Timothy Niessen

Delirium transitions in the medical ICU: exploring the role of sleep quality and other factors.

Objectives:Disrupted sleep is a common and potentially modifiable risk factor for delirium in the ICU. As part of a quality improvement project to promote sleep in the ICU, we examined the association of perceived sleep quality ratings and other patient and ICU risk factors with daily transition to delirium. Design:Secondary analysis of prospective observational study. Setting:Medical ICU over a 201-day period. Patients:Two hundred twenty-three patients with greater than or equal to one night in the medical ICU in between two consecutive days of delirium assessment. Interventions:None. Measurements and Main Results:Daily perceived sleep quality ratings were measured using the Richards-Campbell Sleep Questionnaire. Delirium was measured twice daily using the Confusion Assessment Method for the ICU. Other covariates evaluated included age, sex, race, ICU admission diagnosis, nighttime mechanical ventilation status, prior day’s delirium status, and daily sedation using benzodiazepines and opioids, via both bolus and continuous infusion. Perceived sleep quality was similar in patients who were ever versus never delirious in the ICU (median [interquartile range] ratings, 58 [35–76] vs 57 [33–78], respectively; p = 0.71), and perceived sleep quality was unrelated to delirium transition (adjusted odds ratio, 1.00; 95% CI, 0.99–1.00). In mechanically ventilated patients, receipt of a continuous benzodiazepine and/or opioid infusion was associated with delirium transition (adjusted odds ratio, 4.02; 95% CI, 2.19–7.38; p < 0.001), and patients reporting use of pharmacological sleep aids at home were less likely to transition to delirium (adjusted odds ratio, 0.40; 95% CI, 0.20–0.80; p = 0.01). Conclusions:We found no association between daily perceived sleep quality ratings and transition to delirium. Infusion of benzodiazepine and/or opioid medications was strongly associated with transition to delirium in the ICU in mechanically ventilated patients and is an important, modifiable risk factor for delirium in critically ill patients.

Do internal medicine interns practice etiquette‐based communication? A critical look at the inpatient encounter

Etiquette-based communication may improve the inpatient experience but is not universally practiced. We sought to determine the extent to which internal medicine interns practice behaviors that characterize etiquette-based medicine. Trained observers evaluated the use of 5 key communication strategies by internal medicine interns during inpatient clinical encounters: introducing ones self, explaining ones role in the patients care, touching the patient, asking open-ended questions, and sitting down with the patient. Participants at 1 site then completed a survey estimating how frequently they performed each of the observed behaviors. A convenience sample of 29 interns was observed on a total of 732 patient encounters. Overall, interns introduced themselves 40% of the time and explained their role 37% of the time. Interns touched patients on 65% of visits, asked open-ended questions on 75% of visits, and sat down with patients during 9% of visits. Interns at 1 site estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P < 0.01; 80% vs 37%, P < 0.01; and 58% vs 9%, P < 0.01, respectively). Resident physicians introduced themselves to patients, explained their role, and sat down with patients infrequently during observed inpatient encounters. Residents surveyed tended to overestimate their own practice of etiquette-based medicine.

Variability in hand hygiene practices among internal medicine interns

Hand hygiene compliance remains suboptimal among physicians despite quality improvement efforts. We observed hand hygiene compliance among 29 medicine interns at 2 large academic institutions. Overall compliance was 75%. Although 4 interns averaged <40% compliance, 14 averaged at least 80%. Given variability observed among individuals in the same training programs, targeting those with poor performance may be important in improving overall compliance.

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training

BackgroundPhysicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill.MethodsOne hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE).ResultsInterns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing ‘a’ from ‘v’ waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE.ConclusionsA comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

A post-2011 time motion study--the authors' reply.

DepartmentofMedicine, HofstraNorth Shore-LIJ School ofMedicine, Lake Success, NY, USA; DepartmentofMedicine, University ofMarylandSchool of Medicine, Baltimore, MD, USA; Department of Health Policy andManagement, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins University, Baltimore, MD, USA; Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA.

The Electronic Health Record and the Clinical Examination

This review examines how the adoption of the electronic health record (EHR) has changed the most fundamental unit of medicine: the clinical examination. The impact of the EHR on the clinical history, physical examination, documentation, and the doctor-patient relationship is described. The EHR now has a dominant role in clinical care and will be a central factor in clinical work of the future. Conversation needs to be shifted toward defining best practices with current EHRs inside and outside of the examination room.

Geographically Localized Medicine House-Staff Teams and Patient Satisfaction:

Background: Geographically localized care teams may demonstrate improved communication between team members and patients, potentially enhancing coordination of care. However, the impact of geographically localized team on patient experience scores is not well understood. Objective: To compare experience scores of patients on resident teams home clinical units with patients assigned to them off of their home units over a 10-year period. Participants: Patients admitted to any of the 4 chief resident staffed internal medicine inpatient service were included. Patients admitted to the house-staff teams’ home clinical unit comprised the exposure group and their patients off of their home units comprised the control patients. Measurement: Top-box experience scores calculated from the physician Hospital Consumer Assessment of Healthcare and Provider Systems (HCAHPS) and Press Ganey patient satisfaction surveys. Results: There were 3012 patients included in the study. There were no significant differences in experience scores with physician communication, nursing communication, pain, or discharge planning between the 2 groups. Patients did not report satisfaction more often with the time physicians spent with them on localized teams (48.6% vs 47.5%; P = .54) or that staff were better at working together (63.2% vs 61.3%; P = .29). This did not change during a 45-month period when the proportion of patients on home units exceeded 75% and multidisciplinary rounds were started. Conclusion: Patients cared for by geographically localized teams did not have better patient experience. Other factors such as physician communication skills or limited time spent in direct care may overshadow the impact of having localized teams. Further research is needed to better understand organizational, team, and individual factors impacting patient experience.