Evaluating the impact of clinical librarians on clinical questions during inpatient rounds.
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ABSTRACT: The investigation sought to determine the effects of a clinical librarian (CL) on inpatient team clinical questioning quality and quantity, learner self-reported literature searching skills, and use of evidence-based medicine (EBM).Clinical questioning was observed over 50 days of inpatient pediatric and internal medicine attending rounds. A CL was present for 25 days and absent for 25 days. Questioning was compared between groups. Question quality was assessed by a blinded evaluator, who used a rubric adapted from the Fresno Test of Competence in Evidence-Based Medicine. Team members were surveyed to assess perceived impacts of the CL on rounds.Rounds with a CL (CLR) were associated with significantly increased median number of questions asked (5 questions CLR vs. 3 NCLR; p<0.01) and answered (3 CLR vs. 2 NCLR; p<0.01) compared to rounds without a CL (NCLR). CLR were also associated with increased mean time spent asking (1.39 minutes CLR vs. 0.52 NCLR; p<0.01) and answering (2.15 minutes CLR vs. 1.05 NCLR; p=0.02) questions. Rounding time per patient was not significantly different between CLR and NCLR. Questions during CLR were 2 times higher in adapted Fresno Test quality than during NCLR (p<0.01). Select participants described how the CL's presence improved their EBM skills and care decisions.Inpatient CLR were associated with more and improved clinical questioning and subjectively perceived to improve clinicians' EBM skills. CLs may directly affect patient care; further study is required to assess this. CLs on inpatient rounds may be an effective means for clinicians to learn and use EBM skills.
Journal of the Medical Library Association : JMLA 20180401 2
<h4>Objective</h4>The investigation sought to determine the effects of a clinical librarian (CL) on inpatient team clinical questioning quality and quantity, learner self-reported literature searching skills, and use of evidence-based medicine (EBM).<h4>Methods</h4>Clinical questioning was observed over 50 days of inpatient pediatric and internal medicine attending rounds. A CL was present for 25 days and absent for 25 days. Questioning was compared between groups. Question quality was assessed ...[more]
Project description:PurposeTo estimate the effectiveness of a multimodal educational intervention to increase use of shared decision-making (SDM) behaviors by inpatient pediatric and internal medicine hospitalists and trainees at teaching hospitals at Stanford University and the University of California, San Francisco.MethodThe 8-week Patient Engagement Project Study intervention, delivered at four services between November 2014 and January 2015, included workshops, campaign messaging, report cards, and coaching. For 12-week pre- and postintervention periods, clinician peers used the nine-point Rochester Participatory Decision-Making Scale (RPAD) to evaluate rounding teams' SDM behaviors with patients during ward rounds. Eligible teams included a hospitalist and at least one trainee (resident, intern, medical student), in addition to nonphysicians. Random-effects models were used to estimate intervention effects based on RPAD scores that sum points on nine SDM behaviors per patient encounter.ResultsIn total, 527 patient encounters were scored during 175 rounds led by 49 hospitalists. Patient and team characteristics were similar across pre- and postintervention periods. Improvement was observed on all nine SDM behaviors. Adjusted for the hierarchical study design and covariates, the mean RPAD score improvement was 1.68 points (95% CI, 1.33-2.03; P < .001; Cohen d = 0.82), with intervention effects ranging from 0.7 to 2.5 points per service. Improvements were associated with longer patient encounters and a higher percentage of trainees per team.ConclusionsThe intervention increased behaviors supporting SDM during ward rounds on four independent services. The findings recommend use of clinician-focused interventions to promote SDM adoption in the inpatient setting.
Project description:BACKGROUND:Shared decision-making (SDM) improves patient engagement and may improve outpatient health outcomes. Little is known about inpatient SDM. OBJECTIVE:To assess overall quality, provider behaviors, and contextual predictors of SDM during inpatient rounds on medicine and pediatrics hospitalist services. DESIGN:A 12-week, cross-sectional, single-blinded observational study of team SDM behaviors during rounds, followed by semistructured patient interviews. SETTING:Two large quaternary care academic medical centers. PARTICIPANTS:Thirty-five inpatient teams (18 medicine, 17 pediatrics) and 254 unique patient encounters (117 medicine, 137 pediatrics). INTERVENTION:Observational study. MEASUREMENTS:We used a 9-item Rochester Participatory Decision-Making Scale (RPAD) measured team-level SDM behaviors. Same-day interviews using a modified RPAD assessed patient perceptions of SDM. RESULTS:Characteristics associated with increased SDM in the multivariate analysis included the following: service, patient gender, timing of rounds during patient's hospital stay, and amount of time rounding per patient (P < .05). The most frequently observed behaviors across all services included explaining the clinical issue and matching medical language to the patient's level of understanding. The least frequently observed behaviors included checking understanding of the patient's point of view, examining barriers to follow-through, and asking if the patient has any questions. Patients and guardians had substantially higher ratings for SDM quality compared to peer observers (7.2 vs 4.4 out of 9). CONCLUSIONS:Important opportunities exist to improve inpatient SDM. Team size, number of learners, patient census, and type of decision being made did not affect SDM, suggesting that even large, busy services can perform SDM if properly trained.
Project description:BackgroundMorning walk rounds have lost some of their engagement while remaining a useful and valued practice.AimWe created a pilot study to evaluate the impact on rounds of learning to asking a variety of different questions.SettingOne-hour intervention sessions were voluntarily offered to members of the Department of Medicine and taught by an expert in the question, listen, and respond method.ParticipantsParticipants included attendings and residents in Internal Medicine on medical teams.Program descriptionQuestionnaires were collected on six pre-intervention and six post-intervention days. Nine months later, an anonymous online survey was sent to participants asking about their use of a wider variety of questions.Program evaluationTwo hundred eight physicians (residents 175 (45.5%), attending physicians 25 (27.7%)) filled out pre-intervention surveys. One hundred eighty-one physicians (residents 155 (40.3%), attending physicians 18 (20%)) filled out post-intervention surveys. When survey responses from the attendings and residents on the medical teams were combined, post-intervention rounds were perceived as more worthwhile (1.99 pre-intervention and 1.55 post-intervention, [95% confidence interval 1.831-2.143]) (p?<?0.001) and more engaging (1.68 pre-intervention and 1.30 post-intervention, [95% confidence interval 1.407-1.688]) (p?<?0.001).Non-medical teams' survey responses did not change. Patient census data indicated no significant difference in the hospital's census on the pre- and post-intervention dates. Spontaneous suggestions for improving rounds came largely from the residents and included teaching points, clinical pearls, patient focus, more interactive, increased dedicated time for teaching, inclusive/multidisciplinary, questions, and evidence-based teaching. Of the participants who answered the online survey 9 months later, 75% (6/8) reported that they "actually asked a wider variety of types of questions."DiscussionThis pilot study indicates that the 1-h intervention of learning to ask a variety of different questions is associated with rounds that are rated as more worthwhile and engaging by the medical teams.
Project description:BackgroundA clinical librarian is a member of the medical team in many countries. To strengthen this new job, librarians need to acquire professional skills in order to provide information services to medical staff. In this study, we aimed to explor the skills required for the presence of a clinical librarian in the treatment team.MethodsIn this study, we sonducted a qualitative study in which 15 experienced librarians were interviewed in connection with information services. Also, a treatment team was involved in this study using purposive-convenience and snowball sampling methods. The data collection tool was a semi-structured interview that continued until the data was saturated; finally the data analysis was performed using thematic analysis.ResultsOut of the total interviews, 158 primary codes and, 107 main codes were extracted in 25 subclasses. After careful evaluation and integration of subclasses and classes, they were finally classified into 13 categories and four main themes, namely clinical librarian's role, professional and specialized skills, communication skills, and training programs.ConclusionThe results showed that specialized skills and training programs for the clinical librarian are defined based on his/her duties in the treatment team. We also defined the most important key skills for the clinical librarian in two categories of professional and communication skills such as specialized information search, content production, resource management, familiarity with various sources related to evidence-based medicine, teamwork, and effective communication. To acquire these skills, officials and policy-makers should develop and implement related educational programs at medical universities and colleges.
Project description:Background: Emerging global transformations - including a new Sustainable Development Agenda - are revealing increasingly interrelated goals and challenges, poised to be addressed by similarly integrated, multi-faceted solutions. Research to date has focused on determining the effectiveness of these approaches, yet a key question remains: are synergistic effects produced by integrating two or more sectors? We systematically reviewed impact evaluations on integrated development interventions to assess whether synergistic, amplified impacts are being measured and evaluated. Methods: The International Initiative for Impact Evaluation's (3ie) Impact Evaluation Repository comprised our sampling frame (n = 4,339). Following PRISMA guidelines, we employed a three-stage screening and review process. Results: We identified 601 journal articles that evaluated integrated interventions. Seventy percent used a randomized design to assess impact with regard to whether the intervention achieved its desired outcomes. Only 26 of these evaluations, however, used a full factorial design to statistically detect any synergistic effects produced by integrating sectors. Of those, seven showed synergistic effects. Conclusions: To date, evaluations of integrated development approaches have demonstrated positive impacts in numerous contexts, but gaps remain with regard to documenting whether integrated programming produces synergistic, amplified outcomes. Research on these program models needs to extend beyond impact only, and more explicitly examine and measure the synergies and efficiencies associated with linking two or more sectors. Doing so will be critical for identifying effective integrated development strategies that will help achieve the multi-sector SDG agenda.
Project description:For gastroenterology, The Royal College of Physicians reiterates the common practice of two to three consultant ward rounds per week. The Royal Bolton Hospital NHS Foundation Trust operated a 26-bed gastroenterology ward, covered by two consultants at any one time. A traditional system of two ward rounds per consultant per week operated, but as is commonplace, discharges peaked on ward round days.To determine whether daily consultant ward rounds would improve patient care, shorten length of stay and reduce inpatient mortality.A new way of working was implemented in December 2009 with a single consultant taking responsibility for all ward inpatients. Freed from all other direct clinical care commitments for their 2 weeks of ward cover, they conducted ward rounds each morning. A multidisciplinary team (MDT) meeting followed immediately. The afternoon was allocated to gastroenterology referrals and reviewing patients on the medical admissions unit.The changes had an immediate and dramatic effect on average length of stay, which was reduced from 11.5 to 8.9 days. The number of patients treated over 12 months increased by 37% from 739 to 1010. Moreover, the number of deaths decreased from 88 to 62, a reduction in percentage mortality from 11.2% to 6%. However, these major quality outcomes involved a reduction in consultant-delivered outpatient and endoscopy activity.This new method of working has both advantages and disadvantages. However, it has had a major impact on inpatient care and provides a compelling case for consultant gastroenterology expansion in the UK.
Project description:ObjectiveThe aim of this study was to determine the impact of all-cause inpatient harms on hospital finances and patient clinical outcomes.Research designA retrospective analysis of inpatient harm from 24 hospitals in a large multistate health system was conducted during 2009 to 2012 using the Institute of Healthcare Improvement Global Trigger Tool for Measuring Adverse Events. Inpatient harms were detected and categorized into harm (F-I), temporary harm (E), and no harm.ResultsOf the 21,007 inpatients in this study, 15,610 (74.3%) experienced no harm, 2818 (13.4%) experienced temporary harm, and 2579 (12.3%) experienced harm. A patient with harm was estimated to have higher total cost ($4617 [95% confidence interval (CI), $4364 to 4871]), higher variable cost ($1774 [95% CI, $1648 to $1900]), lower contribution margin (-$1112 [95% CI, -$1378 to -$847]), longer length of stay (2.6 d [95% CI, 2.5 to 2.8]), higher mortality probability (59%; odds ratio, 1.4 [95% CI, 1.0 to 2.0]), and higher 30-day readmission probability (74.4%; odds ratio, 2.9 [95% CI, 2.6 to 3.2]). A patient with temporary harm was estimated to have higher total cost ($2187 [95% CI, $2008 to $2366]), higher variable cost ($800 [95% CI, $709 to $892]), lower contribution margin (-$669 [95% CI, -$891 to -$446]), longer length of stay (1.3 d [95% CI, 1.2 to 1.4]), mortality probability not statistically different, and higher 30-day readmission probability (54.6%; odds ratio, 1.2 [95% CI, 1.1 to 1.4]). Total health system reduction of harm was associated with a decrease of $108 million in total cost, $48 million in variable cost, an increase of contribution margin by $18 million, and savings of 60,000 inpatient care days.ConclusionsThis all-cause harm safety study indicates that inpatient harm has negative financial outcomes for hospitals and negative clinical outcomes for patients.
Project description:AimDetermine changes in rapid response team (RRT) activations and describe institutional adaptations made during a surge in hospitalizations for coronavirus disease 2019 (COVID-19).MethodsUsing prospectively collected data, we compared characteristics of RRT calls at our academic hospital from March 7 through May 31, 2020 (COVID-19 era) versus those from January 1 through March 6, 2020 (pre-COVID-19 era). We used negative binomial regression to test differences in RRT activation rates normalized to floor (non-ICU) inpatient census between pre-COVID-19 and COVID-19 eras, including the sub-era of rapid COVID-19 census surge and plateau (March 28 through May 2, 2020).ResultsRRT activations for respiratory distress rose substantially during the rapid COVID-19 surge and plateau (2.38 (95% CI 1.39-3.36) activations per 1000 floor patient-days v. 1.27 (0.82-1.71) during the pre-COVID-19 era; p = 0.02); all-cause RRT rates were not significantly different (5.40 (95% CI 3.94-6.85) v. 4.83 (3.86-5.80) activations per 1000 floor patient-days, respectively; p = 0.52). Throughout the COVID-19 era, respiratory distress accounted for a higher percentage of RRT activations in COVID-19 versus non-COVID-19 patients (57% vs. 28%, respectively; p = 0.001). During the surge, we adapted RRT guidelines to reduce in-room personnel and standardize personal protective equipment based on COVID-19 status and risk to providers, created decision-support pathways for respiratory emergencies that accounted for COVID-19 status uncertainty, and expanded critical care consultative support to floor teams.ConclusionIncreased frequency and complexity of RRT activations for respiratory distress during the COVID-19 surge prompted the creation of clinical tools and strategies that could be applied to other hospitals.
Project description:BACKGROUND: Medical officers (trainees) in their first to third postgraduate years (PGY-1-3s) work in complex, busy environments, performing tasks that require concentration and application of learned skills. There are frequently competing demands, and being paged is among the most common. OBJECTIVE: We quantified and described the effect of interruptions that paging created on the clinical workflow of PGY-1-3s during ward duties. METHODS: This prospective study was conducted at 2 teaching hospitals in Sydney, Australia. Medical students were recruited as observers to log interruptions of PGY-1-3s' workflow arising from pages from other members of the hospital team. RESULTS: Forty-two pairs consisting of a PGY-1-3 trainee and an observer were recruited, with 24 proceeding to data collection. Nursing was the most frequent source of pages (47%); other medical staff accounted for 16% of pages, allied health for 12%, and others for 24% (with pharmacy the most common). Pages commonly involved direct patient care (46%), followed by medication issues (21%). Tasks interrupted by pages encompassed direct patient care (37%), indirect patient care (15%), and documentation (12%). Only 27% of pages were assessed as appropriate and urgent, while 58% were considered appropriate but not urgent, and 16% were not appropriate. Only 38% of pages were judged to be clinically more important than the task they interrupted. CONCLUSIONS: Pages frequently interrupted direct patient care activities for PGY-1-3 trainees, and a significant proportion of pages were identified as either not requiring immediate attention or not appropriate, resulting in potentially avoidable interruptions to clinical workflow. Alternate means of alerting trainees to nonurgent tasks may reduce interruptions and facilitate patient care.
Project description:IntroductionRecent data have suggested that patient admission during intensive care unit (ICU) morning bedside rounds is associated with less favorable outcome. We undertook the present study to explore the association between morning round-time ICU admissions and hospital mortality in a large Canadian health region.MethodsA multi-center retrospective cohort study was performed at five hospitals in Edmonton, Canada, between July 2002 and December 2009. Round-time ICU admission was defined as occurring between 8 and 11:59 a.m. Multivariable logistic regression analysis was used to explore the association between round-time admission and outcome.ResultsOf 18,857 unique ICU admissions, 2,055 (10.9%) occurred during round time. Round-time admissions were more frequent in community hospitals compared with tertiary hospitals (12.0% vs. 10.5%; odds ratio [OR] 1.16; 95% CI, 1.05-1.29, P < 0.004) and from the ward compared with the emergency department (ED) or operating theater (17.5% vs. 9.2%; OR 2.1; 95% CI, 1.9-2.3, P < 0.0001). Round-time admissions were more often medical than surgical (12.6% vs. 6.6%; OR 2.06; 95% CI, 1.83-2.31, P < 0.0001), had more comorbid illness (11.9% vs. 10.5%; OR 1.15; 95% CI, 1.04-1.27, P < 0.008) and higher APACHE II score (22.2 vs. 21.3, P < 0.001), and were more likely to have a primary diagnosis of respiratory failure (37.0% vs. 31.3%, P < 0.001) or sepsis (11.1% vs. 9.0%, P = 0.002). Crude ICU mortality (15.3% vs. 11.6%; OR 1.38; 95% CI, 1.21-1.57, P < 0.0001) and hospital mortality (23.9% vs. 20.6%; OR 1.21; 95% CI, 1.09-1.35, P < 0.001) were higher for round-time compared with non-round-time admissions. In multi-variable analysis, round-time admission was associated with increased ICU mortality (OR 1.19, 95% CI, 1.03-1.38, P = 0.017) but was not significantly associated with hospital mortality (OR 1.02; 95% CI, 0.90-1.16, P = 0.700). In the subgroup admitted from the ED, round-time admission showed significantly higher ICU mortality (OR 1.54; 95% CI, 1.21-1.95; P < 0.001) and a trend for higher hospital mortality (OR 1.22; 95% CI, 0.99-1.51, P = 0.057).ConclusionsApproximately 1 in 10 patients is admitted during morning rounds. These patients are more commonly admitted from the ward and are burdened by comorbidities, are non-operative, and have higher illness severity. These patients admitted during morning rounds have higher observed ICU mortality but no difference in hospital mortality.
