The aim of this study was to identify global health ethical issues that health professional trainees may encounter during electives or placements in resource-limited countries. We conducted a qualitative study involving focus groups and an interview at the University of California San Francisco. Participants were multi-professional from the Schools of Medicine, Nursing and Pharmacy and had experience working, or teaching, as providers in resource-limited countries. Eighteen participants provided examples of ethical dilemmas associated with global-health outreach work. Ethical dilemmas fell into four major themes relating to (1) cultural differences (informed consent, truth-telling, autonomy); (2) professional issues (power dynamics, training of local staff, corruption); (3) limited resources (scope of practice, material shortages); (4) personal moral development (dealing with moral distress, establishing a moral compass, humility and self awareness). Three themes (cultural differences, professional issues, limited resources) were grouped under the core category of "external environmental and/or situational issues" that trainees are confronted when overseas. The fourth theme, moral development, refers to the development of a moral compass and the exercise of humility and self-awareness. The study has identified case vignettes that can be used for curriculum content for global-health ethics training.

BACKGROUND: Hospitalists frequently work on diverse projects, but often do not have the training and experience necessary to translate projects into peer-reviewed publications and grants. OBJECTIVE: Describe implementation and effect of a works-in-progress (WIP) series on progress and training in scholarly work. DESIGN: Cross-sectional survey. SETTING: Urban academic medical center. INTERVENTION: A weekly WIP session, named Incubator, serving as a forum where researchers, clinicians, and educators meet to review and provide feedback on projects underway across the Division of Hospital Medicine. MEASUREMENTS: We surveyed presenters at Incubator to evaluate the impact of Incubator on scholarly activities. Responses were based on Kirkpatricks 4-level training hierarchy: (1) Reaction: participants satisfaction; (2) Learning: knowledge acquisition; (3) Behavior: application of skills; and (4) Results of projects. We compared responses between researchers and nonresearchers using χ2 tests. RESULTS: Of 51 surveys completed (response rate 70%), 35 (69%) projects were nonresearcher led. Reaction, behavior change, and results were all positive, with >90% respondents reporting a positive outcome in each category, a high rate of publication/funding, and 35% reporting learning as a result of Incubator. Comparison of researchers and nonresearchers revealed no significant differences, except nonresearchers reported significantly more favorable results in behavior and mentoring (P < 0.05). DISCUSSION: A regularly scheduled, researcher-led WIP session within a largely clinically oriented hospital medicine division can provide a venue for feedback that may promote progress and practical training in scholarly projects. In addition to robust career mentorship programs and protected time, a WIP can be an adjunct to improve scholarly output among academic hospitalists. Journal of Hospital Medicine 2016;11:719-723. © 2016 Society of Hospital Medicine.

ICD-11 provides a promising new way to capture healthcare-related harm or injury. In this paper, we elaborate on the framework for describing healthcare-related events where there is a presumed causal link between an event and underlying healthcare-related factors. The three-part model for describing healthcare-related harm or injury in ICD-11 consists of (1) a healthcare-related activity that is the cause of injury or other harm (selected from Chapter 23 of ICD-11); (2) a mode or mechanism of injury or harm, related to the underlying cause (also from Chapter 23 of ICD-11); and (3) the harmful consequences of the event to the patient, selected from any of Chapters 1 through 22 of ICD-11 (most importantly, the injury or harm experienced by the patient). Concepts from these three elements are linked/clustered through postcoordination to reflect the three-part model in a single coded expression. ICD-11 contains many novel features, and the three-part model described here for healthcare-related adverse events is a notable example.

Introduction

Many health care trainees and providers have reported feeling unprepared for the ethical dilemmas they faced while practicing in global health. Simulation is an effective teaching modality in the training of health care professionals. This resource describes the development, implementation, and assessment of an innovative simulation training program for global health ethics.

Methods

We conducted simulation training with trainees and professionals from various health care disciplines. After a didactic component in which general ethical principles were introduced, participants acted as either lead or observer in four simulations representing different ethical challenges. Participants interacted with simulated patients within a set designed to resemble a resource-constrained environment. Data on the participants' experiences and evaluations of the program's effectiveness were collected through pre-/postsession surveys and focus groups.

Results

All 53 participants (100%) agreed that the simulations "effectively highlighted ethical dilemmas I could face abroad," and 98% agreed that the content "was useful in my preparation for an international elective." Responses from surveys and focus groups stressed the importance of the realistic and emotional nature of the simulation in increasing confidence and preparedness, as well as a preference for simulation as the modality for teaching global health ethics.

Discussion

Simulation for global health ethics training can help to raise awareness of the complex ethical challenges one may face abroad. Incorporating simulation training within broader global health curricula can improve trainee preparedness and confidence in appropriately and effectively identifying, strategizing, and navigating through ethical dilemmas in the field.

Background

The term "holdover admissions" refers to patients admitted by an overnight physician and whose care is then transferred to a new primary team the next morning. Descriptions of the holdover process in internal medicine are sparse.

Objective

To identify important factors affecting the quality of holdover handoffs at an internal medicine (IM) residency program and to compare them to previously identified factors for other handoffs.

Design

We undertook a qualitative study using structured focus groups and interviews. We analyzed data using qualitative content analysis.

Participants

IM residents, IM program directors, and hospitalists at a large academic medical center.

Main measures

A nine-question open-ended interview guide.

Key results

We identified 13 factors describing holdover handoffs. Five factors-physical space, standardization, task accountability, closed-loop verification, and resilience-were similar to those described in prior handoff literature in other specialties. Eight factors were new concepts that may uniquely affect the quality of the holdover handoff in IM. These included electronic health record access, redundancy, unwritten thoughts, different clinician needs, diagnostic uncertainty, anchoring, teaching, and feedback. These factors were organized into five overarching themes: physical environment, information transfer, responsibility, clinical reasoning, and education.

Conclusions

The holdover handoff in IM is complex and has unique considerations for achieving high quality. Further exploration of safe, efficient, and educational holdover handoff practices is necessary.

Objective: To explore an interprofessional group of health care providers' perspectives on the facilitators and barriers to implementation of an inpatient acupuncture service for pain and symptom management. Design: Qualitative. Setting: An urban, academic, tertiary care health system. Subjects: Key interprofessional health care providers, including physicians, nurses, and administrators. Methods/interventions: We used interviews and focus group with questions guided by the Promoting Action on Research Implementation in Health Services framework to explore three domains of implementation-evidence, context, and facilitation. Data were analyzed using content analysis. Results: Thirty health professionals participated in 11 interviews and 1 focus group. We identified 12 codes or topics, grouped into 3 categories: (1) facilitators to implementation, (2) barriers to implementation, and (3) strategies to promote successful implementation. Health professionals' awareness of acupuncture was high, and the positive support was based on beliefs that acupuncture fills a biomedical gap in treatment and adds institutional value by enhancing the reputation of the health system. Many thought that to provide comprehensive care, acupuncture should be available to inpatients, but opinions varied on the appropriateness and timing of acupuncture in patients' disease or care trajectory. Concerns about inconsistencies in insurance coverage and resulting expenses patients may incur were noted. Strategies to overcome implementation challenges included ensuring buy-in, setting appropriate expectations of the benefits of acupuncture, and educating patients and providers. Conclusions: Our study finds clear support for acupuncture. These strong endorsements were the foundation of facilitating factors that can guide implementation of acupuncture in the inpatient setting. Although we also identified potential barriers to implementation that must be addressed, we also report a number of actionable steps to operationalize evidence-based acupuncture to patients who are inpatients.

BACKGROUND: Health systems have developed automated telephone call programs to screen and triage patients post-hospital discharge issues and concerns. The aims of our study were to determine whether and how older adults engage with automated post-hospital discharge telephone programs and to describe the prevalence of patient-reported post-discharge issues. METHODS: We identified all telephone calls made by an urban academic medical center as part of a post-hospital discharge program between May 1, 2018 and April 30, 2019. The program used automated telephone outreach to patients or their caregivers that included 11 distinct steps 3 days post-discharge. All adults discharged home from the hospital, were included, and we categorized patients into ≤64 years, 65-84 years, and ≥85 years age groups. We then compared call reach rate, completeness of 11-step calls and patient-reported issues between age groups. RESULTS: Eighteen thousand and seventy six patients were included. More patients 65-84 years old were reached compared to patients ≤64 years old (84.3% vs. 78.9%, AME 5.52%; 95%CI: 3.58%-7.45%). Completion rates of automated calls for those ≥85 years old were also high. Patients ≥85 years old were more likely to have questions about their follow-up plans and need assistance scheduling appointments compared to those ≤64 years old (19.0% vs. 11.9%, AME 7.0% (95%CI: 2.7%-11.3%). CONCLUSION: Post-hospital automated telephone calls are feasible and effective at reaching older adults. Future work should focus on improving discharge communication to ensure older adults are aware of their follow-up plan and appointments.

Background

Night float rotations, where residents admit patients to the hospital, are opportunities for practice-based learning. However, night float residents receive little feedback on their diagnostic and management reasoning, which limits learning.

Aim

Improve night float residents' practice-based learning skills through feedback solicitation and chart review with guided reflection.

Setting/participants

Second- and third-year internal medicine residents on a 1-month night float rotation between January and August 2017.

Program description

Residents performed chart review of a subset of patients they admitted during a night float rotation and completed reflection worksheets detailing patients' clinical courses. Residents solicited feedback regarding their initial management from day team attending physicians and senior residents.

Program evaluation

Sixty-eight of 82 (83%) eligible residents participated in this intervention. We evaluated 248 reflection worksheets using content analysis. Major themes that emerged from chart review included residents' identification of future clinical practice changes, evolution of differential diagnoses, recognition of clinical reasoning gaps, and evaluation of resident-provider interactions.

Discussion

Structured reflection and feedback during night float rotations is an opportunity to improve practice-based learning through lessons on disease progression, clinical reasoning, and communication.

BACKGROUND: Surgeons have made substantial efforts to decrease postoperative opioid prescribing, largely because it can lead to prolonged use. These efforts include adoption of non-opioid pain medication including gabapentin. Like opioids, gabapentin use may be prolonged, increasing the risk of altered mental status and even overdose and death when taken concurrently with opioids. However, little is known about postoperative prolonged use of gabapentin in older adults. METHODS: We merged a 20% sample of Medicare Carrier, MedPAR and Outpatient Files with Part D for 2013-2018. We included patients >65 years old without prior gabapentinoid use who underwent common non-cataract surgical procedures. We defined new postoperative gabapentin as fills for 7 days before surgery until 7 days after discharge. We excluded patients whose discharge disposition was hospice or death. The primary outcome was prolonged use of gabapentin, defined as a fill>90 days after discharge. To identify risk factors for prolonged use, we constructed logistic regression models, adjusted for procedure and patient characteristics, length of stay, disposition location, and care complexity. RESULTS: Overall, 17,970 patients (3% of all eligible patients) had a new prescription for gabapentin after surgery. Of these, the mean age was 73 years old and 62% were female. The most common procedures were total knee (45%) and total hip (21%) replacements. Prolonged use occurred in 22%. Those with prolonged use were more likely to be women (64% vs. 61%), be non-White (14% vs. 12%), have concurrent prolonged opioid use (44% vs. 18%), and have undergone emergency surgery (8% vs. 4%). On multivariable analysis, being female, having a higher Charlson comorbidity score, having an opioid prescription at discharge and at >90 days and having a higher care complexity were associated with prolonged use of gabapentin. CONCLUSIONS: More than one-fifth of older adults prescribed gabapentin postoperatively filled a prescription >90 days after discharge, especially among patients with more comorbidities and concurrent prolonged opioid use, increasing the risk of adverse drug events and polypharmacy.