Significance of high sensitivity C-reactive protein and D-dimer in evaluating intracardiac thrombus and spontaneous echo contrast in patients referred for transesophageal echocardiography: A prospective study

Background: Intra-cardiac thrombus (ICT) and spontaneous echo contrast (SEC) are considered hypercoagulable and inflammatory conditions. We aimed to determine if high sensitivity C-reactive protein (CRP) and D-dimer (DD), in combination with variables of lower thrombotic risk (normal ejection fraction [NEF], sinus rhythm [NSR]), may predict the absence of ICT/SEC. Methods and Results: Consecutive patients referred for transesophageal echocardiogram (TEE) for evaluation of cardioembolic source were prospectively enrolled. CRP and DD levels were determined at the time of TEE. 124 patients were enrolled, of whom 21 had ICT/SEC. The combination of NSR/NEF had a negative predictive value (NPV) of 98.6% for absence of ICT/SEC. The NPVs of CRP and DD were 93.6% and 85%, respectively. Adding either CRP or DD to NSR/NEF combination increased the NPV to 100%. Log CRP was significantly associated with ICT/SEC. Conclusions: The presence of NSR and NEF may defer the need for TEE for ICT/SEC evaluation. CRP association with ICT/SEC suggests that inflammation plays a role in ICT/SEC formation. Whether CRP and DD should become routine in the triage process of TEE for ICT/SEC evaluation requires further large scale prospective studies

Putting the shm key principles into practice: Direct objective clinical evaluation of new-hire hospitalists to improve physician communication and engagement while fulfilling fppe

Background: SHM Key Characteristic 9.1 on patient centered care encourages using guidelines/checklists to reinforce effective communication. Focused practice performance evaluations (FPPE) are a required regulatory hospital process for new medical staff members. In cognitive specialties, such as hospital medicine, completing an objective assessment of clinical skills can be difficult, with most initial evaluations based on more subjective performance assessments completed by peers or ancillary staff, which can be inconsistent across environments and personnel. Purpose: We sought to develop and implement an objective clinical assessment tool for initial FPPE of new hires in a multi-site hospital medicine group to reinforce clinical communication guidelines. Description: After developing divisional evidence based clinical communication guidelines for hospitalists in 2015, an assessment tool was designed based on the already validated SEGUE framework, a communication checklist commonly used in medical education, containing the domains of Set the stage, Elicit information, Give information, Understand the patient’s perspective, and End the encounter. The core SEGUE tool was selected for use in the inpatient environment along with a general comment area to evaluate other observed communication/safety behaviors as it aligned with the hospital medicine group’s clinical communication guidelines reinforcing AIDET (Acknowledge, Introduce, Duration, Explain, Thank You). Using an online survey service, the tool was available electronically, so that it could be used remotely by all authorized users on a variety of devices, including smartphones (Figure 1). After a 2 hour training session of observers, assessments were conducted at the bedside primarily in the direct care clinical environment. A majority of the observations were made on all new hires by the division head to create a level of inter-subject reliability for ratings, and so the division head could directly interact with all new staff. Additional observations were made by the section head at each specific clinical campus. A total of at least 5 observations were made for each subject. Formative feedback was given immediately to the subject hospitalist after each encounter and a summative feedback on the experience was provided to the new hire. The results were also reviewed in the new hire’s formal performance evaluation within approximately 6 months with the division head. Informal feedback from new hires on the observation process was positive, and it also helped to identify opportunities for workflow improvement as divisional leadership was able to more closely observe bedside activities. After successful completion of the first cohort in 2015, a second cohort is being evaluated during the latter half of 2016. To date, over 140 assessments have been performed on over 30 new hire hospitalists. Information from these assessments allowed our group to assess opportunities for continued training and improvement. We plan to correlate observation assessment results with patient experience scores, physician engagement, and staff retention.Conclusions: The use of a modified SEGUE framework adapted for the inpatient setting and operationalized on an online survey service, allowed for an objective evaluation of new hire hospitalists across multiple clinical settings, with completion of requirements for FPPE and generation of meaningful feedback to the hospitalists on their communication with patients