Redonda G. Miller

Evaluation of an audience response system for the continuing education of health professionals

Introduction: Continuing medical education (CME) for physicians and other health personnel is becoming increasingly important in light of recertification requirements. Interactive learning is more effective and may be useful in a continuing education setting. This study examines the use of an audience response system (ARS) as an interactive learning tool for health care providers. Method: We conducted a national randomized controlled trial to evaluate the utility of an ARS to enhance attention and learning. Speakers at 42 clinical round table (CRT) programs in five regions across the United States were randomized to “use” or “no use” of an ARS during their lectures. We surveyed participants to collect data regarding presentation and speaker quality, impressions of the ARS, and knowledge of the material presented. We collected information from speakers regarding ease of use and overall opinions of the ARS. Results: A total of 283 surveys were completed (164 from participants using the ARS and 119 from participants not using the ARS). ARS participants rated the quality of the presentation, the quality of the speaker, and their level of attention more highly than non‐ARS participants (p <.05). Knowledge scores (of material presented) were not significantly different between the two groups. Both participants and speakers felt that the ARS was easy to use and preferred to use the system in future CRTs. Discussion: Participants in CRTs with the ARS rated presentation and speaker quality more favorably than those participants in CRTs without the tool. Participant knowledge scores, however, were not significantly different. ARSs may provide easy‐to‐use tools to enhance attention and enthusiasm in CME learners.

Incidence and prevalence of multidrug-resistant acinetobacter using targeted active surveillance cultures.

To the Editor: Recent legislation mandates active surveillance cultures to detect multidrug-resistant (MDR) organisms in hospitalized patients. The active surveillance strategy has not been widely applied to MDR Acinetobacter, one of the most difficult gram-negative pathogens to control and treat. Universal active surveillance is resource-intensive and may divert resources from other infection control interventions. We conducted a prospective cohort study using universal active surveillance cultures to determine the prevalence and incidence of transmission of MDR Acinetobacter and to estimate the effects of targeting active surveillance to patients with recent exposure to a long-term care facility. Methods. Universal active surveillance cultures from the axilla, wounds, sputum, and endotracheal tube aspiration were performed on admission and weekly among a cohort of 1111 adult patients admitted to medical intensive and intermediate care units of the Johns Hopkins Hospital between March and June in 2006. Isolation precautions were implemented for patients with MDR Acinetobacter isolates susceptible to no more than 1 class of antimicrobial agents, excluding colistin. Patients previously known to have the organism were flagged in an administrative database for identification and isolation on readmission. Susceptibility testing was by the Phoenix 100 Automated Microbiology System (Becton-Dickinson, Sparks, Maryland) and agar dilution methods. Patients with missing data (12.5% for absent admission surveillance cultures and 4.8% for location prior to admission) were included in the analysis. Fisher exact test was used to compare categorical variables. All tests were 2-sided and P .05 was considered statistically significant. Analyses were performed with Stata version 8.2 (Stata Corp, College Station, Texas). Our institutional review board approved the protocol and granted a waiver of informed consent. Results. Five patients were previously known to be colonized with MDR Acinetobacter, 5 grew the organism within 48 hours of admission, and 3 grew the organism more than 48 hours after admission (none of whom had admission surveillance cultures obtained) (TABLE 1). Prevalence on admission was 10 of 1223 patients (0.82%; 95% confidence interval [CI], 0.39%-1.50%). Incidence of possible MDR Acinetobacter transmission (growth more than 48 hours after admission and absent surveillance cultures) was 0.43 (95% CI, 0.09-1.3) per 1000 patient days. Colonization pressure (MDR Acinetobacter patient-days divided by total patientdays) was 1.6% (108 of 6934 patient-days). Of 8 newly identified patients with MDR Acinetobacter, 4 did not grow the organism in clinical cultures but were identified by surveillance cultures alone. A significantly higher proportion of patients with MDR Acinetobacter were admitted from a long-term care facility than patients without MDR Acinetobacter (46.2% vs 3.9%; risk ratio, 18.9; 95% CI, 6.6-54) (TABLE 2). Patients with MDR Acinetobacter were more likely to have paraplegia than were patients without MDR Acinetobacter (23.1% vs 1.1%; risk ratio, 22; 95% CI, 6.7-72). The majority of patients with MDR Acinetobacter were co-colonized with at least 1 other MDR pathogen: methicillin-resistant Staphylococcus aureus (n=8, 62%), vancomycin-resistant Enterococci (n=10, 77%), and extended-spectrum -lactamase gram-negative bacilli (n=5, 38%). Comment. The potential consequences of MDR Acinetobacter transmission and infection include a crude mortality of 28% to 58%, prolonged mechanical ventilation, and prolonged stays in the hospital and intensive care unit. In this cohort, most MDR Acinetobacter was present on hospital admission and the undetected fraction of MDR Acinetobacter was 50%. Limitations include low sensitivity of MDR Acinetobacter surveillance cultures, small sample size of patients with MDR Acinetobacter, absent admission surveillance cultures, few wound and endotracheal cultures, and generalizability to other health care settings. Although active surveillance cultures may be indicated during an outbreak, in general a population at risk should be defined before beginning an active surveillance program to detect MDR organisms. Although universal active surveillance cultures identified otherwise undetected patients with MDR Acinetobacter, screening all admissions required Table 1. Comparison of 3 Surveillance Strategies to Detect Multidrug-Resistant Acinetobacter Among 1111 Patients Admitted to Selected Medicine Units in the Johns Hopkins Hospital, March Through June 2006a

Nurse‐pharmacist collaboration on medication reconciliation prevents potential harm

BACKGROUNDnMedication reconciliation can prevent some adverse drug events (ADEs). Our prospective study explored whether an easily replicable nurse-pharmacist led medication reconciliation process could efficiently and inexpensively prevent potential ADEs.nnnMETHODSnNurses at a 1000 bed urban, tertiary care hospital developed the home medication list (HML) through patient interview. If a patient was not able to provide a written HML or recall medications, the nurses reviewed the electronic record along with other sources. The nurses then compared the HML to the patients active inpatient medications and judged whether the discrepancies were intentional or potentially unintentional. This was repeated at discharge as well. If the prescriber changed the order when contacted about a potential unintentional discrepancy, it was categorized as unintentional and rated on a 1-3 potential harm scale.nnnRESULTSnThe study included 563 patients. HML information gathering averaged 29 minutes. Two hundred twenty-five patients (40%; 95% confidence interval [CI], 36%-44%) had at least 1 unintended discrepancy on admission or discharge. One hundred sixty-two of the 225 patients had an unintended discrepancy ranked 2 or 3 on the harm scale. It cost

Disparities in Osteoporosis Screening Between At-Risk African-American and White Women

113.64 to find 1 potentially harmful discrepancy. Based on the 2008 cost of an ADE, preventing 1 discrepancy in every 290 patient encounters would offset the intervention costs. We potentially averted 81 ADEs for every 290 patients.nnnCONCLUSIONnPotentially harmful medication discrepancies occurred frequently at both admission and discharge. A nurse-pharmacist collaboration allowed many discrepancies to be reconciled before causing harm. The collaboration was efficient and cost-effective, and the process potentially improves patient safety.

Patients' understanding of the regulation of dietary supplements.

BACKGROUND: Despite a lower prevalence of osteoporosis in African-American women, they remain at risk and experience a greater mortality than white women after sustaining a hip fracture. Lack of recognition of risk factors may occur in African-American women, raising the possibility that disparities in screening practices may exist.OBJECTIVE: To determine whether there is a difference in physician screening for osteoporosis in postmenopausal, at-risk African-American and white women.METHODS: We conducted a retrospective chart review at an urban academic hospital and a suburban community hospital. Subjects included 205 African-American and white women, age ≥65 years and weight ≤127 pounds, who were seen in Internal Medicine clinics. The main outcome was dual-energy x-ray absorptiometry (DXA) scan referral. We investigated physician and patient factors associated with referral. Secondary outcomes included evidence of discussion of osteoporosis and prescription of medications to prevent osteoporosis.RESULTS: Significantly fewer African-American than white women were referred for a DXA scan (OR 0.39%, 95% confidence interval (CI): 0.22 to 0.68). Physicians were also less likely to mention consideration of osteoporosis in medical records (0.27, 0.15 to 0.48) and to recommend calcium and vitamin D supplementation for this population (0.21, 0.11 to 0.37). If referred, African-American women had comparable DXA completion rates when compared with white women. No physician characteristics were significantly associated with DXA referral patterns.CONCLUSIONS: Our study found a significant disparity in the recommendation for osteoporosis screening for African-American versus white women of similar risk, as well as evidence of disparate osteoporosis prevention and treatment, confirming results of other studies. Future educational and research initiatives should target this inequality.

The Creation of a Biocontainment Unit at a Tertiary Care Hospital. The Johns Hopkins Medicine Experience.

The Dietary Supplement Health and Education Act (DSHEA) permits manufacturers to sell products without providing pre-market evidence of safety or efficacy. One fundamental reason for the passage of the DSHEA was to empower consumers to make their own choices, free from governmental restriction. Yet, little is known about the public’s understanding of the supplement regulatory process. We undertook a study to assess patients’ knowledge regarding governmental oversight of product marketing and advertising. A survey of 300 adult patients from the Baltimore Metropolitan area was administered after showing participants an advertisement for a dietary supplement. Patients were asked questions regarding their understanding of federal regulation of the advertised product. A total of 52% of respondents were unaware that the dietary supplement had not been approved by the government while 63% were unaware that the advertisement for that supplement had not been pre-approved. Factors associated with a lack of understanding of the product approval process included lower education level (OR 2.52; 95% CI 1.52–4.19) and non-Caucasian race (OR 1.99; 95% CI 1.17–3.36). Lower education level was also associated with confusion regarding the advertisement approval process (OR 2.60; 95% CI 1.48–4.57). Based on these results, patients seem unclear about the government’s role in the regulation of dietary supplements. Educational efforts should be geared towards clarifying these issues.

The Power of Involving House Staff in Quality Improvement: An Interdisciplinary House Staff–Driven Vaccination Initiative

In response to the 2014-2015 Ebola virus disease outbreak in West Africa, Johns Hopkins Medicine created a biocontainment unit to care for patients infected with Ebola virus and other high-consequence pathogens. The unit team examined published literature and guidelines, visited two existing U.S. biocontainment units, and contacted national and international experts to inform the design of the physical structure and patient care activities of the unit. The resulting four-bed unit allows for unidirectional flow of providers and materials and has ample space for donning and doffing personal protective equipment. The air-handling system allows treatment of diseases spread by contact, droplet, or airborne routes of transmission. An onsite laboratory and an autoclave waste management system minimize the transport of infectious materials out of the unit. The unit is staffed by self-selected nurses, providers, and support staff with pediatric and adult capabilities. A telecommunications system allows other providers and family members to interact with patients and staff remotely. A full-time nurse educator is responsible for staff training, including quarterly exercises and competency assessment in the donning and doffing of personal protective equipment. The creation of the Johns Hopkins Biocontainment Unit required the highest level of multidisciplinary collaboration. When not used for clinical care and training, the unit will be a site for research and innovation in highly infectious diseases. The lessons learned from the design process can inform a new research agenda focused on the care of patients in a biocontainment environment.

Impact of Displaying Inpatient Pharmaceutical Costs at the Time of Order Entry: Lessons From a Tertiary Care Center

Immunization for influenza and pneumococcal pneumonia were incorporated into The Joint Commission “global immunization” core measure January 1, 2012. The authors’ hospital chose to adhere strictly to guidelines to avoid overvaccination. An immunization order set was created to aid appropriate ordering practices. In spite of this effort, compliance rates remained below the goal. The objective was to improve compliance with inpatient vaccination core measures to >96%. An educational slide set was created and distributed by the Housestaff Patient Safety and Quality Council (HPSQC). A competition was established among departments. Finally, the HPSQC partnered with quality improvement staff to improve communication and optimize concurrent review processes. The average compliance prior to the HPSQC vaccination initiative was 78% for pneumococcal pneumonia and 84% for influenza; average compliance in the months following the intervention was 96% and 97.5%, respectively. This project yielded significant improvement in compliance with vaccination core measures.

The Importance of Resident Involvement in Quality Improvement: An Investment in Our Future

BACKGROUND: A lack of cost‐conscious medication use is a major contributor to excessive healthcare expenditures in the inpatient setting. Expensive medicines are often utilized when there are comparable alternatives available at a lower cost. Increasing prescriber awareness of medication cost at the time of ordering may help promote cost‐conscious use of medications in the hospital. OBJECTIVE: To evaluate the impact of cost messaging on the ordering of 9 expensive medications. DESIGN: Retrospective analysis of an institutional cost‐transparency initiative. SETTING: A 1145‐bed, tertiary care, academic medical center. PARTICIPANTS: Prescribers who ordered medications through the computerized provider order entry system at the Johns Hopkins Hospital. METHODS: Interrupted time series and segmented regression models were used to examine prescriber ordering before and after implementation of cost messaging for 9 highcost medications. RESULTS: Following the implementation of cost messaging, no significant changes were observed in the number of orders or ordering trends for intravenous (IV) formulations of eculizumab, calcitonin, levetiracetam, linezolid, mycophenolate, ribavirin, and levothyroxine. An immediate and sustained reduction in medication utilization was seen in 2 drugs that underwent a policy change during our study, IV pantoprazole and oral voriconazole. IV pantoprazole became restricted at our facility due to a national shortage (‐985 orders per 10,000 patient days; P < 0.001), and oral voriconazole was replaced with an alternative antifungal in oncology order sets (‐110 orders per 10,000 patient days; P = 0.001). CONCLUSIONS: Prescriber cost transparency alone did not significantly influence medication utilization at our institution. Active strategies to reduce ordering resulted in dramatic reductions in ordering.

Establishing a New Biocontainment and Treatment Unit

As frontline providers of patient care, residents are key drivers of quality at academic medical centers. Therefore, it is essential for teaching hospitals to engage their residents as core participants in organizational initiatives to improve the quality of patient care. Simply put, the success of an academic medical center’s quality improvement programs is dependent on the participation of residents.