (p < 0.001), and 18% (51%-72%) (p = 0.005), respectively. Similarly, the proportion of patients receiving a well-documented exam which includes all three components - neurological, vascular and skin foot exam - increased over time (6% to 24%, p < 0.001). CONCLUSION: Peer chart audits performed by residents in the absence of formal feedback were associated with improved documentation of the foot exam in patients with diabetes mellitus. Although this study suggests that peer chart audits may be an effective tool to improve practice-based learning and documentation of foot care in diabetic patients, evaluating the actual performance of clinical care was beyond the scope of this study and would be better addressed by a randomized controlled trial.

The 10-minute oral presentation: what should I focus on?

BACKGROUND: Little empirical evidence is available in the medical field defining the most important features of a scientific presentation. We sought to empirically identify what features of a scientific oral presentation experienced reviewers focus on when asked to identify the best features and areas to improve. METHODS: Observational study of 44 presenters at a scientific meeting over a 4-year period. Reviewers observed presenters and identified the best features and made suggestions for improvement using an open-ended form. We developed a coding form based on three domains: content, slides, and presentation style. Two raters blinded to the presenter then coded the comments, and disagreement was resolved by concurrent review. RESULTS: Reviewers made at least one comment about content in 42 (95.5%) of the presentations, about slides in 38 (86.4%), and about presentation style in 42 (95.5%). The most frequently extracted comments on best features of presentations in the domain "content" were identifying a key concept (43.2% of presentations) and relevance (43.2%). Similarly, best features in the domain regarding "slides" were clarity (50.0% of presentations), graphics (27.3%), and readability of the text and font size (22.7%). Finally, best features in the domain regarding "presentation style" were clarity (59.1% of presentations), pace (52.3%), voice (47.7%), engaging with the audience (43.2%), addressing questions (34.1%), and eye contact (22.7%). Various other comments were noted to improve presentations. CONCLUSIONS: Important features during oral presentations relate to specific areas of content, clear slides, and a presentation style that was well paced, engaging, and clear. Nonverbal communication is important in oral presentations.