scholarly journals The Impact of a Standardized Pre-visit Laboratory Testing Panel in the Internal Medicine Outpatient Clinic: a Controlled “On-Off” Trial

2021 ◽  
Author(s):  
B. E. L. Vrijsen ◽  
M. J. ten Berg ◽  
C. A. Naaktgeboren ◽  
J. Y. Vis ◽  
H. M. Dijstelbloem ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Outpatient Clinic ◽  
Laboratory Testing ◽  
Correct Diagnosis ◽  
Intervention Group ◽  
Physician Satisfaction ◽  
University Hospital ◽  
Care Utilization ◽  
Time To Diagnosis ◽  
The Impact

Abstract Background In several settings, a shorter time to diagnosis has been shown to lead to improved clinical outcomes. The implementation of a rapid laboratory testing allows for a pre-visit testing in the outpatient clinic, meaning that test results are available during the first outpatient visit. Objective To determine whether the pre-visit laboratory testing leads to a shorter time to diagnosis in the general internal medicine outpatient clinic. Design An “on-off” trial, allocating subjects to one of two treatment arms in consecutive alternating blocks. Participants All new referrals to the internal medicine outpatient clinic of a university hospital were included, excluding second opinions. A total of 595 patients were eligible; one person declined to participate, leaving data from 594 patients for analysis. Intervention In the intervention group, patients had a standardized pre-visit laboratory testing before the first visit. Main Measures The primary outcome was the time to diagnosis. Secondary outcomes were the correctness of the preliminary diagnosis on the first day, health care utilization, and patient and physician satisfaction. Key Results There was no difference in time to diagnosis between the two groups (median 35 days vs 35 days; hazard ratio 1.03 [0.87–1.22]; p = .71). The pre-visit testing group had higher proportions of both correct preliminary diagnoses on day 1 (24% vs 14%; p = .003) and diagnostic workups being completed on day 1 (10% vs 3%; p < .001). The intervention group had more laboratory tests done (50.0 [interquartile range (IQR) 39.0–69.0] vs 43.0 [IQR 31.0–68.5]; p < .001). Otherwise, there were no differences between the groups. Conclusions Pre-visit testing did not lead to a shorter overall time to diagnosis. However, a greater proportion of patients had a correct diagnosis on the first day. Further studies should focus on customizing pre-visit laboratory panels, to improve their efficacy. Trial Registration NL5009

scholarly journals Clinical and Educational Outcomes of an Integrated Inpatient Quality Improvement Curriculum for Internal Medicine Residents

2016 ◽  
Vol 8 (4) ◽  
pp. 563-568 ◽  
Author(s):  
Greg Ogrinc ◽  
Emily S. Cohen ◽  
Robertus van Aalst ◽  
Beth Harwood ◽  
Ellyn Ercolano ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Quality Improvement ◽  
Self Efficacy ◽  
Intervention Group ◽  
Educational Outcome ◽  
Free Text ◽  
Internal Medicine Residents ◽  
Late Intervention ◽  
Hands On ◽  
The Impact

ABSTRACT Background  Integrating teaching and hands-on experience in quality improvement (QI) may increase the learning and the impact of resident QI work. Objective  We sought to determine the clinical and educational impact of an integrated QI curriculum. Methods  This clustered, randomized trial with early and late intervention groups used mixed methods evaluation. For almost 2 years, internal medicine residents from Dartmouth-Hitchcock Medical Center on the inpatient teams at the White River Junction VA participated in the QI curriculum. QI project effectiveness was assessed using statistical process control. Learning outcomes were assessed with the Quality Improvement Knowledge Application Tool–Revised (QIKAT-R) and through self-efficacy, interprofessional care attitudes, and satisfaction of learners. Free text responses by residents and a focus group of nurses who worked with the residents provided information about the acceptability of the intervention. Results  The QI projects improved many clinical processes and outcomes, but not all led to improvements. Educational outcome response rates were 65% (68 of 105) at baseline, 50% (18 of 36) for the early intervention group at midpoint, 67% (24 of 36) for the control group at midpoint, and 53% (42 of 80) for the late intervention group. Composite QIKAT-R scores (range, 0–27) increased from 13.3 at baseline to 15.3 at end point (P &lt; .01), as did the self-efficacy composite score (P &lt; .05). Satisfaction with the curriculum was rated highly by all participants. Conclusions  Learning and participating in hands-on QI can be integrated into the usual inpatient work of resident physicians.

scholarly journals Quick diagnostic unit integrated in an emergency department setting reduces medical admissions – an observational study

2013 ◽  
Vol 3 (3) ◽  
pp. 17 ◽  
Author(s):  
Dan Brun Petersen ◽  
Thomas Andersen Schmidt
Keyword(s):  
Internal Medicine ◽  
Emergency Department ◽  
General Medicine ◽  
University Hospital ◽  
First Year ◽  
Special Focus ◽  
Diagnostic Study ◽  
Diagnostic Unit ◽  
Number Of Patients ◽  
The Impact

Background: Hospitals in countries with public health systems have recently adopted organizational changes to improve efficiency and resource allocation, and reducing inappropriate hospitalizations has been established as an important goal, as well as avoiding or buffering overcrowding in Emergency Departments (EDs). Aims: Our goal was to describe the impact of a Quick Diagnostic Unit established on January 1, 2012, integrated in an ED setting in a Danish public university hospital following its function for the first year. Design: Observational, descriptive and comparative study. Methods: Our sample comprised the total number of patients being admitted and discharged from the Department of Internal Medicine in 2011 and 2012, with special focus on the General Medicine Ward. Results: Compared with 2011 the establishment of the Quick Diagnostic Unit integrated in the Emergency Department resulted in the admittance and discharge of fewer patients (40%; p < .0001) to the hospital’s General Medicine Ward and 11.6% (p < .0001) fewer patients in the whole Department of Internal Medicine. Conclusions: A Quick Diagnostic Unit integrated in an ED setting represents a useful and fast track model for the diagnostic study and treatment of patients with simple internal medicine ailments, and also serves as a buffer for overcrowding of the ED.

scholarly journals Impact of an Antimicrobial Utilization Program on Antimicrobial Use at a Large Teaching Hospital A Randomized Controlled Trial

2009 ◽  
Vol 30 (10) ◽  
pp. 931-938 ◽  
Author(s):  
Bernard C. Camins ◽  
Mark D. King ◽  
Jane B. Wells ◽  
Heidi L. Googe ◽  
Manish Patel ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Teaching Hospital ◽  
Antimicrobial Agents ◽  
Intervention Group ◽  
Control Group ◽  
Antimicrobial Use ◽  
Randomized Controlled ◽  
Antimicrobial Usage ◽  
Antimicrobial Utilization ◽  
The Impact

Background.Multidisciplinary antimicrobial utilization teams (AUTs) have been proposed as a mechanism for improving antimicrobial use, but data on their efficacy remain limited.Objective.To determine the impact of an AUT on antimicrobial use at a teaching hospital.Design.Randomized controlled intervention trial.Setting.A 953-bed, public, university-affiliated, urban teaching hospital.Patients.Patients who were given selected antimicrobial agents (piperacillin-tazobactam, levofloxacin, or vancomycin) by internal medicine ward teams.Intervention.Twelve internal medicine teams were randomly assigned monthly: 6 teams to an intervention group (academic detailing by the AUT) and 6 teams to a control group that was given indication-based guidelines for prescription of broad-spectrum antimicrobials (standard of care), during a 10-month study period.Measurements.Proportion of appropriate empirical, definitive (therapeutic), and end (overall) antimicrobial usage.Results.A total of 784 new prescriptions of piperacillin-tazobactam, levofloxacin, and vancomycin were reviewed. The proportion of antimicrobial prescriptions written by the intervention teams that was considered to be appropriate was significantly higher than the proportion of antimicrobial prescriptions written by the control teams that was considered to be appropriate: 82% versus 73% for empirical (risk ratio [RR], 1.14; 95% confidence interval [CI], 1.04-1.24), 82% versus 43% for definitive (RR, 1.89; 95% CI, 1.53-2.33), and 94% versus 70% for end antimicrobial usage (RR, 1.34; 95% CI, 1.25-1.43). In multivariate analysis, teams that received feedback from the AUT alone (adjusted RR, 1.37; 95% CI, 1.27-1.48) or from both the AUT and the infectious diseases consultation service (adjusted RR, 2.28; 95% CI, 1.64-3.19) were significantiy more likely to prescribe end antimicrobial usage appropriately, compared with control teams.Conclusions.A multidisciplinary AUT that provides feedback to prescribing physicians was an effective method in improving antimicrobial use.Trial Registration.ClinicalTrials.gov identifier: NCT00552838.

scholarly journals Effect of a High Value Care Curriculum on Standardized Patient Exam in the Core Clerkship in Internal Medicine

2020 ◽  
Author(s):  
Amit K Pahwa ◽  
Kevin Eaton ◽  
Ariella Apfel ◽  
Amanda Bertram ◽  
Rebecca Ridell ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Medical Students ◽  
Primary Outcome ◽  
Intervention Group ◽  
Virtual Patients ◽  
The Core ◽  
Standard Curriculum ◽  
And Control ◽  
The Impact ◽  
Core Clerkship

Abstract Background: While there are increasing curricula on high value care, little is published on the effectiveness of curricula on medical students’ ability to practice high value care.Methods: In addition to the standard curriculum, the intervention group received two classroom sessions and three virtual patients focused on the concepts of high value care. The primary outcome was number of tests and charges for tests on standardized patients.Results: One hundred forty-one students enrolled in the Core Clerkship in Internal Medicine and 69 completed the high value care curriculum. There were no significant differences in ordering of appropriate tests (3.1 vs. 3.2 tests/students, p = 0.55) and inappropriate tests (1.8 vs. 2.2, p = 0.13) between the intervention and control. Students in the intervention group had significantly lower median Medicare charges ($287.59 vs. $500.86, p = 0.04) and felt their education in high value care was appropriate (81% vs. 56%, p = 0.02).Conclusions: This is the first study to describe the impact of a high value care curriculum on medical students’ ordering practices. While number of inappropriate tests were not significantly different, students in the intervention group refrained from ordering expensive tests.

Advance care planning for the severely ill in the hospital: a randomized trial

2019 ◽  
pp. bmjspcare-2017-001489 ◽  
Author(s):  
Tanja Krones ◽  
Ana Budilivschi ◽  
Isabelle Karzig ◽  
Theodore Otto ◽  
Fabio Valeri ◽  
...  
Keyword(s):  
End Of Life ◽  
Advance Care Planning ◽  
Decision Aids ◽  
Intervention Group ◽  
University Hospital ◽  
Care Planning ◽  
Medical Inpatients ◽  
Advance Care ◽  
Attending Physicians ◽  
The Impact

ObjectivesTo investigate the impact of advance care planning (ACP) including decision aids for severely ill medical inpatients.MethodsSingle-centre randomised controlled trial at a Swiss university hospital. Patients were randomly assigned (1:1) to receive an extra consultation with the hospital social service or a consultation with in-house facilitators trained according to an internationally established ACP programme. Trial participants with the exception of the observers were fully blinded. 115 competent severely ill adults, their surrogates and their attending physicians were enrolled and followed for 6 months after discharge or 3 months after death. The patient’s wishes regarding resuscitation (primary outcome), last place of care and other end-of-life wishes were recorded. Knowledge and respect of the patient’s wishes by the surrogates and attending physician were monitored.ResultsCompared with controls, 6 months after the intervention, fewer patients wished to be resuscitated or were undecided (p=0.01), resuscitation wishes were documented more frequently (89% vs 64%, p=0.02) and surrogates and/or attending physicians had greater knowledge of the patient’s wishes (62% vs 30%, p=0.01). Groups were not different with regard to wishes being fulfilled, with the exception of last place of care being achieved more frequently in the intervention group (29% vs 11 %, p=0.05).ConclusionACP including decision aids offered to severely ill medical inpatients leads to greater knowledge, documentation and respect of treatment and end-of-life wishes. Introducing ACP to these patients however may be too late for many patients. Early integration of ACP during the illness trajectory and a broader regional approach may be more appropriate.

The impact of the creation of a venous surgical centre within the department of cardiovascular surgery at a university hospital

2007 ◽  
Vol 22 (2) ◽  
pp. 70-74 ◽  
Author(s):  
J T Christenson
Keyword(s):  
Surgical Procedures ◽  
Cardiovascular Surgery ◽  
Physician Satisfaction ◽  
University Hospital ◽  
Treatment Modalities ◽  
Clinical Activity ◽  
Patient Volume ◽  
The Creation ◽  
New Treatment ◽  
The Impact

Background: The establishment of specialty vein clinics has proven beneficial in terms of expansion of clinical volume. Depending on the local situation, the creation of a venous surgical centre may, in addition, result in better collaboration between various specialties, enable active participation in the development and evaluation of new treatment modalities, offer better training/education and provide venues for more complex treatment modalities such as reconstructive surgery of the deep venous system. Objectives: The aim of this study was to analyse the impact of the creation of a venous surgical centre under the auspices of a department of cardiovascular surgery at a university hospital. Methods: A venous surgical centre was established on 1 October 2003, under the direction of one senior surgeon. The impact on clinical activity was measured in terms of patient volume, percentage distribution between venous and arterial surgery and surgical procedures performed, complications following venous surgery as well as evaluation of patient and referring physician satisfaction. Data, from the department's databank, on all patients evaluated and surgically treated for venous and arterial problems from 1 January 2000 to 30 June 2006 were analysed. Number of outpatient clinic visits and operations (patients and surgical procedures) were calculated. Results: The establishment of the venous surgical centre, without additional funding, led to a significant increase in clinical volume. There was a 433% increase in vein surgical procedures and a 774% increase in outpatient clinic visits (comparing 2002 with 2004). Endovenous laser treatment of varicose veins and reconstructive surgery for the deep venous system was started, and a program for training surgeons was established. Complication rate following varicose vein surgery decreased from 5.8% to 1.2% (hematomas and groin infection). Patient and referring physician satisfaction was documented in 2004 and 2006 using questionnaires. Conclusions: The establishment of an academic venous surgical centre has proven useful in increasing clinical activity in terms of patient volume, providing more efficient and better continuity of care, ensuring less complications following varicose vein surgery, allowing the introduction of new treatment modalities, and resulting in overwhelming patient and treating physician satisfaction.

scholarly journals A Randomized Controlled Trial of the Impact of a Teaching Procedure Service on the Training of Internal Medicine Residents

2012 ◽  
Vol 4 (2) ◽  
pp. 170-175 ◽  
Author(s):  
Michelle Mourad ◽  
Sumant Ranji ◽  
Diane Sliwka
Keyword(s):  
Internal Medicine ◽  
Randomized Controlled Trial ◽  
Controlled Trial ◽  
Intervention Group ◽  
Control Group ◽  
First Year ◽  
Randomized Controlled ◽  
Teaching Procedure ◽  
Viable Solution ◽  
The Impact

Abstract Introduction Academic medical centers must provide safe inpatient procedures while balancing resident autonomy and education. We performed a randomized, controlled trial to evaluate the effect of a 2-week hospitalist procedure service (HPS) rotation on interns' self-perceived procedure ability, knowledge, and autonomy versus the standard curriculum. Methods We randomly selected 16 of 57 internal medicine interns (28%) to participate in the intervention group rotation, with 29 interns in the control group. All interns were surveyed before the start of residency and at the end of the postgraduate year-1 (PGY-1) and PGY-2 years to evaluate self-reported knowledge and ability to (1) safely perform procedures, (2) supervise procedures, and (3) use bedside ultrasound. Results Ninety-four percent of HPS interns (15/16) and 71% of control interns (29/41) completed all surveys. Baseline knowledge and experience did not differ significantly between the groups. The intervention group performed significantly more paracentesis (9 versus 4; P &lt; .001), thoracentesis (6 versus 2; P &lt; .001), and lumbar puncture (4 versus 3; P &lt; .001) procedures than did the control group. After their first year, residents who completed the HPS rotation rated their ability to safely perform and supervise all of the assessed procedures as higher (P &lt; .05 for all procedures) and were more likely to rate self-perceived knowledge as very good or excellent in all surveyed aspects of procedure performance (P &lt; .05). Discussion A 2-week hospitalist-supervised procedure service rotation substantially improved residents' experience, confidence, and knowledge in performing bedside procedures early in their training, with this effect sustained through the PGY-2 year. Standardized procedure service rotations are a viable solution for programs seeking to improve their procedure-based education.

Germ Cell Tumors of the Ovary: An Update

2014 ◽  
Vol 138 (3) ◽  
pp. 351-362 ◽  
Author(s):  
Francisco F. Nogales ◽  
Isabel Dulcey ◽  
Ovidiu Preda
Keyword(s):  
Germ Cell ◽  
Correct Diagnosis ◽  
Relevant Literature ◽  
Germ Cell Tumors ◽  
Autoimmune Encephalitis ◽  
University Hospital ◽  
Ovarian Teratoma ◽  
Tumor Type ◽  
Pluripotency Markers ◽  
The Impact

Context.—The field of ovarian germ cell tumors (OGCTs) has remained relatively unchanged in the last 2 decades. However, the introduction of new stem cell pluripotency markers has provided a new understanding into the identification and taxonomy of OGCT types. New data have provided new insights into unusual teratoma-associated autoimmune disorders and the origin of gliomatosis peritonei. Objective.—To review the impact of new pluripotency markers in the diagnosis of malignant OGCT (MOGCT) and analyze new nomenclature proposals and clinicopathologic entities. Data Sources.—Ovarian germ cell tumors from routine material and expert consultation files at San Cecilio University Hospital, Granada, Spain, and the relevant literature were reviewed. Conclusions.—Although a correct diagnosis of MOGCT can often be made with histologic and classic immunohistochemical studies, the new immunohistochemical pluripotency markers give higher diagnostic accuracy. Germ cell tumors represent a caricature of the phases of normal embryonic differentiation from primordial germ and stem cells to extraembryonal and somatic tissue differentiation. Since every stage of differentiation and its related tumor type exhibit characteristic markers, the analysis of their expression facilitates tumor typing, thus complementing the use of classic antibodies. They also allow a more precise evaluation of the degree of immaturity in teratoma. The new term, primitive endodermal tumors, simplifies the understanding of the complex histology of the yolk sac tumor group, as this terminology encompasses its multiple endodermal differentiations. Recently described autoimmune encephalitis due to antibodies against the N-methyl-d-aspartate receptor has become the most frequent autoimmune disorder associated with ovarian teratoma.

scholarly journals Impacto de la ecografía volumétrica portátil en el sondaje vesical por retención urinaria en una unidad de medicina interna

2019 ◽  
Vol 19 (1) ◽  
pp. 42-62
Author(s):  
David Guadarrama Ortega ◽  
Raquel Díaz Díaz ◽  
María Aránzazu Martín Hernández ◽  
María Teresa Peces Hernández ◽  
Jonatan Vallejo Paredes ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Urinary Retention ◽  
Medical Record ◽  
Electronic Medical Record ◽  
University Hospital ◽  
Urinary Catheterization ◽  
Short Term ◽  
The University ◽  
The Impact ◽  
De Medicina

Objetivo: Estimar el impacto que el uso de ecógrafo vesical tiene en los sondajes vesicales por sospecha de retención urinaria de una unidad de Medicina interna.Metodología: Estudio de cohortes retrospectivas, comparando la cohorte expuesta a la disponibilidad del ecógrafo vesical, con la no expuesta el año previo. Se analizan todos los registros en la Historia Clínica Electrónica (HCE) de sondajes vesicales permanentes de corta duración en pacientes adultos que ingresaron en la unidad de hospitalización de Medicina Interna del Hospital Universitario Fundación Alcorcón (HUFA) durante los años 2015 y 2016. Se estima la frecuencia de retención urinaria como causa del sondaje después de la incorporación del dispositivo en la unidad y se compara con la frecuencia en sondajes durante el mismo periodo del año anterior en la misma unidad. Se estima el impacto que disponer de este dispositivo tiene en la frecuencia de retención urinaria como motivo del sondaje.Resultados: Se incluyen 134 sondajes en 113 pacientes, 62 en el grupo sin ecógrafo y 72 en el grupo con ecógrafo. La frecuencia de sondajes por retención se reduce del 47.5% al 21.4% después de introducir el ecógrafo en la unidad. Esto supone una reducción del 50% (RR ajustado= 0.48; IC95%:0.27-0.84, p=0.01) en la frecuencia de sondaje vesical por sospecha de retención urinaria. Aim: To estimate the impact of the use of portable bladder volumetric ultrasound on bladder catheterization due to suspicion of urinary retention in an internal medicine unit. Methodology: Study of retrospective cohorts, comparing the cohort exposed to the availability of bladder ultrasound, with the not exposed the previous year. All records in the Electronic Medical Record (EHR) of short-term permanent bladder catheters in adult patients admitted to the Internal Medicine hospitalization unit of the University Hospital Fundación Alcorcón (HUFA) during the years 2015 and 2016 were analyzed. The urinary retention frequency is estimated as the cause of the catheterization after the device has been incorporated into the unit and compared with the frequency of catheterization during the same period of the previous year in the same unit. It is estimated that the impact of having this device on the urinary retention frequency is the reason for the catheterization. Results: 134 catheters are included in 113 patients, 62 in the group without ultrasound and 72 in the group with ultrasound. The frequency of catheterizations due to retention is reduced from 47.5% to 21.4% after introducing the ultrasound unit into the unit. This represents a 50% reduction (adjusted RR=0.48; CI95%:0.27-0.84, p=0.01) in the frequency of urinary catheterization for suspected urinary retention.

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