Improving Admission Medication Reconciliation Completion at GW Hospital

Background: Medication errors represent a major cause of adverse events in hospitalized inpatients. 27-83% of hospitalized patients will have at least one discrepancy in their medication history at admission, with 11%–59% of errors having clinical importance. Current processes for completing admission medication reconciliations are ill-defined, further increasing the risk of errors. Implementation of a standardized medication reconciliation process has led to a reduction in medication errors. Aim Statement: To increase the number of admission medication reconciliations completed within 48 hours of admission to GW Hospital by 25% over three months. Methods: From September 2017 until December 2017, an educational intervention was delivered to internal medicine residents rotating on the wards at GW Hospital and refined over three PDSA cycles. The intervention included an educational presentation on proper completion of an admission medication reconciliation, given at resident noon conference and to the night float team, a video by hospitalists reinforcing principles of proper medication reconciliation, and creation of a signoff checklist to assess interns for proper completion of medication reconciliations. The number of properly completed admission medication reconciliations within 48 hours of admission for patients admitted to one general medicine day team and to the night float team was assessed. Completion was denoted by green checkmarks next to “Document Medications by History” and “Medication Admission Reconciliation” in Cerner. Data was collected for all new admissions every post-call day and was expanded to an additional daytime team with PDSA Cycle 3. Results: Baseline data revealed that admission medication reconciliations were completed on 20% and 77% of new admissions to the daytime and night float teams, respectively. Completion rates by the day team varied from 16% to 100%, but with a clear trend towards improvement with over 50% completed on the days reviewed. Little change was observed on the night admission team. Expanded data from the additional daytime team showed improved completion rate. Discussion: Our study demonstrated that early provider education, adherence to a standardized process, and reinforced education are ways of improving admission medication reconciliation completion. There was an overall increase in admission medication reconciliation completion in the daytime medicine team, but not in the night float team, likely owing to the more frequent turnover of night float residents. Data collection was expanded to a second daytime medicine team and is ongoing with possible extension to all medicine wards teams. Limitations include provider turnover throughout our interventions, the inability to assess accuracy of completed medication reconciliations, and the varying experience with admission medication reconciliation completion among providers. Future interventions include education at intern orientation, reinforced with successful completion of a signoff checklist, and involvement of pharmacists

Positive relationships between association strength and phenotypic similarity characterize the assembly of mixed-species bird flocks worldwide

Competition theory predicts that local communities should consist of species that are more dissimilar than expected by chance. We find a strikingly different pattern in a multicontinent data set (55 presence-absence matrices from 24 locations) on the composition of mixed-species bird flocks, which are important sub-units of local bird communities the world over. By using null models and randomization tests followed by meta-analysis, we find the association strengths of species in flocks to be strongly related to similarity in body size and foraging behavior and higher for congeneric compared with noncongeneric species pairs. Given the local spatial scales of our individual analyses, differences in the habitat preferences of species are unlikely to have caused these association patterns; the patterns observed are most likely the outcome of species interactions. Extending group-living and social-information-use theory to a heterospecific context, we discuss potential behavioral mechanisms that lead to positive interactions among similar species in flocks, as well as ways in which competition costs are reduced. Our findings highlight the need to consider positive interactions along with competition when seeking to explain community assembly

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial

Colistin Dosing and Nephrotoxicity in a Large Community Teaching Hospital ▿

Thirty adult patients who received intravenous colistin (5.1 ± 2.4 mg/kg/day) were reviewed to evaluate dosing with respect to nephrotoxicity, which occurred in 10 (33%) patients within the first 5 days of treatment. Excessive colistin dosing was frequent (47%), often (71%) resulted from the use of actual body weight in obese patients, and was associated with higher rates of nephrotoxicity (80% versus 30%, P = 0.019)

Improving HIV Screening Rates at an Academic Teaching Institution Internal Medicine Resident Clinic

Introduction: Human immunodeficiency virus (HIV) affects over a million individuals in the United States. Thirteen percent of people with HIV don’t know they have the virus. Washington DC has among the highest rates of HIV in the nation. An important step in the fight against HIV is screening tests, which everyone is recommended to have at least once in his/her life. The goal of this study is go increase HIV screening during annual physical examinations at the George Washington University Internal Medicine Residents Clinic by 25%. Methods: We performed a retrospective chart review of all patients who presented for annual physical examination from July 2016 to January 2017. Rates of HIV screening were determined by search for any laboratory record of an HIV test or documentation by the provider in the clinic visit note. Baseline rates were determined and rates after four subsequent interventions (PDSA cycles) aimed to increase screening rates: email reminders, macro utilization education, patient education posters in rooms, and pocket cards of recommended screening guidelines for residents. Results: Baseline data revealed that 67.6% of patients had ever had HIV screening. In order to meet our predetermined goal of a 25% increase in screening rates, rates would need to increase to 85% of patients. Post-intervention #1 (email reminder to providers), the rate was 64.8%. Post-intervention #2 (macro utilization education), the rate was 69.6%. Post-intervention #3 (posters in patient rooms), the rate was 77.0%. Preliminary results for post-intervention #4 (pocket cards of recommended screening guidelines for residents), the rate was 90%, though a final numbers of this last intervention are still pending analysis. Discussion: HIV screening is a known effective tool in preventing the spread of sexual transmitted diseases. In addition to patient education, focusing on reminding providers of this importance is essential to increasing the rates of testing. Our study demonstrated that direct patient education/exposure and reminder tools for physicians are two possible ways to increase the rate of HIV screening. While preliminary data shows promise in provider reminders such as pocket cards, final analysis of this effect is currently underway. The effects are compounded and do not reflect any single intervention at a time, demonstrating the importance of a multi-focal approach towards increasing screening rates

Implementation and evaluation of a large-scale postpartum family planning program in Rwanda: Study protocol for a clinic-randomized controlled trial

Background: Though the Rwandan Ministry of Health (MOH) prioritizes the scale-up of postpartum family planning (PPFP) programs, uptake and sustainability of PPFP services in Rwanda are low. Furthermore, highly effective long-acting reversible contraceptive method use (LARC), key in effective PPFP programs, is specifically low in Rwanda. We previously pilot tested a supply-demand intervention which significantly increased the use of postpartum LARC (PPLARC) in Rwandan government clinics. In this protocol, we use an implementation science framework to test whether our intervention is adaptable to large-scale implementation, cost-effective, and sustainable. Methods: In a type 2 effectiveness-implementation hybrid study, we will evaluate the impact of our PPFP intervention on postpartum LARC (PPLARC) uptake in a clinic-randomized trial in 12 high-volume health facilities in Kigali, Rwanda. We will evaluate this hybrid study using the RE-AIM framework. The independent effectiveness of each PPFP demand creation strategy on PPLARC uptake among antenatal clinic attendees who later deliver in a study facility will be estimated. To assess sustainability, we will assess the intervention adoption, implementation, and maintenance. Finally, we will evaluate intervention cost-effectiveness and develop a national costed implementation plan. Discussion: Adaptability and sustainability within government facilities are critical aspects of our proposal, and the MOH and other local stakeholders will be engaged from the outset. We expect to deliver PPFP counseling to over 21,000 women/couples during the project period. We hypothesize that the intervention will significantly increase the number of stakeholders engaged, PPFP providers and promoters trained, couples/clients receiving information about PPFP, and PPLARC uptake comparing intervention versus standard of care. We expect PPFP client satisfaction will be high. Finally, we also hypothesize that the intervention will be cost-saving relative to the standard of care. This intervention could dramatically reduce unintended pregnancy and abortion, as well as improve maternal and newborn health. Our PPFP implementation model is designed to be replicable and expandable to other countries in the region which similarly have a high unmet need for PPFP. Trial registration: ClinicalTrials.gov NCT05056545. Registered on 31 March 2022