Faculty Bibliography

Background/Purpose : DLE is a rare, disfiguring disorder in children. Small retrospective studies suggest 20-25% of patients progress to SLE. Progression risk factors are poorly understood, but DLE has been associated with delay in SLE diagnosis and reduced access to care. This multicenter retrospective cohort study aimed to describe baseline characteristics and clinical phenotypes of pediatric DLE patients at diagnosis. Methods : Medical records at eighteen sites were reviewed for pediatric dermatology and rheumatology patients with DLE. For inclusion, patients required clinical and/or histopathologic findings consistent with DLE. Baseline data were collected at the first documented visit including sociodemographic data, ACR/SLICC SLE criteria (i.e. DLE+SLE), date of DLE onset/diagnosis, DLE distribution, family history, comorbidities, and treatment. Outcome variables included ACR (primary outcome) /SLICC SLE criteria. Rates of progression from skin-limited DLE (DLE) to SLE (DLE+SLE) were evaluated. Analysis included descriptive statistics, chi-square and Wilcoxon tests. Results : Out of >1,000 patients reviewed, 441 met inclusion criteria. The cohort was predominantly female (72%) and racially/ethnically diverse (Table 1). A minority presented at baseline with SLE based on ACR and SLICC criteria, respectively (n=165, 37%; n=183, 42%). DLE+SLE patients were older (median 13.7y vs 10.2y) with shorter time from DLE onset to diagnosis (median 2 mo vs 7 mo), compared to DLE patients (p< 0.001). DLE patients presented with low incidence of renal involvement, serositis, seizures or psychosis (p< 0.001, Table 2). DLE+SLE patients had more positive serologies and higher-titer ANAs (p< 0.001, Table 3), although 5% were ANA negative. Among 231 DLE patients with31 follow up visit, median follow-up was 2.7 y (range 0-13.9y) with 747 total subject-years. Progression to SLE occurred in 20% and 25% of patients based on ACR and SLICC criteria, respectively. Conclusion : To date, this is the largest investigation of pediatric DLE. Patients with DLE+SLE were most likely to present in adolescence with abnormal serologies and end-organ disease. Progression of DLE to SLE occurred at rates consistent with previous literature. All patients with DLE require SLE surveillance at diagnosis and regular follow-up, particularly during adolescence. Limitations include the retrospective study design with potential for misclassification, and analysis restricted to the baseline visit. Further analysis of follow up visits will evaluate for baseline risk factors and biomarkers of evolving SLE, as well as timing of progression, identifying DLE patients at highest risk for systemic disease

Background: Newly recruited clinicians have heterogeneous Backgrounds and experiences and need a substantive introduction to their new institution's patient communication expectations and safety culture and standards for clinician performance. We describe a unique onboarding program designed to ensure that newly hired clinicians receive actionable, behaviorally specific feedback from the patients' perspective to support a satisfying transition to the new work environment, enhance patient experience and reduce the need to punitively react to complaints once they have started.
Method(s): During the 2-hour onboarding, participants complete 3, 10-minute Objective Structured Clinical Exam cases designed to assess how they address a medical error, manage the patient's discharge goals of care, and respond to an impaired learner. During each encounter, participants interact with highly trained Standardized Patients (SPs) or Standardized Learners (SLs) who use behaviorally-anchored checklists to evaluate provider performance on communication and case-specific skills. Following each encounter, participants complete a self-assessment while the SPs/SLs complete a behavior-specific checklist, after which the two discuss the encounter and the SL/SP provides confidential and actionable feedback. At the end, participants are encouraged to set individual learning goals to implement in their daily work, complete a program evaluation, and engage in a debrief with experienced facilitators. Participants also receive their SP checklists in addition to an institutional guide containing relevant resources and contacts.
Result(s): Over 2 years, 57 faculty members representing 6 clinical sites participated in the onboarding program. They are heterogeneous with respect to general and case specific performance on these SP/SL cases. For example, 86% adequately elicited the SP/SLs story during the discharge case compared to 66% in the other two cases, 77% addressed pain management (a key patient goal), while 44% did not discuss important medication side effects. Participants have universally found this onboarding to be useful and relevant; 98% agreed/strongly agreed that the program was an effective way to reinforce good habits in patient and learner communication, 96% felt it enhanced confidence about their ability to communicate effectively, and 96% felt it reinforced the institutional culture of safety. All 56 participants who completed the evaluation agreed/strongly agreed that the event was engaging and well-designed, and 93% felt it was a good use of their time and would recommend the program.
Conclusion(s): Traditional orientations are not well recalled and do not address knowledge and skills in real-time. Although it requires additional resources, participants are enthusiastic about our low-stakes introduction to the institution's expectations. This program sets high standards and introduces a new model for skills-based onboarding which may lead to measurably improved patient outcomes

The Accreditation Council for Graduate Medical Education requires integration of quality improvement and patient safety education into graduate medical education (GME). The authors created a novel "Swiss Cheese Conference" to bridge the gap between GME and hospital patient safety initiatives. Residents investigate a specific patient safety event and lead a monthly multidisciplinary conference about the case. Resident presenters introduce the Swiss cheese model, present the case and their findings, and teach a patient safety topic. In groups, participants identify contributing factors and discuss how to prevent similar events. Presenters and stakeholders immediately huddle to identify next steps. The Swiss Cheese Conference has increased participants' comfort analyzing safety issues from a systems perspective, utilizing the electronic reporting system, and launching patient safety initiatives. The Swiss Cheese Conference is a successful multidisciplinary model that engages GME trainees by integrating resident-led, case-based quality improvement education with creation of patient safety initiatives.

BACKGROUND: Prior To March 2016 interdisciplinary rounds were held in the back of the nurses' stations on two inpatient medial units. Patients satisfaction scores around the discharge process and communication were consistently low. Medical director and nurse manager dyad leadership teams redesigned interdisciplinary rounds to improve communication between the patient and the health care team. METHODS: With the At-The-Bedside Walking Interdisciplinary Rounds initiative, every patient is visited by the entire interdisciplinary team each afternoon. The interdisciplinary team consists of the Hospitalist, the unit nurse manager, the bedside nurse, the care manager, the social worker and the medicine resident. Each visit takes 3-5 min and is led by the resident, who starts by introducing everymember of the team. Importantly, the patient is surrounded by every person on the team (a design to be literally and figuratively patient centric). Rounds are structured around four simple questions designed to effectively communicate the diagnosis, the milestones for discharge and the discharge disposition and date. Updated information is written on the patient's white board, located at the foot of the bed. Patients and caregivers have an opportunity to ask clarifying questions. Moreover, the patient can experience first-hand the collaboration that takes place amongst the team members with a streamlined and unified message. The team will use a video language access network for interpreter services for those patients who feel more comfortable speaking in their native language. For those patients who prefer not to discuss discharge planning in large groups, members of the team will return individually. RESULTS: When comparing pre (Q1CY2016, N= 81) and post (Q2CY2016, N= 80) intervention top box HCAHPS patient satisfaction scores, the results were mixed. Care transitions improved slightly from46 to 48 and communication with doctors increased from74 to 75%. Communication with nurses decreased from 78 to 75%. Discharge information, however, improved from 78 to 84%. CONCLUSIONS: While these early results are disappointing, we believe that patient centered care starts with streamlined communication at the bedside with the interdisciplinary team. We will be tweaking how to better contextualize these rounds for patients in the future

BACKGROUND: The CDC reports that 5% of hospitalized patients develop hospital acquired infections, which are responsible for 100,000 deaths annually. Poor hand hygiene compliance on the Medicine service placed patients at higher risk for infection and was the impetus for our Clean Hands Save Lives Initiative. METHODS: The Clean Hands Save Lives initiative was a triple-prong systems based strategy that required the leadership of the medical director and nurse manager and the engagement of the entire floor. First, unit leadership dedicated a portion of the the morning unit-based safety huddle to identify daily hand washing champions. Each day a new group of champions was identified, including 2 nurses, one one floor patient unit technician, and two physicians. Champions were responsible for reinforcing correct hand hygiene procedures in real time, promoting a culture of "if you see something, say something."Each week, 35 different health care providers were hand-hygiene champions, hardwiring best practice. Second, proper hand hygiene procedures were reinforced at the safety huddle several times a week and Purell dispensers were installed outside every patient room. Third, an email was sent to each team member regarding the hand hygiene initiative at the start of each rotation. Real time feedback on hand hygiene technique was provided by unit leadership. RESULTS: At the start of the initiative in quarter 1 of 2015, hand hygiene compliance for the 17 East Medical Unit was at 64%. By quarter 1 of 2016, hand hygiene compliance was at 93 and has remained above 90% for the past 4 quarters (Figure 1). CONCLUSIONS: Successful implementation of our Clean Hands Save Lives Initiative on a hospitalist led medicine unit was due in large part to making this a daily focus of all members of the team, leading to unit culture change. The interdisciplinary approach to the problem, daily reinforcement of the initiative, regular education of unit staff and ease of practicing proper hand hygiene all were contributing factors to its success and sustainability. The initiative is now practiced in all units on the Medicine service

BACKGROUND: Patients admitted to the Medicine Service from the Emergency Department (ED) at times when no beds are available pose a particular challenge to workflow, staffing and patient care. Due to the expansion of our clinically integrated network and recruitment of high-volume surgical teams, the hospital daily census surged, causing an increase in the average number of patients admitted to the hospital but physically located in the ED. The Hospitalist program was charged with developing a coordinated strategy to manage these patients METHODS: In 2015, we created an ED Hospitalist Team composed of a hospitalist and a nurse practitioner to care for patients admitted to the Medicine Service but awaiting beds on the floor. We purposely created this model so that the medicine teams could focus on caring for patients on their own units and not disrupt their workflow by traveling to the ED. We created a Checklist (Figure 1) for this ED Hospitalist Team to ensure that protocols and pathways were followed, just as they would be on the medical floor. We partnered with ED leadership to identify workspace and standardize handoffs, as well as with leadership from Social Work to proactively identify complex situations starting on hospital day 0. Patients requiring ICU level care were excluded (as intensivists were involved immediately). All patients admitted to the medicine service (i.e. patients who would ultimately be cared for on the general medicine, cardiac, oncologic or hepatobiliary teams), were cared for by the ED Hospitalist team until a bed became available on the appropriate unit. RESULTS: The average number of patients admitted to the hospital, but physically located in the ED increased from 2.1/day in April 2015 to 14.5/ day in October 2016. At least 70% of these patients were admitted to the Medicine Service. Even with this increase, the observed to expected length of stay (O:E LOS) for Medicine patients remained at 0.92. The discharge before noon rate increased from 39 to 43% during this same period. CONCLUSIONS: We have demonstrated a strategic and sustainable approach for managing a growing number of patients who are admitted to the Medicine Service but physically located in the ED. By consolidating our resources in creating an ED Hospitalist team, we are able to maintain our workflow efficiencies on the floor, as demonstrated by the O:E LOS and our improved discharge before noon rate. (Figure Presented)