E-cigarette or Vaping Product Use Associated Lung Injury

With the increased popularity of vaping and the recognition of e-cigarette or vaping product use associated lung injury (EVALI), it is important to understand the potential harms and treatment options. A 25 year old female with acute-onset chest pain and shortness of breath. Initial workup reveals tachycardia to 140bpm but she is afebrile. Laboratory and imaging workup reveals leukocytosis and CT scan of the chest reveals a multifocal pneumonia. While in the emergent department, although not hypoxic at rest, she desaturates to 89% on room air with ambulation and is admitted to the general medical unit for CAP. On hospital day 2 she progressively becomes more dyspneic and eventually is saturating only 90% on 6L nasal cannula. At this time, upon speaking further with the patient, it is discovered that she regularly vapes marijuana for anxiety, with the last use being 6 days prior to presentation. On hospital day 3 she is intubated for acute hypoxic respiratory failure. She is paralyzed and due to being asynchronous with the ventilator and is started on steroids for EVALI treatment. She is proned on hospital day 5 to help with her oxygenation, and remains so for approximately 36 hours. On hospital day 8 she is extubated and on hospital day 9 she is transferred to the GPU on 1L nasal cannula. She is discharged home on room air on hospital day 10 and is prescribed a steroid taper for a total of 13 days of treatment. This case illustrates the potential severity and rapid progression of EVALI, as well as an effective therapeutic approach. It is important to identify EVALI early to start appropriate treatment and avoid serious respiratory decompensation.https://scholarlycommons.henryford.com/merf2020caserpt/1045/thumbnail.jp

A Curriculum for Enhancing Physician Teaching Skills: The Value of Physician-Educator Partnerships

Developing as a physician requires an enormous amount of complex training, and quality of instruction greatly affects training outcomes. But while physicians are expected to teach trainees within the clinic, they often do not receive formal training in effective instructional practices. Providing faculty development programs is one way that institutions can help physicians develop teaching skills, but these programs often are developed without the input of educational specialists and not based in educational theory. In this methodology paper, we describe a 5-module curriculum that was developed in a cross-disciplinary collaboration between instructional designers and physician faculty. By merging educational and medical expertise and using adult learning theory with the Charlotte-Danielson educational framework, an essentials for clinical teaching educational endorsement program (ECTEEP) was created as a feature of the institutional curriculum within a large, urban teaching hospital. Here we describe how the program was developed through a physician-educator partnership, outline the program\u27s key content, and highlight essential aspects of successful implementation. The ECTEEP incorporates active learning approaches within an abbreviated format, distilling 5 critical aspects of effective teaching that are relevant to the clinical environment: cultural humility and safe learning environments, instruction practices for engaging learners, instruction and assessment strategies, receiving and giving feedback, and mentorship and coaching. A central feature of the program is that facilitators actively model the teaching behaviors they are conveying, which underscores the critical importance of facilitator preparation and skill. Our curriculum is offered here as a basic template for institutions that may want to establish a program for enhancing physician teaching skill

Using a Frontline Staff Intervention to Improve Cervical Cancer Screening in a Large Academic Internal Medicine Clinic

BACKGROUND: Cervical cancer is the third most common malignancy affecting women. Screening with Papanicolaou (Pap) tests effectively identifies precancerous lesions and early-stage cervical cancer. While the nationwide rate of cervical cancer screening (CCS) is 84%, our urban general internal medicine (GIM) clinic population had a CCS rate of 70% in 2016. OBJECTIVE: To improve our clinic\u27s CCS rate to match or exceed the national average within 18 months by identifying barriers and testing solutions. DESIGN: A quality improvement project led by a multidisciplinary group of healthcare providers. PARTICIPANTS: Our GIM clinic includes 16 attending physicians, 116 resident physicians, and 20 medical assistants (MAs) with an insured and underserved patient population. INTERVENTION: Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period. MAIN MEASURES: Our primary outcome was the number of Pap tests completed per month during the 2 study phases. Our secondary outcome was the clinic population\u27s CCS rate for all eligible clinic patients. KEY RESULTS: After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64-2.10; P \u3c 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40-3.02; P \u3c 0.001). Our clinic\u27s CCS rate improved from 70% to 75% after the 18-month intervention. CONCLUSIONS: The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS

Visual Analytics Dashboard Promises to Improve Hypertension Guideline Implementation

BACKGROUND: Primary care management of hypertension under new guidelines incorporates assessment of cardiovascular disease risk and commonly requires review of electronic health record (EHR) data. Visual analytics can streamline the review of complex data and may lessen the burden clinicians face using the EHR. This study sought to assess the utility of a visual analytics dashboard in addition to EHR in managing hypertension in a primary care setting. METHODS: Primary care physicians within an urban, academic internal medicine clinic were tasked with performing two simulated patient encounters for HTN management: the first using standard EHR, and the second using EHR paired with a visual dashboard. The dashboard included graphical blood pressure trends with guideline-directed targets, calculated ASCVD risk score, and relevant medications. Guideline-appropriate antihypertensive prescribing, correct target blood pressure goal, and total encounter time were assessed. RESULTS: We evaluated 70 case simulations. Use of the dashboard with the EHR compared to use of the EHR alone was associated with greater adherence to prescribing guidelines (95% vs. 62%, p\u3c0.001) and more correct identification of BP target (95% vs. 57%, p\u3c0.01). Total encounter time fell an average of 121 seconds (95% CI 69 - 157 seconds, p\u3c0.001) in encounters that used the dashboard combined with the EHR. CONCLUSIONS: The integration of a hypertension-specific visual analytics dashboard with EHR demonstrates the potential to reduce time and improve hypertension guideline implementation. Further widespread testing in clinical practice is warranted

Restructuring Ambulatory Curriculum

Needs and Objectives: During the 2017-2018 academic year, the curriculum for ambulatory medicine consisted mainly of discussion of clinical trials from scholarly journals. Results of both the mid-year and end of the year survey administered to residents showed dissatisfaction with the educational session, due to emphasis on clinical trials and lack of discussion regarding medical management of common outpatient pathology. This prompted restructuring of the curriculum with the goal of improving resident satisfaction, providing more management guidelines, and better preparing residents for board exams. Setting and Participants: Ambulatory education in our institution takes place prior to our residents\u27 traditional half-day continuity clinic. Small groups of up to 10 residents and 4 faculty participate in a flipped classroom format. Description: In the 2018-2019 academic year, our ambulatory curriculum underwent several key changes. First, educational sessions were shifted to focus more on guidelines and medical management of outpatient conditions. Second, each month a subspecialty topic was assigned that paralleled our inpatient educational noon conference. In this format, the outpatient curriculum built on concepts and topics addressed in our inpatient curriculum. Third, we utilized our in-training Results to help optimize topic selection to help residents focus on areas where scores tend to be lower. At the end of each month we had a resident-lead board review session to review key points and answer questions as a group. Evaluation: Mid-year surveys identical to the previous academic year were used to assess the resident and preceptor response to changes in the curriculum. 77% of residents rated the curriculum as good or excellent, a 30% increase from the year prior. 23% of residents rated it as fair/poor, a 30% decrease from the year prior. When asked about board review content, 56% of residents felt there were enough board review questions, a 38% increase from the year prior. Preceptors also felt their residents were more engaged during the sessions then they had been previously. D I r e C t r e s I d e n t feedback has been positive, including comments that they appreciate the synchrony of the inpatient and outpatient curriculum Discussion/Reflection/Lessons Learned: Resident satisfaction with the ambulatory curriculum has improved with the recent curriculum changes, leading to increased engagement in our educational sessions. Residents prefer broad discussions about clinic management rather than discussing clinical trials. By organizing these discussions to supplement the inpatient curriculum, residents felt they had a more structured educational experience. Board review questions help to reinforce the monthly topic while simultaneously preparing the residents for the ABIM. Choosing topics that are relevant and enjoyable to the targeted learners help enrich the ambulatory educational experience through increased participation and learning opportunities

Effectiveness of Nurse-Driven Protocol for Blood Pressure Management

Statement of Problem Or Question: Is the nurse-driven protocol more effective in controlling blood pressure in patients with hypertension in the outpatient setting than the traditional physician-driven approach? Objectives of Program/Intervention: Improve blood pressure control with dedicated follow-up visits performed by nurses Improve access to health care in traditionally underserved patient populations Utilize a team-based approach in the management of chronic diseases Description of Program/Intervention: The nurse-driven protocol is based on the MUPD campaign (Measure Up Pressure Down) using a team-based approach to improve blood pressure control and counteract clinical inertia in the ambulatory outpatient clinic setting. After patients are referred to the program by their physician, the MUPD nurse will follow up with the patient during cost-free appointments for blood pressure measurements, patient education, and medication titration based on a set protocol. The patients continue in the program until their blood pressures are controlled. The Henry Ford Clinics traditionally treat a disproportionately high number of medically underserved patients from the Detroit City area. The majority of the patients identify as African American. Measures of Success: This was a retrospective case-controlled study including all adults (\u3e 18 years) with hypertension (SBP \u3e 140 and/or a DBP \u3e 90) that presented to a Henry Ford internal medicine clinic between 1/2015 and 9/2017 and who participated in the nurse-driven protocol. The control consisted of a matched cohort who only followed up with their physicians. Blood pressures at 6 months and 1 year following enrollment in the nurse-driven HTN program were obtained from electronic medical records. Categorical variables were compared using chi-square tests. Crude and adjusted odds ratios were obtained using generalized estimating equations with a logit link function presence of blood pressure control as the dependent variable. Findings To Date: The rate of controlled blood pressure (BP) at 6 months is significantly higher in patients who were in the program as compared to those who were not (61% versus 45%, p\u3c 0.001). Similarly, the rate of medical management change was significantly higher in patients who were in the program as compared to those who were not (30% versus 21%, p\u3c 0.001). However, for both endpoints, the rates were similar at all other time points. Patients with at least 1 MUPD visit had 1.46 times the odds of having controlled BP in later visits compared to those with no MUPD visits. When controlling for gender, race, baseline systolic BP, and ratio of the medication change, patients with at least one MUPD have 1.48 times the odds of having controlled BP in later visits compared to those with no MUPD visits. Key Lessons For Dissemination: Nurse-driven clinic visits seem to be more effective in controlling blood pressures in the primary care setting than traditional physician visits. This project furthermore showed that this is also true in outpatient settings with a high proportion of underserved patients with multiple other comorbidities and complex social Backgrounds