PurposeDespite its growing popularity and clinical utility among hospital-based physicians, there are no formal competency requirements nor training standards for United States based Internal Medicine Residencies for learning point-of-care ultrasonography (POCUS). The purpose of this investigation was to study the impact and effectiveness of a novel POCUS curriculum for an Internal Medicine (IM) residency program.Patients and methodsThis was a Single-Group Educational Quasi-Experiment involving Categorical and Preliminary Internal Medicine Residents in Post-Graduate Years 1 through 3 at a single United States academic tertiary center. The study period was from January 1, 2017, through June 30, 2017, during which time the residents participated in monthly modules including didactics and hands-on ultrasound scanning skills with live models. Participants completed a comprehensive knowledge examination at the beginning and end of the six-month period. Participants were also tested regarding hands-on image acquisition and interpretation immediately before and after the hands-on skills labs. The primary outcome measure was performance improvement in a comprehensive medical knowledge assessment.ResultsIn total, 42 residents consented for participation. The residents’ monthly rotations were adjusted in order to accommodate the new educational process. Among 29 participants with complete data sets for analysis, the mean (SD) comprehensive knowledge examination score improved from 60.9% before curriculum to 70.2% after curriculum completion (P<0.001). Subgroup analysis determined that improvement in medical knowledge required attending at least 2 out of the 6 (33%) educational sessions. Attendance at hands-on skills labs correlated significantly with improvement; didactics alone did not.ConclusionA longitudinal POCUS curriculum consisting of both didactic sessions and hands-on skills labs improves knowledge, image acquisition, and interpretation skills of residents. Having this curriculum span at least 6 months provides learners the opportunity to attend multiple classes which strengthens learning through repetition while also providing learners flexibility in schedule.
Education in the form of cost reminders did not significantly reduce the overall ordering of the most common daily laboratory testing in our academic teaching service. We believe further research is needed to fully evaluate the effectiveness of other education forms on the redundant ordering of tests in the hospital setting.
In July 2020, Mayo Clinic introduced a hospital-at-home program, known as Advanced Care at Home (ACH) as an alternate option for clinically stable medical patients requiring hospital-level care. This retrospective cohort study evaluates the impact of the addition of a dedicated ACH patient acquisition Advanced Practice Provider (APP) on average length of stay (ALOS) and the number of patients admitted into the program between in Florida and Wisconsin between 6 July 2020 and 31 January 2022. Patient volumes and ALOS of 755 patients were analyzed between the two sites both before and after a dedicated acquisition APP was added to the Florida site on 1 June 2021. The addition of a dedicated acquisition APP did not affect the length of time a patient was in the emergency department or hospital ward prior to ACH transition (2.91 days [Florida] vs. 2.59 days [Wisconsin], p = 0.22), the transition time between initiation of the ACH consult to patient transfer home (0.85 days [Florida] vs. 1.16 days [Wisconsin], p = 0.28), or the total ALOS (6.63 days [Florida] vs. 6.34 days [Wisconsin], p = 0.47). The average number of patients acquired monthly was significantly increased in Florida (38.3 patients per month) compared with Wisconsin (21.6 patients per month) (p < 0.01). The addition of a dedicated patient acquisition APP resulted in significantly higher patient volumes but did not affect transition time or ALOS. Other hospital-at-home programs may consider the addition of an acquisition APP to maximize patient volumes.
Background: The management of acute gastrointestinal hemorrhage (GIH) is focused on early resuscitation through 2 large-bore intravenous (2LBIV) catheters, although adherence to this recommendation is low. Local Problem: Of 100 patients hospitalized with GIH in 2017, only 14 received 2LBIV access. The goal of this study was to improve this measure. Methods: A multidisciplinary team used the DMAIC (define, measure, analyze, improve, and control) framework to perform a quality improvement initiative. Interventions: The team used quality tools including a stakeholder survey, swimlane diagram, and fishbone diagram. The first intervention involved education of the hospitalists directing admissions, and the second intervention involved education of emergency department (ED) physicians and nurses regarding the importance of 2LBIV placement. Results: Following the second intervention, there was a substantial increase in 2LBIV placement to 37 of 86 (43%). Conclusions: Carefully directed education of ED physicians and nurses with monthly feedback was effective in improving appropriate intravenous placement in patients with GIH.
Background The diagnosis related group (DRG) is used as an economic patient classification system based on clinical characteristics, hospital stay, and treatment costs. Mayo Clinic’s virtual hybrid hospital-at-home program, advanced care at home (ACH), offers high-acuity home inpatient care for a variety of diagnosis. This study aimed to determine the DRGs admitted to the ACH program at an urban academic center. Methods A retrospective study was performed on all patients discharged from the ACH program at Mayo Clinic Florida from July 6, 2020, to February 1, 2022. DRG data were extracted from the Electronic Health Record (EHR). Categorization of DRG was done by systems. Results The ACH program discharged 451 patients with DRGs. Categorization of the DRG demonstrated that the most frequent code assigned corresponded to respiratory infections (20.2%), followed by septicemia (12.9%), heart failure (8.9%), renal failure (4.9%), and cellulitis (4.0%). Conclusion The ACH program covers a wide range of high-acuity diagnosis across multiple medical specialties at its urban academic medical campus, including respiratory infections, severe sepsis, congestive heart failure, and renal failure, all with major complications or comorbidities. The ACH model of care may be useful in taking care of patients with similar diagnosis at other urban academic medical institutions.
Background and Objectives: Direct admissions (DAs) are nonemergent admissions to the inpatient unit that bypass the emergency department. Our institution lacked a standardized DA process, which resulted in postponement of prompt patient care. The purpose of the present study was to review and modify the existing DA process and to decrease the time between patient arrival for DA and placement of initial clinician orders. Methods: A team was assembled and tasked with using quality improvement tools (eg, Define-Measure-Analyze-Improve-Control, fishbone diagrams, process mapping) to streamline the DA process to decrease average time between patient arrival for DA and initial clinician orders, from 84.4 minutes in July 2018 to 60 minutes or less by June 2019, without negatively affecting patient admission loyalty questionnaire scores. Results: In a standardized and streamlined DA process, average time between patient arrival and provider order placement decreased to less than 60 minutes. This reduction was achieved without substantially affecting patient loyalty questionnaire scores. Conclusion: By using a quality improvement methodology, we developed a standardized DA process that resulted in prompt care for patients without decreasing admission loyalty scores.
BackgroundThe Surviving Sepsis Campaign suggested preferential resuscitation with balanced crystalloids, such as Lactated Ringer’s (LR), although the level of recommendation was weak, and the quality of evidence was low. Past studies reported an association of unbalanced solutions, such as normal saline (NS), with increased AKI risks, metabolic acidosis, and prolonged ICU stay, although some of the findings are conflicting. We have compared the outcomes with the preferential use of normal saline vs. ringer’s lactate in a cohort of sepsis patients.MethodWe performed a retrospective cohort analysis of patients visiting the ED of 19 different Mayo Clinic sites between August 2018 to November 2020 with sepsis and receiving at least 30 mL/kg fluid in the first 6 h. Patients were divided into two cohorts based on the type of resuscitation fluid (LR vs. NS) and propensity-matching was done based on clinical characteristics as well as fluid amount (with 5 ml/kg). Single variable logistic regression (categorical outcomes) and Cox proportional hazards regression models were used to compare the primary and secondary outcomes between the 2 groups.ResultsOut of 2022 patients meeting our inclusion criteria; 1,428 (70.6%) received NS, and 594 (29.4%) received LR as the predominant fluid (>30 mL/kg). Patients receiving predominantly NS were more likely to be male and older in age. The LR cohort had a higher BMI, lactate level and incidence of septic shock. Propensity-matched analysis did not show a difference in 30-day and in-hospital mortality rate, mechanical ventilation, oxygen therapy, or CRRT requirement. We did observe longer hospital LOS in the LR group (median 5 vs. 4 days, p = 0.047 and higher requirement for ICU post-admission (OR: 0.70; 95% CI: 0.51–0.96; p = 0.026) in the NS group. However, these did not remain statistically significant after adjustment for multiple testing.ConclusionIn our matched cohort, we did not show any statistically significant difference in mortality rates, hospital LOS, ICU admission after diagnosis, mechanical ventilation, oxygen therapy and RRT between sepsis patients receiving lactated ringers and normal saline as predominant resuscitation fluid. Further large-scale prospective studies are needed to solidify the current guidelines on the use of balanced crystalloids.
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