Swimming With Sharks: Teaching Residents Value-Based Medicine and Quality Improvement Through Resident-Pitched Projects
Background/UNASSIGNED:To create meaningful quality improvement (QI) curricula for graduate medical education (GME) trainees, institutions strive to improve coordination of QI curricula with hospital improvement infrastructure. Objective/UNASSIGNED:We created a curriculum to teach residents about QI and value-based medicine (VBM) and assessed curricular effectiveness. Methods/UNASSIGNED:We designed a 2-week required curriculum for internal medicine residents at a large academic program. After participating in basic skills workshops, trainees developed QI/VBM project ideas with faculty and nonclinical support and pitched them to hospital leaders at the end of the rotation. Pre-post and 1-year follow-up surveys were conducted for residents to self-assess knowledge, attitudes, and skills, participation in QI/VBM projects, and career intentions. We tracked QI/VBM project implementation. Results/UNASSIGNED:â€‰<â€‰.01). Four of 19 projects have been implemented. At 1 year, 95% of residents had presented a quality/value poster presentation, 44% were involved in QI/VBM beyond required rotations, and 26% plan to pursue careers focused on improving quality, safety, or value. Conclusions/UNASSIGNED:Our project-based curriculum culminating in a project pitch to hospital leadership was acceptable to GME trainees, improved self-assessed skills sustained at 1 year, and resulted in successfully implemented QI/VBM projects.
Multi-lingual video consent for upper endoscopy and colonoscopy [Meeting Abstract]
INTRODUCTION: Informed consent involves a thorough understanding of procedural risks, benefits, and alternatives. Among patients with Limited English Proficiency (LEP) it is difficult to ascertain comprehension even with the use of a certified medical interpreter. Prior studies have demonstrated that use of video during informed consent improves patient comprehension relative to traditional verbal consent. This quality improvement initiative aims to improve patient comprehension of endoscopy and colonoscopy though utilization of an educational video in the patient's primary language as a component of informed consent.
METHOD(S): Short videos explaining the risks, benefits, and alternatives for endoscopy and colonoscopy were produced in English and Spanish. All patients underwent a traditional verbal consent process, with the use of a certified medical interpreter if indicated. A group also watched the educational video. Following either the video or the traditional verbal consent, the patients filled out a questionnaire in their preferred language to assess comprehension of the planned procedure and its risks, benefits, and alternatives.
RESULT(S): A total of 74 questionnaires were administered. Group 1 underwent traditional consent alone and group 2 watched the video prior to traditional consent. The colonoscopy cohort included 35 English-language and 11 Spanish-language patients; the endoscopy cohort included 21 English-language and 7 Spanish-language patients. The mean patient score on the colonoscopy questionnaire for group 2 was 77% compared with 54% for group 1 (P = 0.003). In the endoscopy cohort, group 2 also scored higher than group 1 (P = 0.0004). Among Spanishspeaking patients, group 2 had better comprehension scores than group 1 (86% vs 33%, P < 0.0005).
CONCLUSION(S): Our results demonstrate a significant improvement in patient comprehension with the use of video education as part of the consent for colonoscopy and endoscopy. This difference was most notable for Spanish-speaking patients. Future directions include translation of the video into additional languages and incorporation into the standard pre-procedure consent at our institution in order to improve quality of care for patients who are both language concordant and language discordant with their providers. (Figure Presented)
Gastric Solitary Fibrous Tumor Causing Upper Gastrointestinal Bleeding [Case Report]
We present an 81-year-old woman with remote breast cancer who presented with melena and hemorrhagic shock requiring intensive care hospitalization. Endoscopic evaluation showed a 5-cm pedunculated gastric mass with ulceration and friability. She underwent sleeve gastrectomy for definitive treatment of her bleeding. Pathology was consistent with a solitary fibrous tumor (SFT). There are only a few reported cases of gastric SFTs presenting with gastrointestinal bleeding. If a large brown/tan bleeding mass is identified on upper endoscopy, SFT should be considered.
The Swiss Cheese Conference: Integrating and Aligning Quality Improvement Education With Hospital Patient Safety Initiatives
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.
Corticosteroid use is not associated with decreased length of stay in patients hospitalized with crohn's associated small bowel obstruction [Meeting Abstract]
Background: Nearly one-half of Crohn's disease patients require bowel resection within the frst 10 years of disease (1). Small bowel obstruction (SBO) is the most common indication for surgery in Crohn's patients, followed by abscess and presence of fstulizing disease (2). Tere are little data regarding pharmacologic treatment of Crohn's-associated SBO with corticosteroids. In particular, the safety and efcacy of corticosteroids in treating inflammation in the setting of acute Crohn's SBO remains unclear. METHODS: Our group performed a retrospective chart review of patients admitted with Crohn's-disease associated SBO to our institution. Key variables examined included use of corticosteroids, length of stay, infectious complications, and short-term requirement for surgery. Inclusion criteria included adults (>18 years) who were not pregnant and carried a known diagnosis of Crohn's disease. Using the i2b2 search engine, patients admitted with the ICD10 diagnoses for Crohn's disease and a primary diagnosis of SBO were included. Analysis of outcomes was performed comparing patients who received steroids versus those who did not using t-statistics and chi-square analysis. RESULTS: Between 2015 and 2017, ffy-seven patients met inclusion criteria. Te majority (n=32, 56%) received no corticosteroids for the preceding three months nor during the admission for SBO, while the minority (n=25, 44%) did receive steroids. Te mean age of patients (45+/-19 years vs 46+/-18 years, P=0.92), and duration of Crohn's disease (14+/-13 years vs 14+/-12 years, P=0.93) did not differ between groups. C-reactive peptide (CRP) on admission did not differ between groups (23.9+/-17 vs 46.6+/-78, P=0.49). Eleven patients (19%) required surgery related to Crohn's disease during or within the three months following admission. Tere was no difference in requirement for surgery between groups. In multivariable logistic regression, the only factor associated with requirement for surgery was duration of Crohn's disease (P<0.05). Tere was no difference in duration of nasogastric tube placement, time to PO challenge, or length of hospital stay. Tere were no mortalities in either group and no difference in infectious complications afer discharge. CONCLUSION(S): Tese results suggest that corticosteroids are not associated with improved outcomes in patients with Crohn's associated SBO. Length of stay is not decreased due to use of corticosteroids. Te study is limited by its retrospective design and small sample size. However, future case-control or randomized clinical trials can examine the use of corticosteroids during acute Crohn's-associated SBO
Effect of multi-modal educational interventions to improve healthcare maintenance of IBD patients in an urban medical center [Meeting Abstract]
Background: Patients with inflammatory bowel disease (IBD) have many unique health maintenance needs and ofen require therapy necessitating close monitoring. Gastroenterologists ofen serve as the primary care provider for these patients and therefore must be familiar with the health maintenance needs of IBD patients. In this study, we investigated whether implementing a multi-modal educational intervention could improve providers' rates of addressing healthcare maintenance measures. METHODS: A retrospective chart review was performed in 2013-2014 on 208 IBD patients to determine adherence to performance practice measures. From February-April 2016, fellows received a recurring in-service lecture and an IBD clinic note template outlining the 2011 healthcare maintenance recommendations by the American Gastroenterological Association. An iBook was also introduced, which provided a comprehensive overview of IBD practice guidelines. Retrospective chart review was then performed 1 year aferwards. For each patient, performance measures were assessed in both pre-and post-intervention notes in the following categories: vaccinations, bone health, therapy-specifc maintenance, tobacco cessation, and cancer screening. Each performance measure was given a score of 0 (not addressed), 1 (addressed), or N/A (irrelevant to subject). Te primary outcome was improvement in rates of adherence to performance measures. Te adherence rates for pre-and post-intervention groups were compared using a chi-squared test. RESULTS: A total of 208 pre-intervention clinic visits and 40 post-intervention visits were included for analysis. Afer the interventions, the rate of healthcare maintenance measures addressed overall increased from 37% to 52% (P<.001) (Figure 1). Tere were statistically signifcant improvements in addressing bone health (29% to 63%, P<.001), vaccination (33% to 47%, P<.001), and therapy-specifc measures (53% to 74%, P=.01). Tere were no statistically signifcant changes in addressing cancer screening (66% to 58%, P=.19) or smoking (23% to 30%, P=.59). CONCLUSION(S): Te use of multiple educational interventions to enhance delivery of IBD healthcare maintenance resulted in improved adherence to healthcare maintenance measures. Targeted educational programs and a multi-modal approach may be an effective method for teaching GI fellows and reinforcing the importance of addressing these measures to optimize the care of their IBD patients
Development of interprofessional evidence based standard of care for prevention and treatment of mucositis, both inpatient and outpatient, adult and pediatric [Meeting Abstract]
Introduction Mucosal damage secondary to cancer therapy occurs in 30% of patients receiving standard chemotherapy and 80% of patients receiving high dose chemotherapy. Mucositis is painful, interferes with nutrition, hydration, and often causes delay or reduction in chemotherapy. 20%of CLABSIs at NYU Langone Health (NYULH) in 2015 were secondary to mucosal translocation Objectives The goal of the NYULH Interprofessional Mucositis Workgroup is to decrease the incidence of mucositis in adult and pediatric oncology patients. Methods An interprofessional team of inpatient and outpatient, adult and pediatric medical providers, dentists, nurse practitioners, nurses, pharmacists, and IT collaborated to develop a standardized NYULH mucositis guideline for prevention and treatment. Results An evidenced-based standardized guideline for mucositis prevention and treatment across adult and pediatric inpatient and outpatient was developed. Conclusions This project suggests that interprofessional collaboration is an effective strategy for development and implementation of a standardized guideline for both pediatric and adult inpatients and outpatients
Effect of a multi-modal educational intervention to improve healthcare maintenance of IBD patients in a GI fellow clinic in a large urban medical center [Meeting Abstract]
Introduction: Patients with inflammatory bowel disease (IBD) have many unique health maintenance needs and often require therapy necessitating close monitoring. Gastroenterologists often serve as the primary care provider for these patients and therefore must be familiar with the health maintenance needs of IBD patients. In this study, we investigated whether implementing a multimodal educational intervention could improve providers' rates of addressing healthcare maintenance measures. Methods: A retrospective chart review was performed in 2013-2014 on 208 IBD patients to determine adherence to performance practice measures. From February-April 2016, fellows received a recurring in-service lecture and an IBD clinic note template outlining the 2011 healthcare maintenance recommendations by the American Gastroenterological Association. An iBook was also introduced, which provided a comprehensive overview of IBD practice guidelines. Retrospective chart review was then performed 1 year afterwards. For each patient, performance measures were assessed in both pre- and post-intervention notes in the following categories: vaccinations, bone health, therapy-specific maintenance, tobacco cessation counseling, and cancer screening. Each performance measure was given a score of 0 (not addressed), 1 (addressed), or N/A (irrelevant to subject). The primary outcome was improvement in rates of adherence to performance measures. The adherence rates for pre- and post-intervention groups were compared using a chi-squared test. Results: A total of 208 pre-intervention clinic visits and 40 post-intervention visits were included for analysis. After the interventions, the rate of healthcare maintenance measures addressed overall increased from 37% to 52% (p < .001) (Figure 1). There were statistically significant improvements in addressing bone health (29% to 63%, p < .001), vaccination (33% to 47%, p < .001), and therapy-specific measures (53% to 74%, p=.01). There were no statistically significant changes in addressing cancer screening (66% to 58%, p=.19) or smoking (23% to 30%, p=.59). Conclusion: The use of multiple educational interventions to enhance delivery of IBD healthcare maintenance resulted in improved adherence to healthcare maintenance measures. Targeted educational programs and a multi-modal approach may be an effective method for teaching GI fellows and reinforcing the importance of addressing these measures to optimize the care of their IBD patients
Difficult populations : dysphagia/partial SBOs/ICDs/Pediatrics
Cham, Switzerland : Springer, 2017
A Longitudinal OSCE Experience: A Pilot of Progressive Testing to Assess Inflammatory Bowel Disease Training for Gastroenterology Fellows [Meeting Abstract]