Improving inpatient hyperglycaemia in non-critically ill adults in resident wards through audit and feedback.

Inpatient hyperglycaemia is associated with an increase in morbidity and mortality, number of rehospitalisations and length of hospitalisation. Although the advantages of proper glycaemic control in hospitalised patients with diabetes are well established, a variety of barriers limit accomplishment of blood glucose targets. Our primary aim was to decrease the number of glucose values above 180 mg/dL in non-critical care hospitalised patients using an audit and feedback intervention with pharmacy and internal medicine residents. A resident-led multidisciplinary team implemented the quality improvement (QI) project including conception, literature review, educating residents, iterative development of audit and feedback tools and data analysis. The multidisciplinary team met every 5 weeks and undertook three 'plan-do-study-act' cycles over an 8-month intervention period (August 2022 to March 2023) to educate residents on inpatient hyperglycaemia management, develop and implement an audit and feedback process and assess areas for improvement. We performed 1045 audits analysing 16 095 accu-checks on 395 non-duplicated patients. Most audits showed compliance with guidelines. The monthly run-on chart shows per cent of glucose values above 180 mg/dL in our non-ICU hospitalised patients and an overall pre-to-post comparison of 25.1%-23.0% (p value<0.05). The intervention was well accepted by residents evidenced by survey results. We did not meet our primary aim to reduce hyperglycaemia by 30% and this combined with the audits showing mostly compliance with guidelines suggests that prescribing behaviour was not a key driver of inpatient hyperglycaemia in our population. This internal medicine resident and pharmacy interprofessional collaboration with audit and feedback for inpatient hyperglycaemia was feasible, well accepted and had a statistically significant yet small improvement in inpatient hyperglycaemia. The project may be helpful to others wishing to explore inpatient hyperglycaemia, interprofessional QI with pharmacists, resident-led QI and audit and feedback.

Introducing second-year medical students to diagnostic reasoning concepts and skills via a virtual curriculum.

OBJECTIVES: Curriculum for clinical reasoning in the preclinical years is sparse and the COVID-19 pandemic heightened the need for virtual curriculums. METHODS: We developed, implemented and evaluated a virtual curriculum for preclinical students scaffolding key diagnostic reasoning concepts: dual process theory, diagnostic error, problem representation and illness scripts. Fifty-five second-year medical students participated in four 45-min virtual sessions led by one facilitator. RESULTS: The curriculum led to increased perceived understanding and increased confidence in diagnostic reasoning concepts and skills. CONCLUSIONS: The virtual curriculum was effective in introducing diagnostic reasoning and was well-received by second-year medical students.

An innovative approach to comprehensive communication skills training for residents: A resident-led communication curriculum.

Innovations to enhance residency training in interpersonal and communication skills are needed and a resident-led strategy has not been well-described. In this study, we explored a resident-led comprehensive communication skills curriculum for internal medicine residents. Residents and faculty prepared the curriculum as part of an Accreditation Council for Graduate Medical Education (ACGME) Back to Bedside Project and with "The language of caring guide for physicians." Employing active learning techniques, three residents led 43 internal medicine residents in seven 1 h sessions from 2019 to 2020. Using a 35-question survey, we assessed pre and post self-reported competence in: mindful practice, collaboration and teamwork, effective openings and closing, communicating with empathy, effective explanations, engaging patients and families as partners, and hard conversations. A Wilcoxon signed rank test was employed to explore differences in median scores after matching each person's pretest and posttest score. The median score for aggregate communication and the scores for all seven competencies assessed improved from pre to post (p < 0.05). This indicates that residents reported higher incidences of performing patient-centered communication skills after the curriculum compared to before. Using a five-point Likert scale, 100% of participants agreed the program improved their communication skills and improved confidence in bedside patient-centered communications. A resident-led comprehensive communication skills curriculum for internal medicine residents was implemented showing improvement in skills over the course of the curriculum. The curriculum was well-accepted by post-survey evaluation and was feasible with motivated resident-leaders, use of an existing guide to communication, and reserved didactic time to implement the program.

Cultural Competence Guides for COVID-19 Messaging in Hispanic Communities.

PURPOSE: The Rio Grande Valley in South Texas comprises 5% percent of Texas's population yet 17%of Texas's COVID-19 deaths. We aimed to address underlying mistrust and systemic racism in our Hispanic community that contributes to health inequities by developing a cultural competence guide for public health messaging. METHODS: We employed a mixed method design (e.g., focus groups, surveys, interviews) to develop and implement a cultural competence guide in an iterative community-informed process. We created a general cultural competence guide, one for the Hispanic community and one for the hard-of-hearing community. RESULTS: Our cultural competence guides provide an interpretation as to whether the message is culturally competent or requires revisions. The guides have the following five categories: content and clarity, emotions and values, audience and inclusivity, call to action, and gestalt. CONCLUSIONS: The Hispanic community needs more culturally competent public health messaging to address a key root cause of health inequities surrounding COVID-19. Our novel, concise guides can help organizations and individuals seeking to create culturally sensitive and, therefore, more effective public health messaging for Hispanic or deaf and hard-of-hearing communities.

Getting Ahead: A Resident Led Quality Improvement Project to Increase Diabetic Nephropathy Screening in an Underserved Hispanic-Predominant Population.

Introduction: Diabetes is the leading cause of end-stage renal disease (ESRD) in the United States (US), with 37 million having chronic kidney disease. Despite national guidelines recommendations for diabetic nephropathy screening with urine albumin-to-creatinine ratio (UACR), less than 50% receive full screening.Our Internal Medicine residents led a quality improvement project to increase diabetic nephropathy screening rate with UACR in our resident clinic by 50% in one academic year. Methods: We conducted the resident-led quality improvement project from July 2021 to April 2022. We reviewed the electronic medical records (EMR) from our clinic pre-intervention July 2020 to June 2021 and compared this to post intervention July 2021 to March 2022 determining the nephropathy screening rates in patients with diabetes. Our interventions included resident education, pre and post surveys to test foundational knowledge, adding UACR in the affordable laboratory order form and establishing normal reference range of UACR in the EMR. Results: We collected 217 patients with diabetes, 27% were uninsured, 38% had Medicare/Medicaid and 90% identified as Hispanic. Comparing pre to post intervention, there was a significant change of 45 (20.7%) vs 71 (32.7%) patients screened for diabetic nephropathy with a UACR. The correct average score of knowledge-based questions was 82% on the pre survey, which increased to 88% in the post survey. Conclusion: Our study showed promising results on improving diabetic nephropathy screening. The comprehensive approach including resident education about diabetic nephropathy screening with UACR and more so facilitating the order set in the EMR were key to achieve this goal.

End of Life Decision-Making Challenges in a Latino Patient with COVID-19: Facing Barriers.

COVID-19 pandemic brought difficult scenarios that patients and families are facing about end- of-life decisions. This exposed some weak areas in the healthcare system where we can continue improve in reducing disparities and emphasizing advance care planning from a primary level of care. We present a case of challenges in end-of-life decision-making in a Latino patient.

Novel pharmacological therapy in type 2 diabetes mellitus with established cardiovascular disease: Current evidence.

Cardiovascular diseases (CVDs) remain the leading cause of death in the world and in most developed countries. Patients with type 2 diabetes mellitus (T2DM) suffer from both microvascular and macrovascular diseases and therefore have higher rates of morbidity and mortality compared to those without T2DM. If current trends continue, the Center for Disease Control and Prevention estimates that 1 in 3 Americans will have T2DM by year 2050. As a consequence of the controversy surrounding rosiglitazone and the increasing prevalence of diabetes and CVDs, in 2008 the Food and Drug Administration (FDA) established new expectations for the evaluation of new antidiabetic agents, advising for pre and, in some cases, post-marketing data on major cardiovascular events. As a direct consequence, there has been a paradigm shift in new antidiabetic agents that has given birth to the recently published American Diabetes Association/European Association for the Study of Diabetes consensus statement recommending sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon like peptide-1 receptor agonists (GLP-1RA) in patients with T2DM and established CVD. As a result of over a decade of randomized placebo controlled cardiovascular outcome trials, the aforementioned drugs have received FDA approval for risk reduction of cardiovascular (CV) events in patients with T2DM and established CV disease. SGLT2i have been shown to have a stronger benefit in patients with congestive heart failure and diabetic kidney disease when compared to their GLP-1RA counterparts. These benefits are not withstanding additional considerations such as cost and the multiple FDA Black Box warnings. This topic is currently an emerging research area and this mini-review paper examines the role of these two novel classes of drugs in patients with T2DM with both confirmed, and at risk for, CVD.