Development of a post-fall multidisciplinary checklist to evaluate the in-patient fall

Background: Falls suffered by hospitalized patients are an important reportable event. Approximately 4 - 6 % of inpatient falls result in serious injury. Recurrent falls or delayed recognition of injury can harm patients and represents a medico-legal risk. In 2010, our tertiary-care academic medical center reviewed current practice regarding falls prevention and assessment to develop a comprehensive falls prevention program. The committee found that there was no consistent practice in the assessment by nurses or physicians of inpatients who had fallen, either for injury or for conditions which might have led to the fall. A new systematic checklist for evaluation of the hospital faller was developed by a team consisting of nursing, hospitalists, and a medical unit director. Purpose: To develop an evidence-based multi-disciplinary checklist to facilitate evaluation, implementation of secondary prevention interventions and documentation following a hospital fall. Description: The hospitalist and the general medical unit director reviewed relevant literature, consulted national experts, and drafted a multidisciplinary checklist, the UNMH Post-Fall/Huddle Tool, to be used by nurses and physicians in post-fall patient evaluation. The checklist was reviewed and revised with further input from key stakeholders including hospitalists, housestaff, and the adult Medical/Surgical Shared Governance Committee. It was implemented as part of a comprehensive falls prevention program 3 month pilot. The checklist prompts a three step process: (1) an initial 7-item assessment by nursing staff to determine factors which would necessitate immediate evaluation by cross-covering physicians versus deferring evaluation to the primary team; (2) a 5-item focused physical examination to be performed by a physician to assess the likelihood of injury and suggested diagnostic tests based on this examination; and (3) an interdisciplinary face-to-face meeting between the evaluating physician and nurse to review 7 specific possible precipitating events and implement potential interventions. The UNMH Post-Fall/Huddle Tool will be adapted into the electronic health record after pilot completion and evaluation. An educational presentation about falls and how to use the checklist was developed for residents and hospitalists. Use of the checklist was implemented in November, 2010. To date, nurses and residents report that the checklist is easy to use and that it facilitates a timely, multidisciplinary evaluation of patients who have fallen in the hospital. Conclusion: A multi-disciplinary post-fall checklist facilitates a consistent and evidence-based evaluation and treatment of patients who have fallen in the hospital

Junior faculty exchange program assists mid-career clinician-educators increase scholarly activity and meet promotion requirements

Project: Our institution requires peer-review scholarly products and an extramural reputation for promotion of clinician-educators to Associate Professor. Given a lack of robust research skill training during residency and a paucity of research mentors in our Division of Hospital Medicine, meeting these two promotion requirements has been especially challenging for many of our hospitalist faculty. We established a junior faculty exchange with other institutions in order to assist individual faculty members to gain a reputation outside of their home institutions, to develop external mentorship and career advice relationships with early career faculty, and to enhance networking and project collaborations. Methods: Participants were mid-career faculty who would gain the maximal career benefit from delivering an invited visit to an external institution and who have sufficient track record to deliver effective mentoring advice to early career hospitalists. Faculty at the late Assistant Professor level or recently promoted Associate Professors were selected by their Divisions leadership to spend one day at a hosting institution, deliver an invited grand rounds or similar didactic presentation, meet with senior leadership, and provide career advice to junior faculty. The program was reciprocal with one faculty member visiting an institution in exchange for that institution hosting a faculty member for a similar invited visit. Each institution covered the cost of travel and hotel accommodations. No honoraria were paid. Results: Over the first two years, four junior academic hospitalists were exchanged between three institutions. There was a high degree of satisfaction among surveyed visiting and visited junior faculty. Two on-going collaborative relationships and one jointly authored paper have resulted to date. Conclusion: A junior faculty exchange program assisted mid-career academic hospitalists establish extramural collaborations and meet promotion requirements that have been problematic at our institution. Implication: This relatively inexpensive faculty development program is easily adaptable by other institutions and may help generalist faculty increase scholarly activity, develop extra-institutional relationships, and achieve promotion.\u2

Impact of a tailored program on the implementation of evidence-based recommendations for multimorbid patients with polypharmacy in primary care practices — results of a cluster-randomized controlled trial

Background: Multimorbid patients receiving polypharmacy represent a growing population at high risk for negative health outcomes. Tailoring is an approach of systematic intervention development taking account of previously identified determinants of practice. The aim of this study was to assess the effect of a tailored program to improve the implementation of three important processes of care for this patient group: (a) structured medication counseling including brown bag reviews, (b) the use of medication lists, and (c) structured medication reviews to reduce potentially inappropriate medication. Methods: We conducted a cluster-randomized controlled trial with a follow-up time of 9 months. Participants were general practitioners (GPs) organized in quality circles and participating in a GP-centered care contract of a German health insurance. Patients aged >50 years, suffering from at least 3 chronic diseases, receiving more than 4 drugs, and being at high risk for medication-related events according to the assessment of the treating GP were enrolled. The tailored program consisted of a workshop for GPs and health care assistants, educational materials and reminders for patients, and the elaboration of implementation action plans. The primary outcome was the change in the degree of implementation between baseline and follow-up, measured by a summary score of 10 indicators. The indicators were based on structured surveys with patients and GPs. Results: We analyzed the data of 21 GPs (10 - intervention group, 11 - control group) and 273 patients (130 - intervention group, 143 - control group). The increase in the degree of implementation was 4.2 percentage points (95% confidence interval: −0.3, 8.6) higher in the intervention group compared to the control group (p = 0.1). Two of the 10 indicators were significantly improved in the intervention group: medication counseling (p = 0.017) and brown bag review (p = 0.012). Secondary outcomes showed an effect on patients’ self-reported use of medication lists when buying drugs in the pharmacy (p = 0.03). Conclusions: The tailored program may improve implementation of medication counseling and brown bag review whereas the use of medication lists and medication reviews did not improve. No effect of the tailored program on the combined primary outcome could be substantiated. Due to limitations of the study, results have to be interpreted carefully. The factors facilitating and hindering successful implementation will be examined in a comprehensive process evaluation. Trial registration number ISRCTN34664024, assigned 14/08/201

Evaluation of opioid prescribing preferences among surgical residents and faculty

Background: Residents report that faculty preference is a significant driver of opioid prescribing practices. This study compared opioid prescribing preferences of surgical residents and faculty against published guidelines and actual practice and assessed perceptions in communication and transparency around these practices. Methods: Surgical residents and faculty were surveyed to evaluate the number of oxycodone tablets prescribed for common procedures. Quantities were compared between residents, faculty, Opioid Prescribing Engagement Network guidelines, and actual opioids prescribed. Frequency with which faculty communicate prescribing preferences and the desire for feedback and transparency in prescription practices were assessed. Results: Fifty-six (72%) residents and 57 (59%) faculty completed the survey. Overall, faculty preferred a median number of tablets greater than recommended by Opioid Prescribing Engagement Network in 5 procedures, while residents did so in 9 of 14 procedures. On average, across all operations, faculty reported prescribing practices compliant with Opioid Prescribing Engagement Network 56.1% of the time, whereas residents did so 47.6% of the time (P 1/4 .40). Interestingly, opioids actually prescribed were significantly less than recommended in 7 procedures. Among faculty, 62% reported often or always specifying prescription preferences to residents, while only 9% of residents noted that faculty often did so. Residents (80%) and faculty (75%) were amenable to seeing regular reports of personal opioid prescription practices, and 74% and 65% were amenable to seeing practices compared with peers. Only 34% of residents and 44% of faculty wanted prescription practices made public. Conclusion: There is a disconnect between opioid prescribing preferences and practice among surgical residents and faculty. Increased transparency through individualized reports and education regarding Opioid Prescribing Engagement Network guidelines with incorporation into the electronic medical record as practice advisories may reduce prescription variability. (c) 2021 Published by Elsevier Inc

Addressing an epidemic: Improving guideline-concordant opioid prescribing in surgical patients

Background: Excess postoperative opioid prescribing increases the risk of opioid abuse, diversion, and addiction. Clinicians receive variable training for opioid prescribing, and despite the availability of guidelines, wide variations in prescribing practices persist. This quality improvement initiative aimed to assess and improve institutional adherence to published guidelines. Methods: This study represented a quality improvement initiative at an academic medical center implemented over a 6-month period with data captured 1 year before and after implementation. The quality improvement initiative focused on prescribing education and monthly feedback reports for cli-nicians. All opioid-naive, adult patients undergoing a reviewed procedure were included. Demographics, surgical details, hospital course, and opioid prescriptions were reviewed. Opioids prescribed on discharge were evaluated for concordance with recommendations based on published guidelines. Pre -and postimplementation cohorts were compared. Results: There were 4,905 patients included: 2,343 preimplementation and 2,562 postimplementation. There were similar distributions in patient demographics between the 2 cohorts. Guideline-concordant discharge prescriptions improved from 50.3% to 72.2% after the quality improvement initiative was implemented (P < .001). Adjusted analysis controlling for sex, age, discharge clinician, length of stay, outpatient surgery, and procedure demonstrated a 190% increase in odds of receiving a guideline -concordant opioid prescription on discharge in the postimplementation cohort (adjusted odds ratio 2.90; 95% confidence interval 1/4 2.55-3.30). Conclusion: This study represented a successful quality improvement initiative improving guideline -concordant opioid discharges and decreasing overprescribing. This study suggested published guide-lines are insufficient without close attention to elements of effective change management including the critical importance of locally targeting educational efforts and suggested that real-time, data-driven feedback amplifies impact on prescribing behavior. (c) 2022 Published by Elsevier Inc