Background Resident duty-hour restrictions have led to more sign-out transitions, increasing the potential for preventable harm. An unfavorable environment is expected to exacerbate sign-out risks to patient safety. Objective The aim of the study was to evaluate the impact of noise, interruptions, long sign-outs, and sign-outs exceeding allotted time on sign-out quality. Methods Eight trained observers evaluated 620 evening patient sign-outs between interns for 40 weeknights between February and April 2015 at a large internal medicine training program. Quality of sign-out was measured three ways: information quality, scores from the Handoff CEX Tool, and peer evaluations. Results Noise had no impact on information quality. Interruptions negatively affected information quality (−0.10 < r < −0.15, P < 0.001) and Handoff CEX quality scores (−0.11 < r < −0.26, P < 0.001). Long sign-outs taking more than 1 hour negatively affected sign-out quality (−0.09 < r < −0.23, P < 0.05). Sign-outs exceeding allotted time negatively impacted peer evaluations (−0.11 < r < −0.22, P < 0.001). Conclusions Interruptions, long sign-outs, and sign-outs exceeding allotted time were related to lower sign-out quality. Improving the environment to reduce interruptions and training interns to manage their time during sign-outs may improve sign-out quality.
BACKGROUND High blood pressure (HBP) affects nearly half of adults in the United States and is a major factor in heart attacks, strokes, kidney disease, and other morbidities. To reduce risk, guidelines for HBP contain more than 70 recommendations, including many related to patient behaviors, such as home monitoring and lifestyle changes. Thus, the patient's role in controlling HBP is crucial. Patient-facing clinical decision support (CDS) tools may help patients adhere to evidence-based care but customization is required. OBJECTIVE Our objective was to understand how to adapt CDS to best engage patients in controlling HBP. METHODS We conducted a mixed methods study with two phases: (1) semi-structured interviews with a limited cohort; and (2) a nationwide online survey. Participation in each phase was limited to adults between the ages of 18 and 85 who had been diagnosed with hypertension. The survey included general questions that assessed goal-setting, treatment priorities, medication load, comorbid conditions, satisfaction with BP management, and attitudes towards CDS, and also a series of A/B preference questions using paired information displays to assess perceived trustworthiness of potential CDS user interface options. RESULTS We conducted 17 semi-structured interviews to gather patient needs from CDS, then analyzed results to create a survey of 519 adults with clinically diagnosed HBP. A large majority of participants in both populations reported that blood pressure control was a high priority (80-90%), had monitored blood pressure at home (80-90%), and felt comfortable using technology (70-90%.). Survey respondents found displays with enhanced HBP information more trustworthy (60-80% preferred over simpler displays), especially when incorporating social trust and priorities from providers and patients like them, but had no differences in action taken. CONCLUSIONS Respondents to the survey felt CDS capabilities could help them with HBP control. The enhanced information and social/relational displays were felt to be the most trustworthy yet did not differentiate perceived actions.
ABSTRACT Background Evidence-based medicine (EBM) has long been taught to physician trainees for critical appraisal of research manuscripts. There is no parallel or similar framework to guide trainees in the appraisal of quality improvement (QI) literature. Objective To adapt existing guidelines of QI manuscript reporting into an educational QI-EBM appraisal tool to help residents distinguish research and QI manuscripts, assess QI designs and methodologies, and evaluate QI manuscripts' strengths and weaknesses. Methods Between 2018 and 2021, we developed a QI-EBM critical appraisal tool (QI-EBM-CAT) and performed 3 plan-do-study-act cycles to refine the tool based on JAMA and SQUIRE 2.0 guidelines. We then surveyed residents regarding the usefulness of the tool and their confidence in evaluating QI manuscripts before and after completing a QI-EBM workshop using the QI appraisal tool. Results Sixty-six of 74 internal medicine postgraduate year (PGY)-1 to PGY-3 residents (89.2%) completed the workshop and assessment surveys in 2021. The workshop was found to be moderately to very useful by 85.1% (63 of 74) of residents as a framework for QI manuscript critical analysis. The summary confidence score in QI manuscript critical appraisal improved from a 64% rating of moderately to very confident in the pre-period to 94.6% in the post-period (P<.001) with statistical improvements in all 5 confidence areas assessed (P<.001). Conclusions The QI-EBM-CAT, designed to teach residents how to critically assess QI manuscripts using EBM principles, resulted in subjective improvements in confidence of QI manuscript analysis.
BACKGROUND Although previous studies have investigated the efficacy of specific sign‐out protocols (such as the illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by reviewer [I‐PASS] bundle), the implementation of a bundle can be time consuming and costly. We compared 4 sign‐out training pedagogies on sign‐out quality. OBJECTIVE To evaluate training interventions that best enhance multidimensional sign‐out quality measured by information exchange, task accountability, and personal responsibility. INTERVENTION Four general internal medicine firms were randomly assigned into 1 of the following 4 training interventions: didactics (control), I‐PASS, policy mandate on task accountability, and Plan‐Do‐Study‐Act (PDSA). SETTING First‐year interns at a large, Mid‐Atlantic internal medicine residency program. MEASUREMENTS Eight trained observers examined 10 days each in the pre‐ and postintervention periods for each firm using a standardized sign‐out checklist. RESULTS Pre‐ and postintervention differences showed significant improvements in the transfer of patient information, task accountability, and personal responsibility for the I‐PASS, policy mandate, and PDSA groups, respectively, in line with their respective training foci. Compared to the control, I‐PASS reported the best improvements in sign‐out quality, although there was room to improve in task accountability and responsibility. CONCLUSIONS Different training emphases improved different dimensions of sign‐out quality. A combination of training pedagogies is likely to yield optimal results.
To the Editor: Transgender and nonbinary clinicians comprise a growing minority within the medical field, with the percentage of self-reported gender minorities among 2020 matriculating medical students estimated at 0.8% (178/22,239). 1 However, over 50% of gender minorities in the health care field elect not to disclose their gender minority status out of concern for potential negative personal and professional repercussions. 2–4 This problem is compounded by the fact that those entering the medical profession are often not provided with adequate options for disclosing gender identity. All practicing health care professionals in the United States are required to register with the National Provider Identifier (NPI) registry. This publicly accessible database contains information regarding clinician demographics, licensing, practice location, and role. Applicants are provided with only 2 potential selections for gender: “male” or “female”—no nonbinary or gender nonconforming options are available. The response to this mandatory question is prominently displayed at the top of every individual’s publicly accessible NPI page and may inform patient selection of their clinical teams. 5,6 This problem is not unique to the NPI. Other registries that provide limited gender reporting options include the Association of American Medical Colleges’ Electronic Residency Application Service (ERAS), NBME, and the Federation of State Medical Boards (FSMB), which conducts licensure services for 78 state and territory medical boards. If gender reporting is deemed necessary, improvements in gender reporting options would support gender diversity and increase the visibility of nonbinary individuals in medicine. We recommend more inclusive options for self-reporting gender, such as “nonbinary” or “other” with a free text space for users to self-identify. Organizations should avoid using the option “other” without providing space to give a self-reported response, as this contributes to further stigmatization. The issues articulated in this letter mirror the recent movement for recognition of nonbinary, transgender, and gender nonconforming patients through efforts to improve documentation of gender identity and preferred pronouns. The problematic reporting requirements of registries including the NPI, ERAS, NBME, and FSMB highlight the need to deliberately assess options for and necessity of gender reporting in health care. As we strive to build gender-affirming health care systems for our patients, it is imperative to foster inclusivity and awareness within our own community of practice.
Background High blood pressure (HBP) affects nearly half of adults in the United States and is a major factor in heart attacks, strokes, kidney disease, and other morbidities. To reduce risk, guidelines for HBP contain more than 70 recommendations, including many related to patient behaviors, such as home monitoring and lifestyle changes. Thus, the patient’s role in controlling HBP is crucial. Patient-facing clinical decision support (CDS) tools may help patients adhere to evidence-based care, but customization is required. Objective Our objective was to understand how to adapt CDS to best engage patients in controlling HBP. Methods We conducted a mixed methods study with two phases: (1) survey-guided interviews with a limited cohort and (2) a nationwide web-based survey. Participation in each phase was limited to adults aged between 18 and 85 years who had been diagnosed with hypertension. The survey included general questions that assessed goal setting, treatment priorities, medication load, comorbid conditions, satisfaction with blood pressure (BP) management, and attitudes toward CDS, and also a series of questions regarding A/B preferences using paired information displays to assess perceived trustworthiness of potential CDS user interface options. Results We conducted 17 survey-guided interviews to gather patient needs from CDS, then analyzed results and created a second survey of 519 adults with clinically diagnosed HBP. A large majority of participants reported that BP control was a high priority (83%), had monitored BP at home (82%), and felt comfortable using technology (88%). Survey respondents found displays with more detailed recommendations more trustworthy (56%-77% of them preferred simpler displays), especially when incorporating social trust and priorities from providers and patients like them, but had no differences in action taken. Conclusions Respondents to the survey felt that CDS capabilities could help them with HBP control. The more detailed design options for BP display and recommendations messaging were considered the most trustworthy yet did not differentiate perceived actions.
