Changes Made to Orders Placed by Overnight Admitting Residents on Teaching Rounds the Next Day

OBJECTIVES: Increased focus on health care quality and safety has generally led to additional resident supervision by attending physicians. At our children’s hospital, residents place orders overnight that are not explicitly reviewed by attending physicians until morning rounds. We aimed to categorize the types of orders that are added or discontinued on morning rounds the morning after admission to a resident team and to understand the rationale for these order additions and discontinuations. METHODS: We used our hospital’s data warehouse to generate a report of orders placed by residents overnight that were discontinued the next morning and orders that were added on rounds the morning after admission to a resident team from July 1, 2017 to June 29, 2018. Retrospective chart review was performed on included orders to determine the reason for order changes. RESULTS: Our report identified 5927 orders; 538 were included for analysis after exclusion of duplicate orders, administrative orders, and orders for patients admitted to non-Pediatric Hospital Medicine services. The reason for order discontinuation or addition was medical decision-making (n = 357, 66.4%), change in patient trajectory (n = 151, 28.1%), and medical error (n = 30, 5.6%). Medical errors were most commonly related to medications (n = 24, 80%) and errors of omission (n = 19, 63%). CONCLUSIONS: New or discontinued orders commonly resulted from evolving patient management decisions or changes in patient trajectory; medical errors represented a small subset of identified orders. Medical errors were often errors of omission, suggesting an area to direct future safety initiatives.

Shifting the focus of research on effective professional development: Insights from a case study of implementation

Globally, teacher professional development is heralded as a key mechanism for educational reform. With governments investing heavily in PD programs, the aim of these interventions is not only enhanced teacher knowledge and practice but, ultimately, improved student outcomes. A substantial body of research has attempted to identify characteristics of effective PD, generating a growing list of features that ostensibly ‘work’. As such, program design has become the dominant analytic focus. In this paper, we shift attention squarely to program implementation as necessary in conceptualising and evaluating effective PD. We apply the lens of implementation science to a case study of how one regional secondary school in NSW, Australia, implemented a robust PD program called Quality Teaching Rounds that has strong evidence of effectiveness. Despite the school’s attempts to remain true to the spirit of the PD, a combination of remoteness, lack of casual relief teachers, high teacher turnover, and negative perceptions of peer observation result in a form of QTR that is almost unrecognisable from its intended design. We argue greater attention must be given to understanding and supporting successful implementation within and across diverse school contexts in order to take effective forms of PD to scale.

Point of Care Ultrasound during the Medical Teaching Rounds in the COVID-19 Era -The Hospitalist Perspective-

In Internal Medicine, POCUS is gaining significant favorability. An increasing number of clinicians are interested in being trained for POCUS. The newer portable ultrasounds are small and can be transported easily during rounds. Their design is now for a more intuitive use. Training of Internists now involves assessing patients utilizing POCUS technology in residency. Here at Danbury Hospital, we have formal POCUS training. Attending internists are now attempting to incorporate POCUS training as a part of continuing medical education. POCUS in the hospitalist or general practitioner world has not been completely defined. Generally, the patient seen in the medical ward is not ill as the patients seen in intensive care units (ICU), Emergency Department (ED), and other high acute-care settings. However, from time to time, internists need to treat high acuity patients on the medical floors before transferring them to a higher level of care or when they are required to cover an open ICU or Progressive Care Unit (step-down unit). The role of POCUS while managing stable patients may differ significantly compared to the role in more acute patients. A well-defined spectrum for the use of POCUS does not currently exist. However, there are efforts in this regard. POCUS is an emerging and exciting diagnostic modality in the medical ward. We believe that the pandemic has given it a new meaning for the hospitalist and general practitioner, and we expect that its use and significance will only grow in the few years ahead.

Survey of ICU Teaching Rounds: Secrets to Improve Learner Satisfaction

Background: Unique challenges of teaching in the ICU come from the complexity of critically ill patients. This study was designed to examine the different teaching patterns and learners’ emotion load to achieve learners satisfaction on rounds. Methods: The survey of learners was performed on their practices and perceptions of rounds using social media. Results: A total of 82 learners with 195 responses were received. Pathophysiology-based analysis on worsened conditions, problem-based teaching and feedback, discussion about past experience were top three teaching behaviors on rounds, in addition, interesting and storytelling presentation, and evidence-based medicine were significantly correlated with learner satisfaction. However, the leaners still have the expectations for further improvement of some teaching behaviors. During rounding, tense, calm, nervous, relaxed and excited were the most top learners’ emotions, only excited was significantly correlated with learners satisfaction. Conclusions: Pathophysiology-based analysis on worsened conditions, problem-based teaching and feedback, discussion about past experience are top three teaching behaviors during the rounding, however, learners might be dissatisfied barely with these teaching pattens. Teachers should focus on key skills on rounds to enhance satisfaction.