Roger Y. Wong

Adverse outcomes following hospitalization in acutely ill older patients

BackgroundThe longitudinal outcomes of patients admitted to acute care for elders units (ACE) are mixed. We studied the associations between socio-demographic and functional measures with hospital length of stay (LOS), and which variables predicted adverse events (non-independent living, readmission, death) 3 and 6 months later.MethodsProspective cohort study of community-living, medical patients age 75 or over admitted to ACE at a teaching hospital.ResultsThe population included 147 subjects, median LOS of 9 days (interquartile range 5–15 days). All returned home/community after hospitalization. Just prior to discharge, baseline timed up and go test (TUG, P < 0.001), bipedal stance balance (P = 0.001), and clinical frailty scale scores (P = 0.02) predicted LOS, with TUG as the only independent predictor (P < 0.001) in multiple regression analysis. By 3 months, 59.9% of subjects remained free of an adverse event, and by 6 months, 49.0% were event free. The 3 and 6-month mortality was 10.2% and 12.9% respectively. Almost one-third of subjects had developed an adverse event by 6 months, with the highest risk within the first 3 months post discharge. An abnormal TUG score was associated with increased adjusted hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.03 to 1.59, P = 0.03. A higher FMMSE score (adjusted HR 0.89, 95% CI 0.82 to 0.96, P = 0.003) and independent living before hospitalization (adjusted HR 0.42, 95% CI 0.21 to 0.84, P = 0.01) were associated with reduced risk of adverse outcome.ConclusionSome ACE patients demonstrate further functional decline following hospitalization, resulting in loss of independence, repeat hospitalization, or death. Abnormal TUG is associated with prolonged LOS and future adverse outcomes.

Evaluation of resident attitudes and self-reported competencies in health advocacy.

BackgroundThe CanMEDS Health Advocate role, one of seven roles mandated by the Royal College of Physicians and Surgeons Canada, pertains to a physicians responsibility to use their expertise and influence to advance the wellbeing of patients, communities, and populations. We conducted our study to examine resident attitudes and self-reported competencies related to health advocacy, due to limited information in the literature on this topic.MethodsWe conducted a pilot experience with seven internal medicine residents participating in a community health promotion event. The residents provided narrative feedback after the event and the information was used to generate items for a health advocacy survey. Face validity was established by having the same residents review the survey. Content validity was established by inviting an expert physician panel to review the survey. The refined survey was then distributed to a cohort of core Internal Medicine residents electronically after attendance at an academic retreat teaching residents about advocacy through didactic sessions.ResultsThe survey was completed by 76 residents with a response rate of 68%. The majority agreed to accept an advocacy role for societal health needs beyond caring for individual patients. Most confirmed their ability to identify health determinants and reaffirmed the inherent requirements for health advocacy. While involvement in health advocacy was common during high school and undergraduate studies, 76% of residents reported no current engagement in advocacy activity, and 36% were undecided if they would engage in advocacy during their remaining time as residents, fellows or staff. The common barriers reported were insufficient time, rest and stress.ConclusionsMedical residents endorsed the role of health advocate and reported proficiency in determining the medical and bio-psychosocial determinants of individuals and communities. Few residents, however, were actively involved in health advocacy beyond an individual level during residency due to multiple barriers. Further studies should address these barriers to advocacy and identify the reasons for the discordance we found between advocacy endorsement and lack of engagement.

Use of simulator-based medical procedural curriculum: the learner's perspectives

BackgroundSimulation is increasingly used for teaching medical procedures. The goal of this study was to assess learner preferences for how simulators should be used in a procedural curriculum.MethodsA 26-item survey was constructed to assess the optimal use of simulators for the teaching of medical procedures in an internal medicine residency curriculum. Survey domains were generated independently by two investigators and validated by an expert panel (n = 7). Final survey items were revised based on pilot survey and distributed to 128 internal medicine residents.ResultsOf the 128 residents surveyed, 106 (83%) responded. Most responders felt that simulators should be used to learn technical skills (94%), refine technical skills (84%), and acquire procedural teaching skills (87%).Respondents felt that procedures most effectively taught by simulators include: central venous catheterization, thoracentesis, intubation, lumbar puncture, and paracentesis. The majority of learners felt that teaching should be done early in residency (97%).With regards to course format, 62% of respondents felt that no more than 3-4 learners per simulator and an instructor to learner ratio of 1:3-4 would be acceptable.The majority felt that the role of instructors should include demonstration of technique (92%), observe learner techniques (92%), teach evidence behind procedural steps (84%) and provide feedback (89%). Commonly cited barriers to procedural teaching were limitations in time, number of instructors and simulators, and lack of realism of some simulators.ConclusionsOur results suggest that residents value simulator-based procedural teaching in the form of small-group sessions. Simulators should be an integral part of medical procedural education.

Medication Reconciliation: Identifying Medication Discrepancies in Acutely Ill Hospitalized Older Adults

BACKGROUND Medication discrepancies may occur during transitions from community to acute care hospitals. The elderly are at risk for such discrepancies due to multiple comorbidities and complex medication regimens. Medication reconciliation involves verifying medication use and identifying and rectifying discrepancies. OBJECTIVE The aim of this study was to describe the prevalences and types of medication discrepancies in acutely ill older patients. METHODS Patients who were ≥ 70 years and were admitted to any of 3 acute care for elders (ACE) units over a period of 2 nonconsecutive months in 2008 were prospectively enrolled. Medication discrepancies were classified as intentional, undocumented intentional, and unintentional. Unintentional medication discrepancies were classified by a blinded rater for potential to harm. This study was primarily qualitative, and descriptive (univariate) statistics are presented. RESULTS Sixty-seven patients (42 women; mean [SD] age, 84.0 [6.5] years) were enrolled. There were 37 unintentional prescription-medication discrepancies in 27 patients (40.3%) and 43 unintentional over-the-counter (OTC) medication discrepancies in 19 patients (28.4%), which translates to Medication Reconciliation Success Index (MRSI) of 89% for prescription medications and 59% for OTC medications. The overall MRSI was 83%. More than half of the prescription-medication discrepancies (56.8%) were classified as potentially causing moderate/severe discomfort or clinical deterioration. CONCLUSION Despite a fairly high overall MRSI in these patients admitted to ACE units, a substantial proportion of the prescription-medication discrepancies were associated with potential harm.

Adverse Drug Events and Associated Factors in Heart Failure Therapy Among the Very Elderly

Introduction Heart failure (HF) is common in older adults and standard therapy involves the use of multiple medications. We assessed the nature, frequency, and factors associated with adverse drug events (ADEs) associated with standard HF therapy among older adults greater than 75 years of age. The efficacy and predictors of ADEs were assessed in this patient population, as well. Methods Systematic review using standardized databases including MEDLINE, Ageline, and CINAHL from January 1st 1988 to January 1st, 2010 and references from published literature. Randomized trials and studies with observational, cohort, and cross-sectional design were included. Two investigators independently selected the studies and extracted the data (kappa = 0.86). Results Twenty-five studies were identified. ADEs were reported in 13/23 (57%) studies. Syncope, bradycardia, and hypotension as a result of beta blockers occurred in greater frequency compared to younger populations. Spironolactone therapy resulted in increased rates of hyperkalemia, acute renal failure, and medication discontinuation. Factors associated with ADEs included advanced age, poor left ventricular function, and increasing New York Heart Association Class. Efficacy of beta blockers and ACE inhibitors appears to extend to the elderly population, but the magnitude of effect size is unclear. Very few studies reported associations between ADE and patients’ comorbidities (4/13 studies, 31%) or functional status (3/13 studies, 23%). Conclusion ADEs in CHF therapy among the very elderly occurred at a greater frequency, but were generally poorly characterized in the literature despite a relatively common occurrence. Further studies are warranted.

Real time curriculum map for internal medicine residency

BackgroundTo manage the voluminous formal curriculum content in a limited amount of structured teaching time, we describe the development and evaluation of a curriculum map for academic half days (AHD) in a core internal medicine residency program.MethodsWe created a 3-year cyclical curriculum map (an educational tool combining the content, methodology and timetabling of structured teaching), comprising a matrix of topics under various specialties/themes and corresponding AHD hours. All topics were cross-matched against the ACP-ASIM in-training examination, and all hours were colour coded based on the categories of core competencies. Residents regularly updated the map on a real time basis.ResultsThere were 208 topics covered in 283 AHD hours. All topics represented core competencies with minimal duplication (78% covered once in 3 years). Only 42 hours (15%) involved non-didactic teaching, which increased after implementation of the map (18–19 hours/year versus baseline 5 hours/year). Most AHD hours (78%) focused on medical expert competencies. Resident satisfaction (90% response) was high throughout (range 3.64 ± 0.21, 3.84 ± 0.14 out of 4), which improved after 1 year but returned to baseline after 2 years.ConclusionWe developed and implemented an internal medicine curriculum map based on real time resident input, with minimal topic duplication and high resident satisfaction. The map provided an opportunity to balance didactic versus non-didactic teaching, and teaching on medical versus non medical expert topics.

Twelve tips for teaching in a provincially distributed medical education program.

Background: As distributed undergraduate and postgraduate medical education becomes more common, the challenges with the teaching and learning process also increase. Aim: To collaboratively engage front line teachers in improving teaching in a distributed medical program. Method: We recently conducted a contest on teaching tips in a provincially distributed medical education program and received entries from faculty and resident teachers. Results: Tips that are helpful for teaching around clinical cases at distributed teaching sites include: ask “what if ” questions to maximize clinical teaching opportunities, try the 5-min short snapper, multitask to allow direct observation, create dedicated time for feedback, there are really no stupid questions, and work with heterogeneous group of learners. Tips that are helpful for multi-site classroom teaching include: promote teacher–learner connectivity, optimize the long distance working relationship, use the reality television show model to maximize retention and captivate learners, include less teaching content if possible, tell learners what you are teaching and make it relevant and turn on the technology tap to fill the knowledge gap. Conclusion: Overall, the above-mentioned tips offered by front line teachers can be helpful in distributed medical education.

Transferring Nursing Home Residents to Acute Care Hospital–To Do or Not To Do, That is the Question

Nursing home (NH) residents represent a population of particularly frail older adults with multiple comorbid illnesses, high prevalence of physical disabilities, and/or cognitive impairment. When they develop acute exacerbations of their chronic conditions, which occurs commonly, residents either receive treatments locally or are transferred to acute care hospitals, usually to emergency departments (EDs). These transfers often become a source of potential frustration. On the one hand, families and NH staff may feel helpless when residents are transferred to the unfamiliar surroundings in acute care (especially for dementia patients who are at increased risk of developing delirium after the environmental translocation) and subject to long wait times in busy EDs. On the other hand, ED and hospital staff may feel challenged to manage these residents because hospitalization of NH residents is associated with significant risks for adverse events, including functional decline, delirium, and mortality. Multiple factors may be associated with the decision to transfer NH residents to EDs and acute care hospitals. Physiologic determinants are intuitive and include the nature of medical diagnosis, and number and complexity of comorbidities. Functional determinants include the presence and severity of cognitive impairment, duration and extent of mobility problems, and impairment in activities of daily living, to name a few. Together these physiologic and functional determinants contribute to the overall frailty of NH residents. However, there are other important psychosocial determinants that may influence the decision, such as the presence (or absence) of advanced directives, availability of substitute decision makers, family dynamics of the residents, and bigger systemic issues such as NH resources (funding, staffing, and workload), ease of access to medical/nursing support, legislation requirements (eg, some jurisdictions do not allow certification of the deceased in private NHs), and so forth. In this issue of the Journal, Tang et al report the results of a database (using MDS-RAI 2.0) cross-sectional study looking

Measurement properties of the L test for gait in hospitalized elderly.

Nguyen VC, Miller WC, Asano M, Wong RY: Measurement properties of the l test for gait in hospitalized elderly. Am J Phys Med Rehabil 2007;86:463–468. Objective:Evaluate the reliability, validity, and predictive value of the l test, a performance-based walk test, among older inpatients. Design:Cross-sectional study involving a consecutive sample of 50 older adults (mean age 84 ± 5 yrs) admitted to the geriatric unit of a tertiary care hospital. Application of the l test twice and single application of the timed “up and go” test (TUG), and the Frailty and Injuries Cooperative Studies of Intervention Techniques (FICSIT-4) balance scale, were conducted. Results:Interrater and intrarater reliability (two-way ANOVA intraclass correlation coefficients [ICC]) of the l test was 1.00 (95% confidence interval, CI, 0.99–1.00) and 0.97, respectively (CI, 0.95–0.98). Hypothesized associations with the TUG and FICSIT-4 were observed (Pearson product–moment correlation, r = 0.96 and r = −0.45, respectively; P < 0.01) with regard to magnitude and direction of the relationship. l test times demonstrated a small but statistically significant independent risk factor for discharge destination after hospitalization (odds ratio = 1.05; CI, 1.01–1.09) after adjustment for age, sex, and cognitive status. Conclusions:The l test provides reliable, valid data when assessing basic walking skills among older adults in a hospital environment. The l test is potentially an important clinical and research tool to assess the mobility function of older inpatients as they transition back to the community.

Impact of a competency based curriculum on quality improvement among internal medicine residents

BackgroundTeaching quality improvement (QI) principles during residency is an important component of promoting patient safety and improving quality of care. The literature on QI curricula for internal medicine residents is limited. We sought to evaluate the impact of a competency based curriculum on QI among internal medicine residents.MethodsThis was a prospective, cohort study over four years (2007–2011) using pre-post curriculum comparison design in an internal medicine residency program in Canada. Overall 175 post-graduate year one internal medicine residents participated. A two-phase, competency based curriculum on QI was developed with didactic workshops and longitudinal, team-based QI projects. The main outcome measures included self-assessment, objective assessment using the Quality Improvement Knowledge Assessment Tool (QIKAT) scores to assess QI knowledge, and performance-based assessment via presentation of longitudinal QI projects.ResultsOverall 175 residents participated, with a response rate of 160/175 (91%) post-curriculum and 114/175 (65%) after conducting their longitudinal QI project. Residents’ self-reported confidence in making changes to improve health increased and was sustained at twelve months post-curriculum. Self-assessment scores of QI skills improved significantly from pre-curriculum (53.4 to 69.2 percent post-curriculum [p-value 0.002]) and scores were sustained at twelve months after conducting their longitudinal QI projects (53.4 to 72.2 percent [p-value 0.005]). Objective scores using the QIKAT increased post-curriculum from 8.3 to 10.1 out of 15 (p-value for difference <0.001) and this change was sustained at twelve months post-project with average individual scores of 10.7 out of 15 (p-value for difference from pre-curriculum <0.001). Performance-based assessment occurred via presentation of all projects at the annual QI Project Podium Presentation Day.ConclusionThe competency based curriculum on QI improved residents’ QI knowledge and skills during residency training. Importantly, residents perceived that their QI knowledge improved after the curriculum and this also correlated to improved QIKAT scores. Experiential QI project work appeared to contribute to sustaining QI knowledge at twelve months.