Michael J. Maniaci

Functional Health Literacy and Understanding of Medications at Discharge

The objective of this study was to evaluate patient knowledge of newly prescribed medication after hospital discharge. We reviewed the charts of 172 patients who were discharged from February 1, 2006, through April 25, 2006, from the internal medicine residency service at a community-based teaching hospital with prescriptions for 1 or more new medications. Between 4 and 18 days after discharge, patients were contacted by telephone and asked about the name, number, dosages, schedule, purpose, and adverse effects of the new medication(s) and whether they could name their medical contact person. We recorded the number of correct answers, patient age, and years of education. Of the survey respondents, 86% were aware that they had been prescribed new medications, but fewer could identify the name (64%) or number (74%) of new medications or their dosages (56%), schedule (68%), or purpose (64%). Only 11% could recall being told of any adverse effects, and only 22% could name at least 1 adverse effect. Older patients tended to answer fewer questions correctly (P=.02). We observed no association between the number of correctly answered questions and years of education (P=.57), time between discharge and survey (P=.17), or number of new medications (P=.65). Overall, we found that patients had limited knowledge about their medications after discharge from an internal medicine residency service, with age but not years of education significantly associated with level of knowledge.

A multidisciplinary approach to reducing alarm fatigue and cost through appropriate use of cardiac telemetry

Background Alarm fatigue (AF) is a distressing factor for staff and patients in the hospital. Using cardiac telemetry (CT) without clinical indications can create unnecessary alarms, and increase AF and cost of healthcare. We sought to reduce AF and cost associated with CT monitoring. Methods After implementing a new protocol for CT placement, data were collected on telemetry orders, alarms and bed cost for 13 weeks from 1 January 2015 through 31 March 2015. We also retrospectively collected data on the same variables for the 13 weeks prior to the intervention. A survey was administered to nurses to assess past and present perceptions of AF. Interventions included protocol creation and education for participants. Results At baseline, 77% of patients were monitored with CT. A total of 145 (31%) order discrepancies were discovered during data collection, of which 72% had no indication for CT, so CT was discontinued. The other 28% had indications, so orders were placed. A total of 8336 alarms were recorded during 4 weeks of data collection, of which 333 (4%) were classified as true actionable alarms. Postintervention data showed 67% CT assignment with 10% reduction in CT usage, with no increase in mortality (p<0.001 and >0.05, respectively). A 42% cost reduction was achieved after adjusting the patient status. Nurses reported 27% perceived reduction in AF. One-year follow-up revealed that 69% of patients were being monitored by CT, and the rate of order discrepancies due to lack of indication was 9%. Conclusion All hospital units may benefit from the protocols created during this study. If applied appropriately, these protocols can lead to reduced AF and cost per episode of care.

Sepsis and Shock Response Team: Impact of a Multidisciplinary Approach to Implementing Surviving Sepsis Campaign Guidelines and Surviving the Process

The Surviving Sepsis Campaign guidelines are designed to decrease mortality through consistent application of a 7-element bundle. This study evaluated the impact of improvement in bundle adherence using a time-series analysis of compliance with the bundle elements before and after interventions intended to improve the process, while also looking at hospital mortality. This article describes interventions used to improve bundle compliance and hospital mortality in patients admitted through the emergency department with sepsis, severe sepsis, or septic shock. Quality improvement methodology was used to develop high-impact interventions that led to dramatically improved adherence to the Surviving Sepsis Campaign guidelines bundle. Improved performance was associated with a significant decrease in the in-hospital mortality of severe sepsis patients presenting to the emergency department.

Assessing the performance and satisfaction of medical residents utilizing standardized patient versus mannequin-simulated training

Background Conducting simulations of rapidly decompensating patients are a key part of internal medicine (IM) residency training. Traditionally, mannequins have been the simulation tool used in these scenarios. Objective To compare IM residents’ performance and assess realism in specific-simulated decompensating patient scenarios using standardized patients (SPs) as compared to mannequin. Methods Nineteen IM residents were randomized to undergo simulations using either a mannequin or an SP. Each resident in the two groups underwent four different simulation scenarios (calcium channel blocker overdose, severe sepsis, severe asthma exacerbation, and acute bacterial meningitis). Residents completed pretest and post-test evaluations as well as a questionnaire to assess the reality perception (realism score). Results Nine residents completed mannequin-based scenarios, whereas 10 completed SP-based scenarios. Improvement in the post-test scores was seen in both groups. However, there were significantly higher post-test scores achieved with SP simulations in three out of the four scenarios (P=0.01). When compared with the mannequin group, the SP simulation group showed a significantly higher average realism score (P=0.002). Conclusions Applying SP-based specific-simulation scenarios in IM residency training may result in better performance and a higher sense of a realistic experience by medical residents.

73-year-old woman with progressive shortness of breath.

A 73-year-old woman presented to our institution for evaluation of progressive shortness of breath that had gradually worsened during the previous year. Initially, her symptoms were mild and noticeable only with moderate exertion. By presentation, however, she reported severe dyspnea with only minimal exertion. Walking 3 to 6 meters resulted in such severe dyspnea that she had to discontinue activity. She also reported a harsh cough with occasional clear sputum production. A provisional diagnosis of asthma had been suggested before her presentation. This diagnosis was not supported by objective testing nor had bronchodilators been beneficial.

A 32-year-old man with hypoxemia and bilateral upper-lobe predominant ground-glass infiltrates on chest imaging

Abstract Diffuse alveolar hemorrhage (DAH) is a rare, but potentially fatal, complication of antiphospholipid syndrome, and may present with acute and fulminant symptoms. We report a case of DAH presenting as sudden onset dyspnea in a gentleman with known antiphospholipid syndrome. Chest computed tomography angiography with pulmonary embolism protocol showed right lower lobe segmental filling defects, upper-lobe predominant diffuse ground-glass opacities, and centrilobular nodules bilaterally. The presence of DAH can be confirmed by bronchoalveolar lavage with serial aliquots, but this procedure typically does not elucidate the specific etiology for the hemorrhage. The treatment for patients with severe disease typically consists of a combination of immunosuppressive medications in the form of high-dose intravenous glucocorticoids plus rituximab, cyclophosphamide or mycophenolate; and/or plasma exchange. This case both provides an example of high-quality diagnostic imaging of diffuse alveolar hemorrhage as well as demonstrates the clinical and image-based improvement after treatment.

Central Line Proficiency Test Outcomes after Simulation Training versus Traditional Training to Competence

Rationale: Studies have shown the importance of simulation‐based training on the outcomes of central venous catheter (CVC) insertion by trainees. Objectives: To compare the performance of internal medicine trainees who underwent standardized simulation training of CVC insertion with that of internal medicine trainees who had traditional CVC training and were already deemed competent to perform the procedure during a proficiency evaluation using a training mannequin. Methods: Trainees who perform CVC insertion were enrolled in the institutional Central Line Workshop, which includes both an online and an experiential simulation component. The training is followed by a certification station proficiency assessment. Residents and fellows previously certified competent to perform CVC placement without supervision completed the online module, but they could opt out of the experiential component and proceed directly to the evaluation. Results: Forty‐eight trainees participated in the study. Twenty‐one (44%), 15 (31%), 6 (13%), 1 (2%), 2 (4%), and 3 (6%) were in postgraduate year 1 (PGY1), PGY2, PGY3, PGY4, PGY5, and PGY6, respectively. Twenty‐nine completed the hands‐on instruction, 28 (97%) of whom successfully passed the simulation‐based assessment on their first attempt. Nineteen trainees previously credentialed to perform CVC placement without supervision opted out of the simulation‐based experiential training. Of these, five (26%) failed in their first attempt (P = 0.02 vs. trainees who completed the simulation training). Conclusions: Standardized simulation‐based training can improve CVC insertion proficiency, even among trainees with previous experience sufficient to have been deemed competent in the procedure. Improved performance at simulation‐based testing may translate to improved outcomes of CVC placement by trainees.

Violent behavior by emergency department patients with an involuntary hold status

Background: Violence against health care workers has been increasing. Health care workers in emergency departments (EDs) are highly vulnerable because they provide care for patients who may have mental illness, behavioral problems, or substance use disorders (alone or in combination) and who are often evaluated during an involuntary hold. Our objective was to identify factors that may be associated with violent behavior in ED patients during involuntary holds. Methods: Retrospective review of patients evaluated during an involuntary hold at a suburban acute care hospital ED from January 2014 through November 2015. Results: Of 251 patients, 22 (9%) had violent incidents in the ED. Violent patients were more likely to have a urine drug screen positive for tricyclic antidepressants (18.2% vs 4.8%, P = 0.03) and to present with substance misuse (68.2% vs 39.7%, P = 0.01), specifically with marijuana (22.7% vs 9.6%, P = 0.06) and alcohol (54.5% vs 24.9%, P = 0.003). ED readmission rates were higher for violent patients (18.2% vs 3.9%, P = 0.02). No significant difference was found between violent patients and nonviolent patients for sex, race, marital status, insurance status, medical or psychiatric condition, reason for involuntary hold, or length of stay. Conclusion: Violent behavior by patients evaluated during an involuntary hold in a suburban acute care hospital ED was associated with tricyclic antidepressant use, substance misuse, and higher ED readmission rates.

37-Year-Old Man With Abdominal Pain

37-year-old man with an unremarkable medical history presented to the emergency department because of abdominal pain. The patient stated that over thepreviousmonthhehadexperiencedgradually worsening discomfort that he described as being dull and located diffusely throughout the abdomen. He rated the pain as a 7 on a severity scale of 1 to 10. He also said that during this same period, he had been having mucuslike bowel movements that had increased in frequency to approximately 10 bowel movements daily. He denied any sick contacts, recent illness, travel, or recent antibiotic use. The patient has no known family history of inflammatory bowel disease. He stated that about 1 month before the onset of these symptoms, he began training for a marathon, at which time he also stopped smoking cigarettes. On physical examination, the patient had no acute distress, but hyperactive bowel sounds and tenderness were noted on deep palpation. He was found to have a fever of 38 Celsius and heart rate of 100 beats per minute.Resultsoflaboratoryanalysis,includingcomplete blood cell count, metabolic profile, and lactic acid level, were unremarkable except for a hemoglobin level of 10.2 g/dL (reference range, 13.5-17.5 g/dL), and computed tomography (CT) of the abdomen with contrast medium revealed bowel wall thickening from the hepatic flexuretotherectum.Mesentericlymphadenopathywasalsonoted.Hewasadmittedtothehospital for further evaluation and treatment.