From the Director
Hello everyone! First, a FINAL thank you to the entire program for an amazing recruitment effort! A special thanks to Erin Payne and Dave Butterly for their phenomenal work putting together fantastic recruitment days for our applicants, and to Lynsey Michnowicz, Lauren Dincher, Jen Averitt and Randy Heffelfinger for the on the scene and behind the scenes help. Additional thanks to our fantastic chiefs and APDs for coming in early, talking with applicants and helping us show them that we are the best place to do residency! Our ACRs (Jim Gentry, Lindsay Boole, Chris Hostler and Mandar Aras) were extremely helpful in hanging out with applicants as they waited for interviews and organizing reports and chairs conferences, taking applicants to rounds and stepping in to give tours. Thanks to our Gen Med SARs and interns for hosting applicants on rounds, and also to all those who did tours and resident share (including Jesse Tucker, Adrienne Belasco and Lindsay Boole for Friday’s share). I know many of you have communicated with the applicants that you know from med school and that is much appreciated! Can’t wait to bring in a new outstanding intern class.
Kudos this week go to Chris Merrick from a family he cared for at the DVAMC (thanks Mike Cicale for sending this in!) and to Myles Nickolich from a 9300 family (thanks to Chris Jones for sending this in!). Sneha Vakamudi gave an outstanding chair’s conference on Friday, and we had really great audience participation, with Audrey Metz leading the discussion. Also to Marcus Ruopp and Jenn Rymer for working on the Discharge Rapid Improvement Project with Jon Bae and team. Other kudos to Ryan Huey for helping DOC residents identify patient panels in Maestro, to Adrienne Belasco, Marcus Ruopp, Andy Mumm and Dinushika Mohogitte for spear-heading the PCP continuity subgroup of DOC Kempner Stead (B) and to Adrienne Belasco and Marcus Ruopp for creating a PCP “owner’s bill of rights” (thanks also to Dani Zipkin for letting us know about these great efforts)!
Do you want to know how the DOC redesign efforts of last year are working? Word is they are PHENOMENAL! Talk to Alex Cho for more details, and great work on the parts of the entire DOC team! This ongoing effort really exemplifies the mission to care for our patients in the best possible way.
Stephen Bergin and I got the opportunity to visit PRIME clinic this week. We are looking forward to having the DRH ACR visit PRIME to co-precept with the great attendings there, and to share best practices between the DOC and PRIME. Dr. Patel will be contacting many of the PRIME residents to meet and work together to enhance the PRIME experience for residents and patients.
Congratulations to Chris and Carol Hostler on the birth of Cameron Hostler, the newest VA Jet! I don’t think they make Jets jerseys in newborn size, but I am sure he will have his share of American flag onesies!
Please take the time to fill out your ACGME survey! We are inching towards the required 70% mark, and I appreciate all who have taken time to log in and do the survey. We have until FEB 16th, so please check your email, log in and fill out the survey!
Pubmed from the program this week goes to Tim Mercer, who is one of several residents who will be presenting at the upcoming Society of Hospital Medicine meeting (others to follow in subsequent Med Res News!). Tim’s poster is THE HIGHEST UTILIZERS OF CARE: INDIVIDUALIZED CARE PLANS TO COORDINATE CARE, IMPROVE HEALTH CARE SERVICE UTILIZATION AND REDUCE COSTS AT AN ACADEMIC TERTIARY CARE CENTER.
Have a great week, (Subliminal message: fill out your ACGME survey), and stay warm!
VA Jets Recruit Early!
“Cameron David Hostler, born at 8:19 pm. Mom and baby are doing great!”
What Did I Read This Week?
“Submitted by Krish Patel, MD.”
Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle. JAMA.2013;310(21):2262-2270. Dec 4 2013
Why I read this: It’s been really amazing to reflect on the increasing awareness and focus on quality improvement that has taken place in the program since my intern year. Through the tremendous efforts of our program leadership and Jon Bae’s undying enthusiasm (yes Jon I promise I did all my QI modules!!!) thinking about and finding opportunities for QI has really become an integral aspect of our day-to-day experiences. Handoffs are a great example of such a QI opportunity. As work hour changes have shaped changes in our care models, we have all been increasingly aware that the numbers of patient handoffs and potential adverse events related to handoffs have increased. The AHRQ (Agency for Healthcare Research and Quality) and ACGME have both identified improving handoffs as an important national effort and the ACGME now requires residency programs to provide formal handoff instruction. This issue of improving handoffs is not unique to our program and as we navigate the challenges posed by increasing numbers of handoffs I’ve been wondering what other institutions have been doing to meet the challenge. To date, there have been a number of different strategies assessed in the literature to improve handoff processes but the data from prior studies have been mixed and ultimately the impact of these strategies on actual patient outcomes is at best unclear. This study was recently published in JAMA and is a bit more robust in terms of study design and outcomes reported than some of the prior studies.
Background: This observational study out of Boston Children’s Hospital sought to bundle a number of previously studied strategies for improving handoffs into a single standardized intervention and assess outcomes in terms of adverse events and medical errors pre and post intervention. The study took place on two different pediatrics units. Both units had a mix of high complexity and subspecialty patients. It included PGY1 and PGY3 trainees rotating on the two units over a roughly 6-month period of time (July 2009 to Jan 2010). The handoff intervention (or bundle) that was implemented combined communication training, use of the SIGNOUT mnemonic, and modifications to handoff environment to minimize interruptions during handoffs (quiet dedicated space etc.). Furthermore, one of the two units incorporated use of a partially EMR generated handoff tool (similar to our Maestro generated signoff reports) which included auto-imported variables such as vitals, meds, problem list, code status etc. I won’t go into the nitty gritty details of how adverse events and medical errors were observed, collected, and reported, but suffice to say it was a fairly rigorous process that adhered to accepted standards used in the medical safety literature. It even included independent blinded review of all adverse events and medical errors reported by the initial study personnel. In addition to following patient safety outcomes, the study also assessed resident workflow patterns (i.e. time spent on various tasks) to determine whether the bundle might have a negative impact on typical resident workflow.
This table summarizes the major primary outcome: there was a statistically significant reduction in overall medical error rates from 33.8 per 100 admissions pre intervention to 18.3 per 100 admissions and a significant decrease in errors classified as adverse or potentially adverse events (clinically meaningful). As you would expect, errors classified as non-preventable did not differ pre and post intervention. Most of the errors reported in the study were related to medications (~77%). Also, the intervention did not appear to adversely affect resident workflow. There was no significant change in time spent on handoffs, time spent on documentation, or time in front of the computer post intervention. Interestingly, resident time spent with patients and families did significantly increase (8.3% vs. 10.6%; p=0.03) in the post intervention group. This was mostly driven by significant change on the unit using a computer generated handoff tool.
What does this mean for us?
Well this data shows that implementing a systematic handoff bundle can help reduce medical errors and specifically reduce clinically meaningful errors (adverse or potentially adverse events). There are of course a few limitations of this study that are worth touching on. This study was done on a pediatric unit, so its ultimate application to adult patient care units may vary. But many of the types of errors that existed in this study (med related), exist in adult care settings with similar incidences. Some might point out that the post intervention data collection also occurred during a later period in the resident’s academic year, so there is always the potential that some of the improvement in error reduction was a result of improved resident experience/emerging competency. But that’s unlikely to explain all of the improvement, as there are numerous studies that show that medical error rates in teaching hospitals don’t seem to change as much from July to December as we often believe they might. Then there is always the matter of the Hawthorne Effect (changes in behavior related to being observed as opposed to due to intervention being studied) to consider. And finally, the study personnel reporting errors in real time were not blinded to the intervention and even though there was blinded review of the reported events, the physicians reviewing the events had only moderate interobserver agreement about the categorization and preventability of the reported errors. While not always straightforward to implement, a randomized study, with blinded data collection might have mitigated some of these potential confounders.
I think, limitations aside, this study supports our continued efforts to standardize handoff training. We already employ several of the strategies used in this study (EMR handoff tool, SIGNOUT mnemonic). As we prepare for new interns in July (crazy to think they’ll be here sooner than we realize), I think this study provides a good evidence-based framework for how to structure handoff training.
QI Corner (submitted by Joel Boggan)
Dr. George Cheely will be giving our next QI noon conference on ‘Overcoming Barriers to High Value, Cost-Conscious Care’ on Wednesday, 1/29, in 2002.
From the Chief Residents
SAR Talks: January 30, 2014
Tyler Black and Jodel Giraud
January 31, 2013:
Dr Craig Brater – Visiting Professor
Topic: Diuretic Resistance
|1/27||MKSAP Mondays||12:00||Pita Pit|
|1/28||MED PEDS SAR TALK (Balasubramanian/Sudan)||12:00||Chick-Fil-A|
|1/29||IM-EM Combined QI Patient Safety Noon Conference||Cheely||12:00||Cosmic Cantina|
|1/30||SAR talks||Tyler Black / Jodel Giraud||12:00||Sushi|
From the Residency Office
SAR Class Pictures
Please mark your calendars for Friday, February 14th immediately after Grand Rounds. The group picture will be taken at 9:15am in the Duke Cancer Institute healing path (the lobby).
Thankful to capture such a remarkable class!! Erin
Attendance At DoM Grand Rounds
As you may have noticed, there are changes underway as to how we record attendance at DoM Grand Rounds. For the past 4 yrs we have captured attendance with a bar code scanner. The data that we capture is uploaded to MedHub, and for faculty who wish to have CME credit, is uploaded to the CME office database. Effective February 1, 2014, this system is being replaced with a new record keeping system called Ethos. Internal Medicine will be using this new system to track residents’ attendance at Medicine Grand Rounds. In addition, other services will also be using Ethos to track conference attendance, so it is very important that you take the time to register, per the instructions below, ASAP. We will continue to use the card scanning method for Noon Conferences for the immediate future.
Many thanks in advance for taking the time to register for this new system at your earliest convenience!
How to register with Ethos
- Go to the Duke Continuing Medical Education home page.
- In the upper right corner, click Join. The Account Information page opens.
- Complete the fields on the screen. A field with an asterisk is required.
- NOTE: Please make sure you include your Duke Unique ID – even though it does not show as a required field.
- Be sure to include your mobile phone number; you will use this number to send a text message with a code supplied at each event and get credit for CME events you attend.
- At the bottom of the account information form, click Create New Account. A green feedback message near the top of the screen informs you that a confirmation has been sent to the email address you provided.
- Open the email (from email@example.com) and click the top link in the body of the message.
- In your browser window, enter a password of your choice in both fields and note your user name. Click Save at the bottom of the page.
- In the same window, click the Mobile settings tab in the gray menu bar at the top of the page. If you entered your mobile number when you registered, it should appear on this page. Click confirm number. You will receive a text message to that mobile number with a confirmation code from DCRI CME.
- Enter the confirmation code in the box in your browser window and click Confirm Number. A message will appear below your number saying “Your number has been confirmed.”
- Now when you attend an event for CME credit you can use your registered mobile phone to text the provided event codes and earn CME credit.
To record your CME attendance via text message, follow these steps
- The 6-character SMS code will be provided on a slide during your CME event.
- Begin a new text message on your registered mobile phone. Note: The provided code is only good for eight hours. You must text the code the day you attend Medicine Grand Rounds.
- In the To field, enter the Duke CME phone number: 919-213-8033. Tip: Add this number to your mobile phone contacts.
- In the message area, type the 6-character SMS code that was provided during the session (note: this code is not case sensitive).
- Press send.
- If you have set up your Ethos account, you will receive the successful confirmation text message, “Your attendance has been recorded for “[Name of Session].”
To view your CME training history
- Log into Ethos by visiting the Duke Continuing Education home page and click Log In at the top right of the page.
- Enter your username and password. Click My Account in the upper right corner.
- Navigate the gray toolbar and click My Activities.
- Click Transcript to view and search completed activities.
- Click the Courses (in progress) tab to view pending activities.
- Medicine Grand Rounds are listed at https://continuingeducation.dcri.duke.edu/medgr. Consider bookmarking this link in your browser for quick access.
MKSAP – Mid Year Opportunity
The program encourages residents to take advantage of the opportunity to obtain Medical Knowledge Self-Assessment (MKSAP) at a significantly discounted rate.
How? First, you need to become a member of the ACP.
Associate membership costs $109/yr https://www.acponline.org/membership/dues/new_us.htm . Please make note to record your ACP # – you will need it to complete our online request form
- Which MKSAP format do you want?
The cost for either the hard copy or digital MKSAP set is covered by the program – simply complete the order blank using the following link.
- This offer is open to all Categorical, Med Peds, and Med Psych trainees who have NOT previously received a copy of MKSAP
- You are required to be a current ACP member to participate
- You have the option to request the printed or digital version. Should you want the complete set you have to cover the additional cost.
- We do not place orders randomly at different times in the year. This offer is for a limited time only – ending on February 9, 2014.
Annual Faculty Resident Research Grant applications are due on April 11, 2014.
Please find attached the forms and the link to our website below where the application instructions, forms and NIH format biosketch example can also be downloaded.
Please note that each proposal must have a Human Subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues related to your project. Upon approval of the grant at the end of this academic year, each awardee will be asked to please submit a CITI human subjects basic training certificate.
Please email firstname.lastname@example.org for any questions and look out for the Open Office hours coming up in February to schedule an appointment.
Wishing you continued success with your research projects !
Murat and Aimee
A new Best Practice Advisory (BPA) has been activated in Maestro Care to help prevent anticoagulant administration in patients with an epidural or regional catheter in place.
The BPA will read:
“An anticoagulant and epidural have both been ordered on this patient. Check with Anesthesiology before proceeding.” A screen is included below.
Purpose of the BPA: to warn providers, pharmacists and nurses of the dangerous combination of anticoagulant therapy in a patient with epidural or regional catheters.
The BPA will read “An anticoagulant and epidural have both been ordered on this patient. Check with Anesthesiology before proceeding.” This BPA will fire at these points:
- When an ordering provider enters an order for an anticoagulant (see list of medications below) on a patient with an active order for epidural or deep regional catheter (sciatic or lumbar plexus). The provider should select “I will discontinue order” and proceed to cancel the order with an acknowledgement reason of “Contraindicated”.
- If the ordering provider opts to not remove the order, the BPA will fire again upon order signature
- The BPA will fire again when the order reaches Pharmacy for verification. Pharmacy should verify Attending APS approval.
- The BPA will fire one final time at the point of medication administration. The nursing staff should again verify Attending APS approval.
Anticoagulants that trigger the BPA:
|abciximab (Reopro)||alteplase (tPa, Cathflo Activase)||anagrelide (Agrylin)|
|apixaban (Eliquis)||cilostazol (Pletal)||clopidogrel (Plavix)|
|dabigratan (Pradaxa)||enoxaparin (Lovenox)||eptifibatide (Integrilin)|
|fondaparinux (Arixtra)||prasugrel (Effient)||reteplase (Retevase)|
|rivaroxaban (Xarelto)||tenecteplase (TNKase)||ticagrelor (Brilinta)|
|ticlodipine (Ticlid)||tirofiban (Aggrastat)||warfarin (Coumadin)|
Lisa Clark Pickett MD FACS
Resident/Fellow Survey Instructions Now Open
Program Scheduled: Duke University Hospital Program – 1403621320
Survey Timeframe: January 13, 2014 – February 16, 2014
HOW TO ACCESS THE SURVEY:
Residents that started the program off-cycle (after Aug 31 of the current academic year) will not be asked to participate in this year’s implementation.
- 1. Open a new window using your internet browser (Internet Explorer [8.0 or higher]; Firefox; Google Chrome; etc.)
- 2. Click the following URL, or copy and paste it into your internet window’s address bar – https://www.acgme.org/Surveys/Security/LogOn
- 3. Your username for this survey is the program’s 10-digit number – 1403621320
- 4. Your password for this survey is unique to you. It will consist of your date of birth, followed by the LAST TWO letters of your LAST NAME.
For example, if we want the password for Mary Smith, born 01/01/1969 (or January 1, 1969):
The birth date with no slashes is 01011969 and the last two letters of Mary Smith’s entire name are ‘t’ and ‘h’, making her password in this example – 01011969th
Every username and password must be changed upon initial login. Please remember your new ID and password. You can use it to re-access the survey until your program’s deadline.
You will have until February 16, 2014 to complete the survey. Responses may be modified anytime during the reporting timeframe, using your CHOSEN username and password to log in. Contact your program coordinator if you encounter problems or have questions.
Jennifer L. Averitt
RESIDENTS, FELLOWS wanted to be “SUPER USERS” FOR MAESTRO CARE Go LIVE : at Duke Regional and Duke Raleigh Hospitals: OPPORTUNITY FOR TSMA (“internal moonlighting”)
The Need: To support providers going Live on Maestro Care at Duke Regional and Duke Raleigh. We are again offering “moonlighting” (TSMA) shifts for the first two weeks of the Go Live. These are nonclinical at- the-elbow support on the floor supporting other providers in the first two weeks of March, 2014. Pay is $75/hour. Most shifts are during the weekend and evening times with more limited opportunities for regular AM shifts. We are looking for more coverage the first few days of the Go Live and the need tapers off from there.
Who’s eligible: Any resident/fellow (PGY2 to end of fellowship training is eligible) if they have
1. Approval from their Program or Fellowship Director, Chair, and DIO (as for any TSMA)
2: Nonclinical time to spare to complete the additional training and support and remain duty hour compliant..
Any specialty is possible, but you will be asked to support your “Base” clinical activity. For example, a radiology resident would support Radiology. Moonlighters will need to be identified into their primary specialty.
What’s needed: This position requires a can-do helpful attitude, approval of your Residency or Fellowship Director and a commitment to a minimum of two shifts of service. Shifts range from 6 to 12 hours in duration
Shifts needed: Check excel spreadsheet attached and let Mary Beth Magallanes email@example.com know of your interest
Necessary training: Super users will need to have been clinically active for at least 6 months in Maestro Care.
Interested Residents/fellows should contact Mary Beth Magallanes. firstname.lastname@example.org to “schedule” shifts. Complete the TSMA approval process. You will be notified by February 3rd of dates and times.
“TSMA” forms (for approval) are on MedHub.
Information/OpportunitiesFrankfort IM Flyer (1-23-14) Richmond IM Flyer (Mansilla) (1-21-2014) SRMC – Internal Medicine (1-21-2014) SWVA IM Flyer (Updated January 2014)
Upcoming Dates and Events
- January 31: Medicine Research Conference at 12 noon in DUH 2002.
- February 14: SAR Class Pictures
- April 18th: Charity Auction
- Main Internal Medicine Residency website
- Main Curriculum website
- Ambulatory curriculum wiki
- Department of Medicine
- Confidential Comment Line Note: ALL submissions are strictly confidential unless you chose to complete the optional section requesting a response.