Kambria H. Evans

Smarter hospital communication: Secure smartphone text messaging improves provider satisfaction and perception of efficacy, workflow

BACKGROUND Though current hospital paging systems are neither efficient (callbacks disrupt workflow), nor secure (pagers are not Health Insurance Portability and Accountability Act [HIPAA]-compliant), they are routinely used to communicate patient information. Smartphone-based text messaging is a potentially more convenient and efficient mobile alternative; however, commercial cellular networks are also not secure. OBJECTIVE To determine if augmenting one-way pagers with Medigram, a secure, HIPAA-compliant group messaging (HCGM) application for smartphones, could improve hospital team communication. DESIGN Eight-week prospective, cluster-randomized, controlled trial SETTING Stanford Hospital INTERVENTION Three inpatient medicine teams used the HCGM application in addition to paging, while two inpatient medicine teams used paging only for intra-team communication. MEASUREMENTS Baseline and post-study surveys were collected from 22 control and 41 HCGM team members. RESULTS When compared with paging, HCGM was rated significantly (P < 0.05) more effective in: (1) allowing users to communicate thoughts clearly (P = 0.010) and efficiently (P = 0.009) and (2) integrating into workflow during rounds (P = 0.018) and patient discharge (P = 0.012). Overall satisfaction with HCGM was significantly higher (P = 0.003). 85% of HCGM team respondents said they would recommend using an HCGM system on the wards. CONCLUSIONS Smartphone-based, HIPAA-compliant group messaging applications improve provider perception of in-hospital communication, while providing the information security that paging and commercial cellular networks do not. Journal of Hospital Medicine 2014;9:573–578.

Septris: a novel, mobile, online, simulation game that improves sepsis recognition and management.

Problem Annually affecting over 18 million people worldwide, sepsis is common, deadly, and costly. Despite significant effort by the Surviving Sepsis Campaign and other initiatives, sepsis remains underrecognized and undertreated. Approach Research indicates that educating providers may improve sepsis diagnosis and treatment; thus, the Stanford School of Medicine has developed a mobile-accessible, case-based, online game entitled Septris (http://med.stanford.edu/septris/). Septris, launched online worldwide in December 2011, takes an innovative approach to teaching early sepsis identification and evidence-based management. The free gaming platform leverages the massive expansion over the past decade of smartphones and the popularity of noneducational gaming. The authors sought to assess the game’s dissemination and its impact on learners’ sepsis-related knowledge, skills, and attitudes. In 2012, the authors trained Stanford pregraduate (clerkship) and postgraduate (resident) medical learners (n = 156) in sepsis diagnosis and evidence-based practices via 20 minutes of self-directed game play with Septris. The authors administered pre- and posttests. Outcomes By October 2014, Septris garnered over 61,000 visits worldwide. After playing Septris, both pre- and postgraduate groups improved their knowledge on written testing in recognizing and managing sepsis (P < .001). Retrospective self-reporting on their ability to identify and manage sepsis also improved (P < .001). Over 85% of learners reported that they would or would maybe recommend Septris. Next Steps Future evaluation of Septris should assess its effectiveness among different providers, resource settings, and cultures; generate information about how different learners make clinical decisions; and evaluate the correlation of game scores with sepsis knowledge.

Patient whiteboards to improve patient-centred care in the hospital.

Background Patient whiteboards facilitate communication between patients and hospital providers, but little is known about their impact on patient satisfaction and awareness. Our objectives were to: measure the impact in improving patients’ understanding of and satisfaction with care; understand barriers for their use by physicians and how these could be overcome; and explore their impact on staff and patients’ families. Methods In 2012, we conducted a 3-week pilot of multidisciplinary whiteboard use with 104 inpatients on the general medicine service at Stanford University Medical Center. A brief, inperson survey was conducted with two groups: (1) 56 patients on two inpatient units with whiteboards and (2) 48 patients on two inpatient units without whiteboards. Questions included understanding of: physician name, goals of care, discharge date and satisfaction with care. We surveyed 25 internal medicine residents regarding challenges of whiteboard use, along with physical therapists, occupational therapists, case managers, consulting physicians and patients’ family members (n=40). Results The use of whiteboards significantly increased the proportion of patients who knew: their physician (p≤=0.0001), goals for admission (p≤=0.0016), their estimated discharge date (p≤=0.049) and improved satisfaction with the hospital stay overall (p≤=0.0242). Physicians, ancillary staff and patient families all found the whiteboards to be helpful. In response, residents were also more likely to integrate whiteboard use into their daily work flow. Conclusions Inpatient whiteboards help physicians and ancillary staff with communication, improve patients’ awareness of their care team, admission plans and duration of admission, and significantly improve patient overall satisfaction.

Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost

BACKGROUND Telemetry monitoring is a widely used, labor-intensive, and often-limited resource. Little is known of the effectiveness of methods to guide appropriate use. OBJECTIVE Our intervention for appropriate use included: (1) a hospitalist-led, daily review of bed utilization, (2) hospitalist-driven education module for trainees, (3) quarterly feedback of telemetry usage, and (4) financial incentives. DESIGN/METHODS Hospitalists were encouraged to discuss daily telemetry utilization on rounds. A module on appropriate telemetry usage was taught by hospitalists during the intervention period (January 2013-August 2013) on medicine wards. Pre- and post-evaluations measured changes regarding telemetry use. We compared hospital bed-use data between the baseline period (January 2012-December 2012), intervention period, and extension period (September 2014-March 2015). During the intervention period, hospital bed-use data were sent to the hospitalist group quarterly. Financial incentives were provided after a decrease in hospitalist telemetry utilization. SETTING Stanford Hospital, a 444-bed, academic medical center in Stanford, California. RESULTS Hospitalists saw reductions for both length of stay (LOS) (2.75 vs 2.13 days, P = 0.005) and total cost (22.5% reduction) for telemetry bed utilization in the intervention period. Nonhospitalists telemetry bed utilization remained unchanged. We saw significant improvements in trainee knowledge of the most cost-saving action (P = 0.002) and the least cost-saving action (P = 0.003) in the pre- and post-evaluation analyses. Results were sustained in the hospitalist group, with telemetry LOS of 1.93 days in the extension period. CONCLUSIONS A multipronged, hospitalist-driven intervention to improve appropriate use of telemetry reduces LOS and cost, and increases knowledge of cost-saving actions among trainees.

An Innovative Blended Preclinical Curriculum in Clinical Epidemiology and Biostatistics: Impact on Student Satisfaction and Performance.

PROBLEM There is little understanding of the impact of teaching clinical epidemiology and biostatistics in a flipped or blended format. At Stanford University School of Medicine, the quantitative medicine (QM) curriculum for first-year students was redesigned to use a blended format, in response to student feedback. APPROACH The blended QM curriculum introduced in 2013 integrated self-paced, online learning with small-group collaborative learning. The authors analyzed the blended formats impact on student satisfaction and performance, comparing the pilot cohort of students (n = 101) with students who took the traditional curriculum in 2011 and 2012 (n = 178). They also analyzed QM resource utilization in 2013. OUTCOMES The blended curriculum had a positive impact on satisfaction and mastery of core material. Comparing the 2013 blended cohort with the 2011-2012 traditional cohort, there were significant improvements in student satisfaction ratings (overall, P < .0001; organization, P < .0001; logical sequence, P = .008; value of content, P < .0001). The mean (SD) overall satisfaction rating for small-group sessions increased: 3.40 (1.03) in 2013 versus 2.79 (1.00) in 2011 and 2.83 (1.06) in 2012. Performance on the QM final exam showed no significant changes in 2013 versus 2011 and 2012. The majority of students in 2013 reported using the QM online videos as their primary learning resource (69%-85% across modules). NEXT STEPS The positive impact of the curricular elements studied will inform continued development of the QM curriculum. Features of the curriculum could serve as a model for future blended courses.

Hand hygiene of medical students and resident physicians: predictors of attitudes and behaviour

Objectives We measured medical students’ and resident trainees’ hand hygiene behaviour, knowledge and attitudes in order to identify important predictors of hand hygiene behaviour in this population. Methods An anonymous, web-based questionnaire was distributed to medical students and residents at Stanford University School of Medicine in August of 2012. The questionnaire included questions regarding participants’ behaviour, knowledge, attitude and experiences about hand hygiene. Behaviour, knowledge and attitude indices were scaled from 0 to 1, with 1 representing superior responses. Using multivariate regression, we identified positive and negative predictors of superior hand hygiene behaviour. We investigated effectiveness of interventions, barriers and comfort reminding others. Results 280 participants (111 students and 169 residents) completed the questionnaire (response rate 27.8%). Residents and medical students reported hand hygiene behaviour compliance of 0.45 and 0.55, respectively (p=0.02). Resident and medical student knowledge was 0.80 and 0.73, respectively (p=0.001). The attitude index for residents was 0.56 and 0.55 for medical students. Regression analysis identified experiences as predictors of hand hygiene behaviour (both positive and negative influence). Knowledge was not a significant predictor of behaviour, but a working gel dispenser and observing attending physicians with good hand hygiene practices were reported by both groups as the most effective strategy in influencing trainees. Conclusions Medical students and residents have similar attitudes about hand hygiene, but differ in their level of knowledge and compliance. Concerns about hierarchy may have a significant negative impact on hand hygiene advocacy.

The Medical Education of Generation Y

Medical schools face challenges preparing students to meet evolving health-care needs in society. However, little has changed in the way that education is delivered to aspiring health professionals [1]. The in-class lectures continuing in the majority of classrooms across the country do not acknowledge the unique proclivities of the current crop of medical students. An explanation of this observation is gleaned by understanding the fundamental attributes of the current generation of medical trainees. Educational research in schools outside of medicine demonstrates that students with different learner characteristics will value instructional measures in relation to the way they suit their own habits, ideas, and preferences of learning well [2]. To be effective, teaching styles have to take into account learning styles [3]. Therefore, instructional measures should address learner beliefs to improve the quality of student learning [2]. Our paper responds to the need to examine the impact of social and motivational variables in learning. Specially, we sought to understand the implications of generational differences in medical education, and how medical education can consciously evolve to accommodate the learning styles of current trainees.

Pending Studies at Hospital Discharge

The Authors’ Response—We thank Dr. Singh for highlighting a very important point. We agree that the prevalence of pending studies is a health systems problem with multifactorial origins, including shorter lengths of stay and increased handoffs. As Dr. Singh pointed out, and our study confirmed, physicians overestimate their awareness of pending studies. We showed that an EMR-based tool that automatically generated a list of pending studies from the EMR improved communication of pending studies via the discharge summary. We hope that the use of this tool will help change ordering behavior by allowing inpatient providers to become more aware of the volume of studies that are pending and for which they are responsible. In addition, at our institution, we are implementing quality improvement initiatives to try to change ordering behavior by displaying turnaround time and cost for some tests. Further work will need to be done in this area. In the meantime, the responsibility for pending studies falls to the inpatient provider (even if he or she disagrees with the test having been done in the first place), and communication to the primary care provider taking over care is essential. Our paper described a quality improvement intervention to help meet this need.

A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback

Purpose Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns. Design Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine’s Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments. Results The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001). Conclusions We successfully implemented a novel high value care curriculum that specifically targets intern physicians.