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Clinical Pharmacist Led Medication Reconciliation Program in an Emergency Department Observation Unit

Cardinale, Stephanie; Saraon, Tajinderpal; Lodoe, Nawang; Alshehry, Abdullah; Raffoul, Melanie; Caspers, Christopher; Vider, Etty
OBJECTIVES/OBJECTIVE:Medication reconciliation is the process of comparing a patient's hospital medication orders to all of the medications that the patient has been taking prior to admission. The primary aim of this study was to evaluate the effectiveness of pharmacist-led medication reconciliation in reducing ED visit rates. The secondary aim of this study was to evaluate if a clinical pharmacist reduces medication errors in an ED observation unit (OBS). METHODS:This was a retrospective, IRB approved, chart review conducted at New York University Langone Health-Tisch Hospital. The study defines the year before a clinical pharmacist was present on the unit (July 5, 2016 through July 4, 2017) as the control group and the first year a clinical pharmacist was present on the unit (July 5, 2017 through July 4, 2018) as the intervention group. The primary endpoint was 30-day ED re-visits. The secondary endpoints were 60-and 90-day ED re-visits, number, type and severity of medication history and reconciliation discrepancies. RESULTS:The primary endpoint of 30-day ED visits occurred in 153 patients in the no pharmacist group and 88 patients in the OBS clinical pharmacist group (19.1% vs 9.9%, P < .00001). The secondary endpoint of 60- day ED visits occurred in 53 patients in the no pharmacist group and 39 patients in the OBS clinical pharmacist group (8.2% vs 4.9%, P = .01). The secondary endpoint of 90- day ED visits occurred in 31 patients in the no pharmacist group and 26 patients in the OBS clinical pharmacist group (5.2% vs 3.4%, P = .01). CONCLUSION/CONCLUSIONS:The benefits of having a clinical pharmacist perform medication reconciliation are highlighted by the reduction in ED visits, cost savings, and the prolific amount of errors corrected.
PMID: 35465767
ISSN: 1531-1937
CID: 5205422

Implementation of the Surviving Sepsis Campaign one-hour bundle in a short stay unit: A quality improvement project

Gripp, Lauren; Raffoul, Melanie; Milner, Kerry A
OBJECTIVE:To improve timely sepsis care by implementing the 2018 Surviving Sepsis Campaign one-hour interventions. DESIGN/METHODS:Ten-month prospective quality improvement project. SETTING/METHODS:A 38-bed short stay unit within an 800-bed hospital in New York City. PARTICIPANTS/METHODS:Patients admitted to the short stay unit who screened positive for sepsis. INTERVENTION/METHODS:A sepsis implementation tool was created from the 2018 Surviving Sepsis Campaign guidelines. Sepsis champions delivered education on sepsis recognition, treatment, and management, and the sepsis implementation tool to the healthcare staff. PROCESS AND OUTCOME MEASURES/UNASSIGNED:Time to first lactate, blood cultures × 2, antibiotic administration, length of stay and mortality were tracked weekly for five months. RESULTS:From May 6, 2019 to October 1, 2019, 32 patients were diagnosed with sepsis. Initial lactate and blood cultures were completed on every patient within 1one-hour of sepsis diagnosis. Administration of antibiotics within one-hour reached 100% after week four and was sustained. CONCLUSION/CONCLUSIONS:Use of a registered nurse-initiated sepsis implementation tool in a short stay unit led to the completion of blood cultures, initial lactate, and antibiotic administration within one-hour. Key factors to support this practice improvement were increasing registered nurse, physician and physician assistant sepsis knowledge, registered nurse and physician/physician assistant early collaboration, increased staffing and intravenous access equipment.
PMID: 33358134
ISSN: 1532-4036
CID: 4762252

In Reply to Fyfe and Douglass

Raffoul, Melanie; Bartlett-Esquilant, Gillian; Phillips, Robert L
PMID: 32097146
ISSN: 1938-808x
CID: 4324262

Recruiting and Training a Health Professions Workforce to Meet the Needs of Tomorrow's Health Care System

Raffoul, Melanie; Bartlett-Esquilant, Gillian; Phillips, Robert L
The quality of any health care system depends on the caliber, enthusiasm, and diversity of the workforce. Yet, workforce research often focuses on the number and type of health professionals needed and anticipated shortages compared with anticipated needs. These projections do not address whether the workforce will have the requisite social, intellectual, cultural, and emotional capital needed to deliver care in an increasingly complex health care system.Building a workforce that can deliver care in such a system begins by recruiting individuals with the requisite knowledge, skills, and attributes. To address this and other workforce needs, the authors argue that health professions education programs must make purposeful changes to their admissions criteria, such as focusing on emotional intelligence and diversity and recruiting students from the communities where they will return to work; partner with communities; ensure that accreditation systems support these goals of fostering diversity; recruit students who can bridge the gap between public health and health care; and invest in health professions education research.In this article, they contemplate how health professions education programs can recruit and educate talented health professionals to create a high performing workforce that is capable of serving in the complex health care system of tomorrow. They provide examples of successful programs to highlight the potential effects of their recommendations.
PMID: 30681446
ISSN: 1938-808x
CID: 3610762

Increased Public Accountability for Hospital Nonprofit Status: Potential Impacts on Residency Positions

Raffoul, Melanie C; Phillips, Robert L
BACKGROUND:The Institute of Medicine recently called for greater graduate medical education (GME) accountability for meeting the workforce needs of the nation. The Affordable Care Act expanded community health needs assessment (CHNA) requirements for nonprofit and tax-exempt hospitals to include community assessment, intervention, and evaluation every 3 years but did not specify details about workforce. Texas receives relatively little federal GME funding but has used Medicaid waivers to support GME expansion. The objective of this article was to examine Texas CHNAs and regional health partnership (RHP) plans to determine to what extent they identify community workforce need or include targeted GME changes or expansion since the enactment of the Affordable Care Act and the revised Internal Revenue Service requirements for CHNAs. METHODS:Texas hospitals (n = 61) received federal GME dollars during the study period. Most of these hospitals completed a CHNA; nearly all hospitals receiving federal GME dollars but not mandated to complete a CHNA participated in similar state-based RHP plans. The 20 RHPs included assessments and intervention proposals under a 1115 Medicaid waiver. Every CHNA and RHP was reviewed for any mention of GME-related needs or interventions. The latest available CHNAs and RHPs were reviewed in 2015. All CHNA and RHP plans were dated 2011 to 2015. RESULTS:Of the 38 hospital CHNAs, 26 identified a workforce need in primary care, 34 in mental health, and 17 in subspecialty care. A total of 36 CHNAs included implementation plans, of which 3 planned to address the primary care workforce need through an increase in GME funding, 1 planned to do so for psychiatry training, and 1 for subspecialty training. Of the 20 RHPs, 18 identified workforce needs in primary care, 20 in mental health, and 15 in subspecialty training. Five RHPs proposed to increase GME funding for primary care, 3 for psychiatry, and 1 for subspecialty care. CONCLUSIONS:Hospital CHNAs and other regional health assessments could be potentially strategic mechanisms to assess community needs as well as GME accountability in light of community needs and to guide GME expansion more strategically. Internal Revenue Service guidance regarding CHNAs could include workforce needs assessment and intervention requirements. Preference for future Medicaid or Medicare GME funding expansion could potentially favor states that use CHNAs or RHPs to identify workforce needs and track outcomes of related interventions.
PMID: 28720635
ISSN: 1558-7118
CID: 3071492

Scheduling followup for patients with low-risk chest pain: Efforts to decrease unscheduled return rates to the emergency department and improve outpatient followup [Meeting Abstract]

Nanayakkara, S; Caspers, C; Raffoul, M; Ty, D V
Background: In our ED Observation Unit (OU), chest pain patients comprise 16.4% of 72-hour unscheduled revisits among patients with specific diagnosis protocols. Given that most returning chest pain patients are discharged, these patients' complaints could potentially be addressed by a primary care provider or cardiologist. We aimed to reduce ED re-presentations and improve rates of post-discharge evaluation and follow up by scheduling primary care or cardiology follow up appointments. Methods: All consecutive patients admitted to the ED OU during July 2016 under the 'chest pain' protocol were offered the services of a medical staff facilitator (MSF) to schedule a follow up appointment within 72 hours of discharge from the observation unit. The rate of return to the ED was evaluated by chart review. Results: 49 chest pain protocol patients were placed in the OU. 15 patients were excluded due to incomplete charting (n=1), lack of chest pain noted in patient's initial history (n=11) and inpatient admission from the observation unit (n=3). 34 patient charts were reviewed for follow up instructions and rate of return to the ED. 38% of patients overall had a follow up appointment within 72 hours of discharge. For patients using a MSF the rate of scheduled follow up was 78% (n=7/9). For patients not using a MSF, the rate of scheduled follow up was 24% (n=6/25). There was no unexpected return to the ED within 72 hours for any patient (n=0/34). Since the conclusion of the pilot, by-phone follow up with patients who participated in this study was conducted. Of those patients, four reported they followed up with a cardiologist of PCP within 72 hours of being discharged, while two reported they did not. Conclusion: Patients using a MSF had a higher rate of 72-hour follow up (78% vs. 24%). Further study regarding effect of timely follow up care is being designed, as this pilot indicated that scheduled follow-up prior to discharge can result in more timely follow up which may decrease rates of unscheduled ED return. Education of all care providers regarding this resource would help optimize overall follow-up care, as patients are more likely to arrange an outpatient reassessment visit when utilizing a medical staff facilitator
EMBASE:616279992
ISSN: 1553-2712
CID: 2579972

Office Visits for Women Aged 45-64 Years According to Physician Specialties

Raffoul, Melanie C; Petterson, Stephen M; Rayburn, William F; Wingrove, Peter; Bazemore, Andrew W
BACKGROUND:The increase in access to healthcare through the Affordable Care Act highlights the need to track where women seek their office-based care. The objectives of this study were to examine the types of physicians sought by women beyond their customary reproductive years and before being elderly. METHODS:This retrospective cohort study involved an analysis of national data from the Medical Expenditure Panel Survey (MEPS) between 2002 and 2012. Women between 45 and 64 years old (n = 44,830) were interviewed, and reviews of corresponding office visits (n = 330,114) were undertaken. RESULTS:In 2002, women aged 45-64 years (62%) went to a family or internal medicine physician only and this reached 72% in 2012. The percentage of women who went to an obstetrician-gynecologist (ob-gyn) only decreased from 20% in 2002 to 12% in 2012. Most went to a family physician or general internist for a general checkup or for diagnosis or treatment. By contrast, visits to ob-gyn physicians were predominantly for general checkups. Those who went to an ob-gyn office were more likely to have a higher family income, live in the Northeast, and describe their overall health as being excellent. CONCLUSIONS:Women aged 45-64 years were substantially more likely to obtain care exclusively at offices of family physicians or general internists than of ob-gyn physicians. Overlap in care provided at more than one physician's office requires continued surveillance in minimizing redundant cost and optimizing resource utilization.
PMID: 27585369
ISSN: 1931-843x
CID: 3098842

Graduates of Teaching Health Centers Are More Likely to Enter Practice in the Primary Care Safety Net

Bazemore, Andrew; Wingrove, Peter; Petterson, Stephen; Peterson, Lars; Raffoul, Melanie; Phillips, Robert L Jr
PMID: 26554280
ISSN: 1532-0650
CID: 1934202

Cultural Competence Education for Health Care Professionals

Raffoul, Melanie; Lin, Kenneth W
ISI:000353249800003
ISSN: 1532-0650
CID: 2373972

Smaller Practices Are Less Likely to Report PCMH Certification

Raffoul, Melanie; Petterson, Stephen; Moore, Miranda; Bazemore, Andrew; Peterson, Lars
PMID: 25884741
ISSN: 1532-0650
CID: 1934222