BACKGROUND: Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided. OBJECTIVES: We aimed to examine the impact of a video decision tool for CPR and intubation on patients' choices, knowledge, medical orders, and discussions with providers. DESIGN: This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston. PARTICIPANTS: One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51 % were women. INTERVENTION: Three-minute video describing CPR and intubation plus verbal communication of participants' preferences to their physicians (intervention) (N=75) or control arm (usual care) (N=75). MAIN MEASURES: The primary outcome was participants' preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants' knowledge of CPR/ intubation (five-item test, range 0-5, higher scores indicate greater knowledge). RESULTS: Intervention participants (vs. controls) were more likely not to want CPR (64 % vs. 32 %, p <0.0001) and intubation (72 % vs. 43 %, p<0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57 % vs. 19 %, p<0.0001) and intubation (64 % vs.19 %, p<0.0001) by hospital discharge, documented discussions about their preferences (81 % vs. 43 %, p<0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p<0.0001).CONCLUSIONS: Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers. Trial registration: Clinicaltrials.gov NCT01325519 Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients.

This article provides detailed examples from written feedback obtained during collaborative peer observation to emphasize the richness of this combined experience.

IMPORTANCE While the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient safety. OBJECTIVE To determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes. DESIGN, SETTING, AND PARTICIPANTS This 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program. INTERVENTIONS Twenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order. MAIN OUTCOMES AND MEASURES The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings. RESULTS Of the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04). CONCLUSIONS AND RELEVANCE Increased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy.

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) has established the requirement for residency programs to assess trainees' competencies in 6 core domains (patient care, medical knowledge, practice‐based learning, interpersonal skills, professionalism, and systems‐based practice). As attending rounds serve as a primary means for educating trainees at academic medical centers, our study aimed to identify current rounding practices and attending physician perceived capacity of different rounding models to promote teaching within the ACGME core competencies. METHODS We disseminated a 24‐question survey electronically using educational and hospital medicine leadership mailing lists. We assessed attending physician demographics and the frequency with which they used various rounding models, as defined by the location of the discussion of the patient and care plan: bedside rounds (BR), hallway rounds (HR), and card‐flipping rounds (CFR). Using the ACGME framework, we assessed the perceived educational value of each model. RESULTS We received 153 completed surveys from attending physicians representing 34 institutions. HR was used most frequently for both new and established patients (61% and 43%), followed by CFR for established patients (36%) and BR for new patients (22%). Most attending physicians indicated that BR and HR were superior to CFR in promoting the following ACGME competencies: patient care, systems‐based practice, professionalism, and interpersonal skills. CONCLUSIONS HR is the most commonly employed rounding model. BR and HR are perceived to be valuable for teaching patient care, systems‐based practice, professionalism, and interpersonal skills. CFR remains prevalent despite its perceived inferiority in promoting teaching across most of the ACGME core competencies. Journal of Hospital Medicine 2014;9:239–243. © 2014 Society of Hospital Medicine

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BACKGROUND: Hospital discharges are vulnerable periods for patient safety, especially in teaching hospitals where discharges are done by residents with competing demands. We sought to assess whether embedding a nurse practitioner on a medical team to help physicians with the discharge process would improve communication, patient follow‐up, and hospital reutilization. METHODS: A 5‐month randomized controlled trial was conducted on the medical service at an academic tertiary‐care hospital. A nurse practitioner was randomly assigned to 1 resident team to complete discharge paperwork, arrange follow‐up appointments and prescriptions, communicate discharge plans with nursing and primary care physicians, and answer questions from discharged patients. RESULTS: Intervention patients had more discharge summaries completed within 24 hours (67% vs 47%, P < 0.001). Similarly, they had more follow‐up appointments scheduled by the time of discharge (62% vs 36%, P < 0.0001) and attended those appointments more often within 2 weeks (36% vs 23%, P < 0.0002). Intervention patients knew whom to call with questions (95% vs 85%, P = 0.003) and were more satisfied with the discharge process (97% vs 76%, P < 0.0001). Attending rounds on the intervention team finished on time (45% vs 31%, P = 0.058), and residents signed out on average 46 minutes earlier each day. There was no significant difference between the groups in 30‐day emergency department visits or readmissions. CONCLUSIONS: Helping resident physicians with the discharge process improves many aspects of discharge communication and patient follow‐up, and saves residents' time, but had no effect on hospital reutilization for a general medicine population. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.