Electronic Health Record Skills Workshop for Medical Students.

Introduction: The adoption of electronic health records (EHRs) presents new challenges for information gathering, documentation, and patient care. Medical students spend a significant amount of time using the EHR during their clerkship experiences and will continue to do so as they progress to residency. However, formal training varies between institutions and leaves gaps in data-gathering skills, documentation skills, and order entry-these three skills formed the basis for our learning objectives. We designed a workshop using a simulated EHR to teach these skills. Methods: We offered the workshop during a class-wide transition-to-internship course for senior medical students. After a brief didactic, students worked in small groups using a simulated EHR to complete cases addressing each of the three learning objectives. Faculty facilitators assisted groups and then guided a large-group discussion of the challenges encountered during the cases. Results: Twenty-five senior medical students attended the first optional workshop. Of these students, 66.7% recommended that the workshop continue to be included in the curriculum. Comments from those who recommended otherwise suggested that many of them would recommend the workshop if it used our local EHR (Epic). Correct answers to the factual questions increased for most questions between the pretest and the posttest. Confidence to perform all skills targeted in the learning objectives increased between the pretest and the posttest. Discussion: This EHR workshop was well received by senior medical students and increased confidence in EHR skills, including data gathering, documentation, and handling unsolicited information with a plan including order entry

We Are What We Pre-Attend To Be: Piloting a Pre-Attendingship Rotation in Hospital Medicine

Problem Definition New-to-practice attendings (NPTAs) lack readiness for independent practice Graduated autonomy – understood but not structurally enforced in residency training Curricular expectations not explicitly defined despite experiential differences between graduate training levels of PGY2 and PGY3 internal medicine residents Although residents achieve competencies established by the ACGME prior to graduation, NTPAs feel unprepared suggesting opportunities to change the clinical learning environment to increasehttps://jdc.jefferson.edu/medposters/1022/thumbnail.jp

Improving Rates of Nephrology Referral for Patients with Chronic Kidney Disease in Resident Clinic

According to the KDIGO (Kidney Disease Improving Global Outcomes), evaluation by a nephrologist is recommended for patients with CKD stage 4 or higher (corresponding to a GFR of 30 or lower). Studies have shown that patients who are not referred to a nephrologist or referred later suffer from increased complications of renal disease, accelerated progression to ESRD, and have an increased overall mortality rate. At Jefferson Hospital Ambulatory Practice (JHAP), we noted decreased rates of nephrology follow-up in our patients with chronic kidney disease stage 4 and 5. We identified that the most prevalent reason for the decreased referral rates is due to the lack of knowledge of the KDIGO guidelines. Our goals were to implement an intervention to educate our internal medicine residents and improve the referral rates for advanced chronic kidney disease in our practice

Patient Safety Escape Room: A Graduate Medical Education Simulation for Event Reporting.

Introduction: Although residents are on the front lines of patient care, they enter few formal patient safety reports on the adverse events and near misses they witness. Demonstrating the rationale and mechanics of reporting may improve this. Methods: We designed and implemented an escape room patient safety simulation to incorporate active learning, gamification, and adult learning theory into intern patient safety onboarding. Interns from all sponsoring institution programs participated, identifying, mitigating, and reporting a range of patient safety hazards. Props and faculty time were the major resources required. Results: One hundred twenty interns participated in this simulation in June 2018. Forty-one percent reported previous training on reporting errors, and only 5% had previously entered an event report. Average confidence in ability to identify patient safety hazards improved after the simulation from 6.35 to 8.00 on a 10-point rating scale. The simulation was rated as relevant or highly relevant to practice by 96% of interns. Discussion: Several factors contribute to a low error-reporting rate among house staff. We developed a simulation modeled on popular escape room activities to increase awareness of safety hazards and ensure familiarity with the actual online reporting system our interns will use in the clinical environment

1,000 conversations I\u27d rather have than that one: A qualitative study of prescriber experiences with opioids and the impact of a prescription drug monitoring program.

BACKGROUND: Prescription Drug Monitoring Programs (PDMPs) have shown impacts on a number of opioid-related outcomes but their role in clinician emotional experience of opioid prescribing has not been studied. OBJECTIVES: This study explores the impact of PDMPs on clinician attitudes toward and comfort with opioid prescribing, their satisfaction with patient interactions involving discussion of opioid prescriptions, and their recognition of opioid use disorder (OUD) and ability to refer patients to treatment. METHODS: Researchers conducted semi-structured interviews with five physicians and two nurse practitioners from a variety of specialties and practice environments. RESULTS: Many participants reported negative emotions surrounding opioid-related patient encounters, with decreased anxiety related to PDMP availability. These effects were less pronounced with clinicians who had greater opioid prescribing experience (either longer careers or higher-volume pain practices). Many participants felt uncomfortable around opioid prescribing. Data from the PDMP often changed prescribing practices, sometimes leading to greater comfort writing a prescription that might have felt riskier without PDMP data. Clinicians easily recognized patient behaviors, symptoms, and prescription requests suggesting that opioid-related adverse events were accumulating, but did not usually apply a label of OUD to these situations. PDMP findings occasionally contributed to a diagnosis and treatment referral for OUD. CONCLUSIONS: PDMP data is part of a nuanced approach to prescribing opioids. The objectivity of the data may be helpful in mitigating clinician negative emotions that are common around opioid therapy

Improving Inpatient Management of Opioid Use Disorder

Research Question: What aspects of successful OUD treatment teams are most needed at Thomas Jefferson

Medication Initiation, Patient-directed Discharges, and Hospital Readmissions Before and After Implementing Guidelines for Opioid Withdrawal Management

OBJECTIVES: Rising rates of hospitalization for patients with opioid use disorder (OUD) result in high rates of patient-directed discharge (PDD, also called discharge against medical advice ) and 30-day readmissions. Interdisciplinary addiction consult services are an emerging criterion standard to improve care for these patients, but these services are resource- and expertise-intensive. A set of withdrawal guidelines was developed to guide generalists in caring for patients with opioid withdrawal at a hospital without an addiction consult service. METHODS: Retrospective chart review was performed to determine PDD, 30-day readmission, and psychiatry consult rates for hospitalized patients with OUD during periods before (July 1, 2017, to March 31, 2018) and after (January 1, 2019, to July 31, 2019) the withdrawal guidelines were implemented. Information on the provision of opioid agonist therapy (OAT) was also obtained. RESULTS: Use of OAT in patients with OUD increased significantly after guideline introduction, from 23.3% to 64.8% ( P \u3c 0.001). Patient-directed discharge did not change, remaining at 14% before and after. Thirty-day readmissions increased 12.4% to 15.7% ( P = 0.05065). Receiving any OAT was associated with increased PDD and readmission, but only within the postintervention cohort. CONCLUSIONS: A guideline to facilitate generalist management of opioid withdrawal in hospitalized patients improved the process of care, increasing the use of OAT and decreasing workload on the psychiatry consult services. Although increased inpatient OAT has been previously shown to decrease PDD, in this study PDD and readmission rates did not improve. Guidelines may be insufficient to impact these outcomes

Hawks and Doves: Perceptions and Reality of Faculty Evaluations

OBJECTIVES Internal medicine clerkship grades are important for residency selection, but inconsistencies between evaluator ratings threaten their ability to accurately represent student performance and perceived fairness. Clerkship grading committees are recommended as best practice, but the mechanisms by which they promote accuracy and fairness are not certain. The ability of a committee to reliably assess and account for grading stringency of individual evaluators has not been previously studied. METHODS This is a retrospective analysis of evaluations completed by faculty considered to be stringent, lenient, or neutral graders by members of a grading committee of a single medical college. Faculty evaluations were assessed for differences in ratings on individual skills and recommendations for final grade between perceived stringency categories. Logistic regression was used to determine if actual assigned ratings varied based on perceived faculty's grading stringency category. RESULTS “Easy graders” consistently had the highest probability of awarding an above-average rating, and “hard graders” consistently had the lowest probability of awarding an above-average rating, though this finding only reached statistical significance only for 2 of 8 questions on the evaluation form ( P  = .033 and P  = .001). Odds ratios of assigning a higher final suggested grade followed the expected pattern (higher for “easy” and “neutral” compared to “hard,” higher for “easy” compared to “neutral”) but did not reach statistical significance. CONCLUSIONS Perceived differences in faculty grading stringency have basis in reality for clerkship evaluation elements. However, final grades recommended by faculty perceived as “stringent” or “lenient” did not differ. Perceptions of “hawks” and “doves” are not just lore but may not have implications for students’ final grades. Continued research to describe the “hawk and dove effect” will be crucial to enable assessment of local grading variation and empower local educational leadership to correct, but not overcorrect, for this effect to maintain fairness in student evaluations

Use of Naltrexone for Alcohol Use Disorder: Closing The Gap in Inpatient Initiation

Project AIM: increase the prescribing of this medication as an inpatient to ideally provide more support to patients with alcohol use disorde