Effectiveness of a medical student-led, advanced care planning intervention in an inpatient cancer population.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e24010-e24010
Author(s):  
Linda Nguyen ◽  
Shelly S. Lo ◽  
William Adams ◽  
Paul J. Hutchison
Keyword(s):  
Medical Student ◽  
Advance Directives ◽  
Medical Center ◽  
Academic Medical Center ◽  
Comfort Level ◽  
Care Planning ◽  
Advanced Care Planning ◽  
Structured Interviews ◽  
Power Of Attorney ◽  
Post Intervention

e24010 Background: In an effort to provide patients with care that aligns with their values and goals, patients are encouraged to complete advance directives (ADs). While research has shown the benefits of advanced care planning (ACP) sessions, few studies have examined the thematic content of ACP discussions in an inpatient hematology or oncology population. Methods: We enrolled patients admitted to the hematology and oncology unit of an academic medical center who had never completed a power-of-attorney for healthcare form. One medical student 1) helped patients complete a power-of-attorney for healthcare form and 2) performed semi-structured interviews that explored patient's values, beliefs about end-of-life care, and preferences for medical treatments. Interviews were audio-recorded, transcribed, and analyzed through thematic analysis. Subjects completed pre- and post- surveys assessing their knowledge and attitudes about ACP. Results: All 48 patients enrolled in the study completed an advance directive. There was no significant change between pre- and post- intervention surveys evaluating patients’ trust in their physicians or family members to choose the right treatments for them in a life-threatening situation. Similarly, there was no change in patients’ comfort level discussing advance care planning after the interview. 79.2% of patients agreed or strongly agreed that they would recommend this ACP conversation to family and friends. 35.5% of patients agreed or strongly agreed that having this ACP conversation made them anxious. In the qualitative arm of the study, analysis suggests that cancer patients are willing to undergo further treatment unless it burdens their loved ones or interferes with quality time spent with family and friends. Motivating factors for patients included their spirituality and ability to fulfill a responsibility in a defined role. Conclusions: An ACP intervention performed by a medical student can increase the number of advance directives among patients admitted to inpatient hematology and oncology units. While this intervention may be anxiety-provoking for patients, it can illuminate the relative value patients place on the quality of their life versus their longevity.

Engaging the cancer care team in advance care planning.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 14-14
Author(s):  
Tallat Mahmood ◽  
Jane Alcyne Severson ◽  
Laura Thompson
Keyword(s):  
Advance Directives ◽  
Advance Care Planning ◽  
Metastatic Cancer ◽  
Care Team ◽  
Care Planning ◽  
Power Of Attorney ◽  
Post Intervention ◽  
Improvement Program ◽  
Advanced Directives ◽  
Advance Care

14 Background: Engagement of oncologists and their care team is essential to ensure advance care planning (ACP) occurs for cancer patients. However, numerous barriers to ACP exists, including the availability of trained staff with competence and confidence to have discussions with patients as well as resources to ensure ACP is effectively and efficiently integrated into the oncology practice. Methods: A baseline audit to determine the presence of documented ACP discussions for patients with metastatic cancer was conducted, followed by a quality improvement program with subsequent reassessment. The baseline audit identified only 20% (10/50) compliance with documentation of such discussions. Subsequently, we joined the Michigan Oncology Quality Consortium’s (MOQC) ACP Collaborative where the care team (MA, RN, PA, MD) were taught how to request and complete a durable power of attorney, conduct ACP conversations, and document pertinent information in a standard EHR location. Results: A one-year post-intervention audit found that 80% (40/50) of patients with metastatic cancer had an ACP documented in their record - a four fold improvement. A post-implementation staff survey noted that the team improved their understanding of both the legal issues and importance of asking about advance directives as well as using the designated chart location to document. 100% of staff agreed or strongly agreed with the statement “I understand the importance of asking patients about advanced directives”. Staff gained confidence in how to talk to patients about advance directives again with 100% of staff agreeing or strongly agreeing with the statement,” I feel more confident now in how to talk to a patient about advanced directives”. Conclusions: It is critical that all members of the oncology care team understand the importance of ACP and that staff feel confident in how to have discussions with patients. While physician/patient discussion is both necessary and expected, patients often discuss their wishes and fears with others in the practice. It is critical that all members of the team understand the importance of and opportunities where they can both support patients’ wishes and direct patients to their oncologist if necessary for further discussion.

Abstract 248: Initiation and Assessment of Timekeeping Roles During In-Hospital Cardiac Arrests to Track Rhythm Checks and Epinephrine Dosing

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Conor Crowley ◽  
Peter Clardy ◽  
Jessica McCannon ◽  
Rebecca Logiudice
Keyword(s):  
Small Sample Size ◽  
Medical Center ◽  
Academic Medical Center ◽  
Small Sample ◽  
Post Intervention ◽  
Epinephrine Administration ◽  
Team Members ◽  
Minute Post ◽  
Chaotic Nature ◽  
Strongly Agree

Introduction: Compliance to ACLS cardiac arrest algorithm is low and associated with worse outcomes from in-hospital cardiac arrests (IHCA). Reasons for non-compliance include reduced communication due to chaotic nature of IHCAs and difficulty timing epinephrine administration and rhythm check intervals. Hypothesis: Delegating two separate code team members for rhythm and epinephrine timing will increase adherence to ACLS algorithm during IHCAs. Methods: This is a pre-post interventional study of IHCAs at a single academic medical center. Two stopwatches were placed on all code carts and two new timekeeping roles were created. Education was provided to staff regarding the alteration of existing code team member roles for the use of stopwatches. Algorithm adherence was analyzed pre and post implementation of timekeeper roles. Deviation from the 2-minute rhythm check or 3-5-minute epinephrine administration was counted as one deviation. Anonymous surveys were delivered to evaluate providers perceived benefits of timekeeper roles for IHCAs. Results: Data from 13 pre intervention IHCAs were compared to 12 IHCAs post intervention. The initial rhythm was PEA/asystole in 69% pre-intervention vs 83% post intervention. Prior to implementation 82 deviations vs. 11 deviations post implementation occurred (p=0.006). The mean time until first dose of epinephrine was administered pre intervention was 2.3 ± 3.3 minutes vs 0.4 ±1 minute post. Pre-implementation ROSC rate was 53.8% vs. 66.7% post intervention. Surveys were delivered to 100% of code team members post intervention, with a 79% response rate. Surveys demonstrate providers felt time keeping roles made it easier to track epinephrine administration and rhythm checks. On a Likert scale, 78% of providers “strongly agree” that the use of timekeeping roles and devices improved code team communication. Conclusion: Two separate timekeeper roles during IHCAs improved algorithm compliance, code team function and communication, and was favored by code team members. Timekeeper roles may be associated with improved rates of ROSC and less time until the first dose of epinephrine is administered. This study is limited by its small sample size, single center and requires validation.

scholarly journals MON-134 Incorporating Transgender Competent Care into the Medical School Curriculum

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Elizabeth M Lamos ◽  
Sandra Quezada ◽  
Rana Malek
Keyword(s):  
Medical Student ◽  
Medical School ◽  
School Curriculum ◽  
Comfort Level ◽  
Endocrine Treatment ◽  
Post Intervention ◽  
Endocrine Society ◽  
Knowledge And Skills ◽  
Interest Level ◽  
Student Training

Abstract BACKGROUND: According to recent estimates, the US transgender population has doubled in the last decade. Incorporating transgender competent care into medical education is a growing need, and a focus of the AAMC. Care of the transgender individual is multifaceted, and medical school curriculae on transgender care are limited and lack standardization. Similarly, strategies for measuring effectiveness and impact of these curriculae remain limited. Methods: Over 3 years, the use of a transgender clinical correlation in the endocrine section of the second-year medical student pre-clerkship curriculum progressed to the use of a triple modality intervention. This included (1) a self-directed written handout with terminology and the basic tenants of medical transition therapy with an optional podcast, (2) a traditional presentation covering social, ethical and multi-disciplinary transgender care, and (3) an interactive session with a transfemale and transmale patient. An anonymous 8 question pre-and post-intervention survey using an electronic clicker system was performed. Questions included interest level, comfort level with various aspects of transgender-competent care and resource awareness. Results: Prior to the intervention, 74% of students were interested in learning more about transgender competent care. After the learning intervention, in all questions focusing on knowledge and skills of transgender care, students reported a significant increase in their comfort level (Figure 1, p<0.5, all). This included reporting now higher comfort levels regarding goals of hormone therapy (8 to 63%), use of transgender affirming medications (19 to 44%), barriers to care (30 to 79%), and long term and multi-disciplinary care (8 to 63% and 13 to 71%, pre- and post-intervention respectively). At the end of the intervention, students felt they had more resources to access information about transgender-competent care (pre-23% to post-94% p= <0.05). Conclusion: Knowledge and skills in the care of transgender individuals is poor in the pre-clerkship medical school years. The interest to learn about transgender care is positive. This multi-modality intervention was successful in increasing medical student comfort and knowledge about comprehensive transgender care, and increased student awareness of available resources. Introduction of transgender care should be implemented early in medical student training. 1. Hembree WC et al. Endocrine Treatment of Gender-Dysphoric/ Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. Endocr Pract. 2017 Dec;23(12):1437. 2. Harris M, Johnson C. Only Human. Trans Kids Update: Dating, PMS, And, Yeah, Bathrooms. NYPR WNYC Studios, 2017. Figure 1. Change in student comfort across transgender competent care. * p < 0.05

Patient Involvement in Anesthesia Decision-making: A Qualitative Study of Knee Arthroplasty

2021 ◽  
Author(s):  
Veena Graff ◽  
Justin T. Clapp ◽  
Sarah J. Heins ◽  
Jamison J. Chung ◽  
Madhavi Muralidharan ◽  
...  
Keyword(s):  
Decision Making ◽  
Qualitative Study ◽  
Shared Decision Making ◽  
Knee Arthroplasty ◽  
Patient Involvement ◽  
Medical Center ◽  
Academic Medical Center ◽  
Shared Decision ◽  
Structured Interviews ◽  
Primary Knee Arthroplasty

Background Calls to better involve patients in decisions about anesthesia—e.g., through shared decision-making—are intensifying. However, several features of anesthesia consultation make it unclear how patients should participate in decisions. Evaluating the feasibility and desirability of carrying out shared decision-making in anesthesia requires better understanding of preoperative conversations. The objective of this qualitative study was to characterize how preoperative consultations for primary knee arthroplasty arrived at decisions about primary anesthesia. Methods This focused ethnography was performed at a U.S. academic medical center. The authors audio-recorded consultations of 36 primary knee arthroplasty patients with eight anesthesiologists. Patients and anesthesiologists also participated in semi-structured interviews. Consultation and interview transcripts were coded in an iterative process to develop an explanation of how anesthesiologists and patients made decisions about primary anesthesia. Results The authors found variation across accounts of anesthesiologists and patients as to whether the consultation was a collaborative decision-making scenario or simply meant to inform patients. Consultations displayed a number of decision-making patterns, from the anesthesiologist not disclosing options to the anesthesiologist strictly adhering to a position of equipoise; however, most consultations fell between these poles, with the anesthesiologist presenting options, recommending one, and persuading hesitant patients to accept it. Anesthesiologists made patients feel more comfortable with their proposed approach through extensive comparisons to more familiar experiences. Conclusions Anesthesia consultations are multifaceted encounters that serve several functions. In some cases, the involvement of patients in determining the anesthetic approach might not be the most important of these functions. Broad consideration should be given to both the applicability and feasibility of shared decision-making in anesthesia consultation. The potential benefits of interventions designed to enhance patient involvement in decision-making should be weighed against their potential to pull anesthesiologists’ attention away from important humanistic aspects of communication such as decreasing patients’ anxiety. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

A preliminary investigation of opinions and behaviors regarding advance directives for medical care

1993 ◽  
Vol 2 (2) ◽  
pp. 161-167 ◽  
Author(s):  
EH Elpern ◽  
SB Yellen ◽  
LA Burton
Keyword(s):  
Advance Directives ◽  
Advance Directive ◽  
Medical Center ◽  
Academic Medical Center ◽  
Preliminary Investigation ◽  
Tertiary Care ◽  
Living Will ◽  
Treatment Preferences ◽  
Convenience Sample ◽  
And Behaviors

BACKGROUND: Advance directives are a means of promoting patient autonomy in end-of-life decisions but are used infrequently. A recent federal law requires healthcare organizations to provide information to patients about advance directives. This study explored attitudes and behaviors related to the use of advance directives in three areas: familiarity with advance directives, reasons for completing or not completing advance directives and preferences for receiving information about advance directives. METHODS: A questionnaire was administered by personal interview to a nonrandomized convenience sample of 46 inpatients and 50 outpatients at a large, tertiary care, urban academic medical center in the summer of 1991. RESULTS: Most respondents (77%) had heard of either the living will or durable power of attorney for healthcare, but only 52% correctly understood the purpose of these documents. Twenty-nine percent of the sample had executed an advance directive. Those who had advance directives were older and considered themselves less healthy than did those without advance directives. Unfamiliarity with advance directives and procrastination were cited most often as reasons for not having an advance directive. Most subjects (65%) had spoken with someone, usually a family member or close friend, about preferences for treatment during a critical illness. Although they had rarely discussed advance directives, 83% anticipated that they would be comfortable doing so with a physician or a nurse. CONCLUSIONS: Advance directives are used infrequently to document treatment preferences. The success of programs to promote greater use of advance directives depends on a clearer understanding of the factors that influence both decision and action to execute an advance directive. Patients claim to be comfortable in discussing the topic and prefer that such discussions occur in the outpatient setting.

scholarly journals 1154. Impact of Educational Feedback on Reducing Hospital-Onset Catheter-Associated Urinary tract Infections at an Academic Medical Center

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S412-S412
Author(s):  
Bhagyashri D Navalkele ◽  
Nora Truhett ◽  
Miranda Ward ◽  
Sheila Fletcher
Keyword(s):  
Infection Prevention ◽  
Medical Center ◽  
Academic Medical Center ◽  
Prevention Strategies ◽  
Intervention Period ◽  
Post Intervention ◽  
Frontline Staff ◽  
Post Intervention Period ◽  
Tract Infections ◽  
The Impact

Abstract Background High regulatory burden on hospital-onset (HO) infections has increased performance pressure on infection prevention programs. Despite the availability of comprehensive prevention guidelines, a major challenge has been communication with frontline staff to integrate appropriate prevention measures into practice. The objective of our study was to evaluate the impact of educational intervention on HO CAUTI rates and urinary catheter days. Methods At the University of Mississippi Medical Center, Infection prevention (IP) reports unit-based monthly HO infections via email to respective unit managers and ordering physician providers. Starting May 2018, IP assessed compliance to CAUTI prevention strategies per SHEA/IDSA practice recommendations (2014). HO CAUTI cases with noncompliance were labeled as “preventable” infections and educational justification was provided in the email report. No other interventions were introduced during the study period. CAUTI data were collected using ongoing surveillance per NHSN and used to calculate rates per 1,000 catheter days. One-way analysis of variance (ANOVA) was used to compare pre- and post-intervention data. Results Prior to intervention (July 2017–March 2018), HO CAUTI rate was 1.43 per 1,000 catheter days. In the post-intervention period (July 2018–March 2019), HO CAUTI rate decreased to 0.62 per 1,000 catheter days. Comparison of pre- and post-intervention rates showed a statistically significant reduction in HO CAUTIs (P = 0.04). The total number of catheter days reduced, but the difference was not statistically significant (8,604 vs. 7,583; P = 0.06). Of the 14 HO CAUTIs in post-intervention period, 64% (8/14) were reported preventable. The preventable causes included inappropriate urine culturing practice in asymptomatic patients (5) or as part of pan-culture without urinalysis (2), and lack of daily catheter assessment for necessity (1). Conclusion At our institute, regular educational feedback by IP to frontline staff resulted in a reduction of HO CAUTIs. Feedback measure improved accountability, awareness and engagement of frontline staff in practicing appropriate CAUTI prevention strategies. Disclosures All authors: No reported disclosures.

scholarly journals Physicians as Advisors Not Leaders of Multidisciplinary Teams: A Qualitative Study of an Innovative Practice

2019 ◽  
Vol 1 (3) ◽  
Author(s):  
Eliezer Mendelev ◽  
Madhu Mazumdar ◽  
Laurie Keefer ◽  
Ksenia Gorbenko
Keyword(s):  
Medical Home ◽  
Medical Center ◽  
Academic Medical Center ◽  
Cost Savings ◽  
Leadership Role ◽  
Multidisciplinary Teams ◽  
Structured Interviews ◽  
Home Team ◽  
Team Meetings ◽  
Physician Role

Abstract Background and Aims As various models of team-based chronic disease management have proliferated, physicians have assumed the leadership role in most of them. However, physician time is costly, and regular attendance of team meetings adds another task to a long list of responsibilities. This is the first study to explore the role of physicians as advisors rather than leaders of a multidisciplinary team. Methods We conducted an exploratory qualitative research study of a subspecialty medical home located within a tertiary academic medical center that cares for highly complex pediatric and adult patients with inflammatory bowel diseases. The medical home team consists of a psychologist, dieticians, social workers, a clinical pharmacist, and nurses. No physicians regularly attend team meetings. We conducted semi-structured interviews with nonphysician team members (N = 11) and gastroenterologists (N = 6). Two authors coded interview transcripts in NVivo 11 for themes related to “physician role” using an inductive qualitative analysis approach. Results Nonphysician participant believed gastroenterologists did not need to attend weekly meetings. Having only nonphysician personnel in the room made them feel more empowered to openly express their views. Gastroenterologists expressed interest in attending one or more, but not all meetings, in order to better understand the process of the team and desired a more formal feedback loop for staying informed about their patients’ progress. Conclusions Our findings suggest that gastroenterologist participation may not require regular attendance of team meetings. Team meeting consisting of nonphysician providers would result in cost savings and may empower nonphysician providers.

scholarly journals Impact of Changes in Urine Culture Ordering Practice on Antimicrobial Utilization in Intensive Care Units at an Academic Medical Center

2016 ◽  
Vol 37 (4) ◽  
pp. 448-454 ◽  
Author(s):  
Mohamed Sarg ◽  
Greer E. Waldrop ◽  
Mona A. Beier ◽  
Emily L. Heil ◽  
Kerri A. Thom ◽  
...  
Keyword(s):  
Intensive Care ◽  
Urine Culture ◽  
Medical Center ◽  
Academic Medical Center ◽  
Intervention Group ◽  
Antimicrobial Use ◽  
Post Intervention ◽  
Icu Patients ◽  
Antimicrobial Utilization ◽  
Academic Medical

OBJECTIVETo assess antimicrobial utilization before and after a change in urine culture ordering practice in adult intensive care units (ICUs) whereby urine cultures were only performed when pyuria was detected.DESIGNQuasi-experimental studySETTINGA 700-bed academic medical centerPATIENTSPatients admitted to any adult ICUMETHODSAggregate data for all adult ICUs were obtained for population-level antimicrobial use (days of therapy [DOT]), urine cultures performed, and bacteriuria, all measured per 1,000 patient days before the intervention (January–December 2012) and after the intervention (January–December 2013). These data were compared using interrupted time series negative binomial regression. Randomly selected patient charts from the population of adult ICU patients with orders for urine culture in the presence of indwelling or recently removed urinary catheters were reviewed for demographic, clinical, and antimicrobial use characteristics, and pre- and post-intervention data were compared.RESULTSStatistically significant reductions were observed in aggregate monthly rates of urine cultures performed and bacteriuria detected but not in DOT. At the patient level, compared with the pre-intervention group (n=250), in the post-intervention group (n=250), fewer patients started a new antimicrobial therapy based on urine culture results (23% vs 41%, P=.002), but no difference in the mean total DOT was observed.CONCLUSIONA change in urine-culture ordering practice was associated with a decrease in the percentage of patients starting a new antimicrobial therapy based on the index urine-culture order but not in total duration of antimicrobial use in adult ICUs. Other drivers of antimicrobial use in ICU patients need to be evaluated by antimicrobial stewardship teams.Infect. Control Hosp. Epidemiol. 2016;37(4):448–454

The Nonphysician “Medical Student Educator”: A Formal Addition to the Clerkships and Key Programs at an Academic Medical Center

2007 ◽  
Vol 19 (2) ◽  
pp. 154-161 ◽  
Author(s):  
Donna Elliott ◽  
Sarah Ingersoll ◽  
Maura Sullivan ◽  
Madeleine Bruning ◽  
Moreen Logan ◽  
...  
Keyword(s):  
Medical Student ◽  
Medical Center ◽  
Academic Medical Center ◽  
Academic Medical
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