Anneliese M. Schleyer

Adherence to Guideline-Directed Venous Thromboembolism Prophylaxis Among Medical and Surgical Inpatients at 33 Academic Medical Centers in the United States

This study’s purpose was to describe compliance with established venous thromboembolism (VTE) prophylaxis guidelines in medical and surgical inpatients at US academic medical centers (AMCs). Data were collected for a 2007 University HealthSystem Consortium Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE) Benchmarking Project that explored VTE in AMCs. Prophylaxis was considered appropriate based on 2004 American College of Chest Physicians guidelines. A total of 33 AMCs from 30 states participated. In all, 48% of patients received guideline-directed prophylaxis—59% were medical and 41% were surgical patients. VTE history was more common among medical patients with guideline-directed prophylaxis. Surgical patients admitted from the emergency department and with higher illness severity were more likely to receive appropriate prophylaxis. Despite guidelines, VTE prophylaxis remains underutilized in these US AMCs, particularly among surgical patients. Because AMCs provide the majority of physician training and should reflect and set care standards, this appears to be an opportunity for practice and quality improvement and for education.

‘Speaking up’ about patient safety concerns and unprofessional behaviour among residents: validation of two scales

Objective To develop and test the psychometric properties of two new survey scales aiming to measure the extent to which the clinical environment supports speaking up about (a) patient safety concerns and (b) unprofessional behaviour. Method Residents from six large US academic medical centres completed an anonymous, electronic survey containing questions regarding safety culture and speaking up about safety and professionalism concerns. Results Confirmatory factor analysis supported two separate, one-factor speaking up climates (SUCs) among residents; one focused on patient safety concerns (SUC-Safe scale) and the other focused on unprofessional behaviour (SUC-Prof scale). Both scales had good internal consistency (Cronbachs α>0.70) and were unique from validated safety and teamwork climate measures (r<0.85 for all correlations), a measure of discriminant validity. The SUC-Safe and SUC-Prof scales were associated with participants’ self-reported speaking up behaviour about safety and professionalism concerns (r=0.21, p<0.001 and r=0.22, p<0.001, respectively), a measure of concurrent validity, while teamwork and safety climate scales were not. Conclusions We created and provided evidence for the reliability and validity of two measures (SUC-Safe and SUC-Prof scales) associated with self-reported speaking up behaviour among residents. These two scales may fill an existing gap in residency and safety culture assessments by measuring the openness of communication about safety and professionalism concerns, two important aspects of safety culture that are under-represented in existing metrics.

Survey of overnight academic hospitalist supervision of trainees

In 2003, Accreditation Council for Graduate Medical Education (ACGME) announced the first in a series of guidelines related to the residency training. The most recent recommendations include explicit recommendations regarding the provision of on-site clinical supervision for trainees of internal medicine. To meet these standards, many internal medicine residency programs turned to hospitalist programs to fill that need. However, much is unknown about the current relationships between hospitalist and residency programs, specifically with regard to supervisory roles and supervision policies. We aimed to describe how academic hospitalists currently supervise housestaff during the on-call, or overnight, period and hospitalist program leader their perceptions of how these new policies would impact trainee-hospitalist interactions.

The role of quality improvement and patient safety in academic promotion: results of a survey of chairs of departments of internal medicine in North America.

The Association of Professors of Medicine (APM) is the national organization of departments of internal medicine at the US medicalschools and numerous affiliated teaching hospitals as represented by chairs and appointed leaders. As the official sponsor of TheAmerican Journal of Medicine, the association invites authors to publish commentaries on issues concerning academic internalmedicine.For the latest information about departments of internal medicine, please visit APM’s website at www.im.org/APM.

Effects of the Revised HCFA Evaluation and Management Guidelines on Inpatient Teaching

AbstractOBJECTIVE: In 1996, the Health Care Financing Administration (HCFA) introduced new evaluation and management (E&M) guidelines mandating more intensive supervision and documentation by attending physicians. We assessed the effects of the guidelines on inpatient teaching. DESIGN: Pretest-posttest, nonequivalent control group design. SETTING: A university hospital and an affiliated county hospital where the guidelines were implemented and an affiliated VA medical center where they were not. PARTICIPANTS: Sixty-one full-time faculty who had attended on the general medical wards for at least 1 month for 2 of 3 consecutive years prior to July 1996 and for at least 1 month during the 18 following months. MEASUREMENTS AND MAIN RESULTS: We evaluated standardized, confidential evaluations of attending physicians that are routinely completed by residents and students after clinical rotations at all three sites. Comparing 863 evaluations completed before July 1, 1996 and 497 completed after that date, there were no significant differences at any of the hospitals on any items assessed. There were also no differences between the university and county hospitals as compared with the VA. Eighty-seven percent of 39 university and county attending physicians returned a survey about their perceptions of inpatient teaching activities before and after July 1, 1996. They reported highly significant increases in time devoted to attending responsibilities but diminished time spent on teaching activities. CONCLUSIONS: Physicians reported a dramatic increase in overall time spent attending but a decrease in time spent teaching following implementation of the revised E&M guidelines. Yet, evaluations of their teaching effectiveness did not change.

Role of nasal methicillin-resistant Staphylococcus aureus screening in the management of skin and soft tissue infections

We set out to determine whether nasal swab isolates can identify methicillin-resistant Staphylococcus aureus (MRSA) colonization and guide therapy in skin and soft tissue infections (SSTI). Among hospitalized patients admitted to a general medicine service with SSTI, specificity and positive predictive value for MRSA in nasal swab isolates were 100%; sensitivity was 55%. Thus, positive nasal swab cultures may help identify MRSA colonization and guide antimicrobial therapy for SSTI when wound cultures cannot be obtained.

Upper extremity deep vein thrombosis in hospitalized patients: A descriptive study

Increasingly, there is a focus on the prevention of hospital-acquired conditions including venous thromboembolism. Many studies have evaluated pulmonary embolism and lower extremity deep vein thrombosis, but less is known about upper extremity deep vein thrombosis (UEDVT) in hospitalized patients. The objective of this study was to describe UEDVT incidence, associated risks, outcomes, and management in our institution. Using an information technology tool, we reviewed records of all symptomatic adult inpatients diagnosed with UEDVT at an academic tertiary center between September 2011 and November 2012. Fifty inpatients were diagnosed with 76 UEDVTs. Their mean age was 49 years; 70% were men. Sixteen percent had a history of venous thromboembolism; 20% had a history of malignancy. The mean length of stay (LOS) was 24.6 days (range, 2-91 days); 50% were transferred from outside hospitals. Thirty-eight percent of UEDVTs were in internal jugular veins, 21% in axillary veins, and 25% in brachial veins. Forty-four percent of patients had UEDVT associated with central venous catheters (CVCs). During hospitalization, 78% were fully anticoagulated; 75% of survivors at discharge. Only 38% were discharged to self-care; 10% died during hospitalization. Patients with UEDVT were more likely to have CVCs, malignancy, and severe infection. Many patients were transferred critically ill with prolonged LOS and high in-hospital mortality. Most UEDVTs were treated even in the absence of concurrent lower extremity deep vein thrombosis or pulmonary embolism. Additional research is needed to modify risks and optimize outcomes. Journal of Hospital Medicine 2014;9:48-53.

Documenting quality improvement and patient safety efforts: the quality portfolio. A statement from the academic hospitalist taskforce.

ABSTRACTPhysicians increasingly investigate, work, and teach to improve the quality of care and safety of care delivery. The Society of General Internal Medicine Academic Hospitalist Task Force sought to develop a practical tool, the quality portfolio, to systematically document quality and safety achievements. The quality portfolio was vetted with internal and external stakeholders including national leaders in academic medicine. The portfolio was refined for implementation to include an outlined framework, detailed instructions for use and an example to guide users. The portfolio has eight categories including: (1) a faculty narrative, (2) leadership and administrative activities, (3) project activities, (4) education and curricula, (5) research and scholarship, (6) honors, awards, and recognition, (7) training and certification, and (8) an appendix. The authors offer this comprehensive, yet practical tool as a method to document quality and safety activities. It is relevant for physicians across disciplines and institutions and may be useful as a standalone document or as an adjunct to traditional promotion documents. As the Next Accreditation System is implemented, academic medical centers will require faculty who can teach and implement the systems-based practice requirements. The quality portfolio is a method to document quality improvement and safety activities.

Improving Resident Engagement in Quality Improvement and Patient Safety Initiatives at the Bedside The Advocate for Clinical Education (ACE)

Quality improvement (QI) and patient safety (PS) are essential competencies in residency training; however, the most effective means to engage physicians remains unclear. The authors surveyed all medicine and surgery physicians at their institution to describe QI/PS practices and concurrently implemented the Advocate for Clinical Education (ACE) program to determine if a physician-centered program in the context of educational structures and at the point of care improved performance. The ACE rounded with medicine and surgery teams and provided individual and team-level education and feedback targeting 4 domains: professionalism, infection control, interpreter use, and pain assessment. In a pilot, the ACE observed 2862 physician-patient interactions and 178 physicians. Self-reported compliance often was greater than the behaviors observed. Following ACE implementation, observed professionalism behaviors trended toward improvement; infection control also improved. Physicians were highly satisfied with the program. The ACE initiative is one coaching/feedback model for engaging residents in QI/PS that may warrant further study.

Using an Electronic Medical Record Tool to Improve Pneumococcal Screening and Vaccination Rates for Older Patients Admitted with Community-Acquired Pneumonia

An electronic medical record tool was developed that determines if a patient meets criteria for screening for the vaccine; it then poses a series of screening questions. Use of the tool has improved performance on pneumococcal vaccination from 44% to more than 90%, with an increase in vaccine units of 305%.