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Thursday, September 10, 2015

Seven Days Remaining in CME TweetFest, Highlighting Clinical Education Outcomes Articles!

Check out this month’s service project featuring #Meded QI, PI, and #CME outcomes articles at blog http://fullcirclece.blogspot.com/. Only 7 days remain for $100 prize contest for retweeting at https://twitter.com/SHB_CMEedit. Blog comments earn prize entries too! This campaign is led by Donald Harting and yours truly, at #CMEtf, from August 17 - September 17, 2015. Don’t miss Don’s video introduction to the series at https://www.youtube.com/embed/VlVY4KlkdmA (but I have to insist that he deserves at least as much credit for starting the campaign as he gives me)!

I wanted to mention some colleagues who have authored the featured articles or been mentioned in Don Harting's or my blogs thus far: Ed Dellert, William Mencia, Derek Dietze, Erik Brady, Alexandra Howson, Jason Olivieri, Wendy Turell, Sara Miller, Allison Gardner, and Kathleen Moreo. Support publication of Medical Education outcomes reports!

3-Hospital Quality- and Performance-Improvement CME Project With Systems Change Support for Diabetes Care, With CE Measure Editor, Derek Dietze

This performance-improvement/continuingmedical education (PI-CME) study by Lapolla and colleagues at three mid-sized, regional hospitals in the United States focused on clinicians’ behaviors that can be documented as “validated metrics of diabetes care” in patient charts.

When you look at this example of a multi-center performance-improvement initiative with educational and institutional change supports, you’ll see that most of the intervention involved obvious reminders of the change initiative and its measures, graphs and data regarding performance trends, and a PI specialist as leader or champion of the campaign in each hospital. Even though the researchers chose hospitals that were willing to invest in change, the following implementation tools and collaborative approaches were incorporated as being necessary to change: "In the design and implementation of this program, we applied recognized PI principles and developed a dedicated working group to evaluate, monitor, and disseminate data, provide timely feedback, monitor outliers, attend to project management details, and maintain support of institutional leadership. We encouraged physicians' engagement by minimizing their time requirements, soliciting their input throughout the initiative, sharing meaningful data, and taking an 'improvement-oriented' approach rather than 'mandating change.'” [Emphases added.]

I wanted to point out the reminder of the American Medical Association’s recommendation of using a three-stage PI-CME structure, “comprising assessment of current performance (Stage A), design and implementation of strategies to improve performance (Stage B), and evaluation of PI efforts (Stage C).” Any outcomes project or program evaluation that sets its goals after educational content and resources are nearly final faces great challenges for later measurement. Permit me to include related content from the May 2015 Almanac article that Erik Brady and I wrote for the series, “Beginner’s Guide to Measuring Educational Outcomes in CEhp”: "A common error in assessment item-writing is the construction of assessment items that focus on a minor or trivial data point found in the content. This practice is particularly common in two cases: first, when assessment items are written from finished content that offers too little material for assessment; and second, when the minimum score a learner needs to request educational credit dictates the number of items on a tool, causing planners to test trivial points in their desperation to hit an arbitrary quota."

Because assessment items are optimally designed to assess how well a learning objective has been met, aligning a learning objective with an assessment item should ensure that your items are focused on the key points of the activity content and that activity content consistently supports learners’ achievement of the educational and performance objectives. Thus when Lapolla et al planned the educational content and reinforcing health-systems supports according to well-established metrics, they made certain that they had all desired outcomes mapped to hospital-specific care gaps before they started. This allowed the research team to provide “timely feedback” and manage the project better at each institution by identifying outliers in the PI datasets. A previously featured article in this month’s “Back to School” Tweet Fest mentioned incorporation of VTE prophylaxis therapies into order sets, and how this was effective. Notably, we see the same in this study: “the PI specialists at all 3 participating hospitals saw marked improvement once order sets included the metrics.”

Look at this article for its insights into quality improvement, implementation science, and educational methods. It is also nicely written and described, with model writing and brevity for a research report—especially remarkable given the number of study authors. Finally, note that Derek Dietze, Editor-in-Chief of CE Measure, participated in this large PI-CME study on improving care practices for diabetes, one of the most challenging epidemiological issues in the United States.

References cited:
Lapolla J, Morrice A, Quinn S, et al. Diabetes management in the hospital setting: a performance improvement continuing medical education program. CE Meas. 2013;7(1):54-60. doi:10.1532/CEM08.12103. doi:10.1532/CEM08.12103. http://www.cardenjenningspublishing.com/journal/index.php/cem/article/view/116. Accessed September 10, 2015. [FREE full text]
Brady ED, Binford SH. How to write sound educational outcomes questions: a focus on knowledge and competence assessments [series: “Beginner’s Guide to Measuring Educational Outcomes in CEhp”]. The Almanac. 2015;37(5):4-9. http://www.acehp.org/p/do/sd/topic=216&sid=811. Accessed September 10, 2015. [Full text]
Raffini L, Trimarchi T, Beliveau J, Davis D. Thromboprophylaxis in a pediatric hospital: a patient-safety and quality-improvement initiative. Pediatrics. 2011 May;127(5):e1326-32. doi: 10.1542/peds.2010-3282. http://pediatrics.aappublications.org/content/127/5/e1326.full.pdf+html. Accessed September 8, 2015. [FREE full text (Pediatrics final version)]

Tuesday, September 8, 2015

Implementation Science Extends Multidisciplinary Education on VTE Prophylaxis at World-Class Children’s Hospital

Let’s continue yesterday's thread with venous thromboembolism (VTE) education in a new patient population: children. In this quality improvement article, Raffini et al point out that while risks of VTE are far lower in children than in adults, children still need clinicians to maintain an appropriate level of suspicion and take action on VTE risk with prophylaxis.

What a nice way to phrase a practice gap and the need to narrow that gap: “VTE prophylaxis for patients at risk is often overlooked in pediatric health care institutions, which provides an opportunity to improve patient care.” Even at the world-class Children’s Hospital of Philadelphia (CHOP) at the University of Pennsylvania, children and adolescents were not receiving an appropriate level of risk assessment and prophylaxis, leading researchers to undertake this four-year quality improvement study.

CME/CEhp initiatives often do not extend into local facilities, but this study used reinforcing methods of implementation science to communicate and support the desired behaviors and tasks. These extended “multidisciplinary educational forums” into patient-care settings. Here’s a summary of the intervention’s rollout of CHOP’s locally established guidelines to “encourage timely initiation of thromboprophylaxis." These interventions included 1) VTE risk assessment in the nursing admission intake forms; 2) a VTE-prophylaxis order set implemented into the computerized ordering system; 3) ICU nurses assessing VTE risk and preventive practice daily during team rounds; 4) trials of various pneumatic compression devices with appropriate sizing for children; 5) acquisition of more compression devices with storage near high-risk areas; and 6) development of a protocol for perioperative nurses to initiate pneumatic compression before surgery for certain patients, later expanded to all inpatient settings.

So was extension of multidisciplinary education into care settings, using methods of implementation science, effective? YES. The study’s primary outcome measure was “compliance with thromboprophylaxis guidelines in patients at risk for VTE.” Clinically meaningful improvements were seen: “Over the 4-year study period, the observed rate of VTE prophylaxis in patients at risk increased from a baseline of 22% to an average rate of 82%, and there were intermittent improvements up to 100%.” Implementation science methods, when added to multidisciplinary clinical education, quadrupled or even quintupled guidelines-based care in an underserved population.

There’s also a nice feature to point out to those watching IRB “requirements” that peer-reviewed journals increasingly expect of performance-change initiatives: “This project was a quality-improvement activity and exempt from review from the institutional review board at the Children's Hospital of Philadelphia.” The QI initiative was not seen as human subjects research (HSR).

Reference cited: Raffini L, Trimarchi T, Beliveau J, Davis D. Thromboprophylaxis in a pediatric hospital: a patient-safety and quality-improvement initiative. Pediatrics. 2011;127(5):e1326-32. PMID: 21464186.
See also the ACCP and ICSI guidelines linked from the September 7, 2015 post (http://fullcirclece.blogspot.com/2015/09/pharmacy-education-for-hospital.html)
PubMed: http://www.ncbi.nlm.nih.gov/pubmed/21464186
Free full text (Pediatrics final version): http://pediatrics.aappublications.org/content/127/5/e1326.full.pdf+html
MeSH *Major* terms: Anticoagulants/administration & dosage*; Guideline Adherence*; Patient Selection*; Primary Prevention/organization & administration*; Venous Thromboembolism/prevention & control*
(And for those of you who love MeSH and UMLS, many quality-improvement and program change-related MeSH terms were assigned by NLM but not starred as “major” terms.)

Monday, September 7, 2015

Pharmacy Education for Hospital Clinicians on VTE Prophylaxis Changed Performance, Bringing Guideline-Adherent Care To Most Patients

Earlier today, I wrote of interprofessional clinical education regarding team communication during cardiac surgery. Now I continue the theme of nonphysician education by highlighting contributions of pharmacy education to patient care, and one that particularly relates to (post)surgical care. While this month’s Back-to-School campaign (illustrating published educational outcomes) mainly features recent articles, this 2005 study by Dobesh and Stacy in the Journalof Managed Care Pharmacy (free full text available) is a worthy read for its contributions to quality care research from the pharmacy perspective and scope of practice.

Venous thromboembolism (VTE and/or DVT, PE) is a great concern among surgeons and other physicians. In fact, the VTE evidence-basedguideline by the Institute for Clinical Systems Improvement (ICSI; Jobin et al 2012) names 10 stakeholder groups—including physicians and pharmacists—as “intended users.” The current article used the 2004 American College of Chest Physicians (ACCP) recommendations. Effectively preventing VTE can dictate the chances of successful outcomes and reduce patient readmission rates for many conditions. Because of the challenges of selecting the optimal anticoagulant agent and dosage for individual patients, pharmacists can clearly collaborate with physicians in making decisions about VTE prophylaxis. The 2012 guideline considered pharmacological thromboprophylaxis with unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), fondaparinux, warfarin, aspirin, apixaban, dabigatran, and rivaroxaban—enough therapeutic options to suggest the need for consultation between physicians and pharmacists.

The pharmacy intervention for nurses, pharmacists, and physicians in the community hospital was traditional in instructional format, involving reinforcing in-service and quality-assurance presentations, as well as newsletters. The educational outcomes assessment method was more notable, using retrospective chart reviews with statistically similar patients before and after the educational intervention (15 months of patient charts before, and 6 months after). Patient chart reviews showed statistically significant and clinically meaningful change in VTE prophylaxis performance in practice. Specifically, both “suitable” and “optimal” prophylaxis increased (P = .006 and P < .0001 respectively), with a fourfold increase in the optimally treated percentage of patients associated with pharmacy education of physicians, nurses, and pharmacists.

These data show that traditional educational initiatives developed by one health care profession for others can be effective in changing performance, especially when guidelines for practice and risk categories are presented in reinforcing text-based and live formats. This intervention brought guideline-adherent care to 93% of patients with risk, up from 49% before the intervention.

References cited:
Dobesh PP, Stacy ZA. Effect of a clinical pharmacy education program on improvement in the quantity and quality of venous thromboembolism prophylaxis for medically ill patients. J Manag Care Pharm. 2005;11(9):755-62. PMID: 16300419.
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:338S-400S. PMID: 15383478.
Jobin S, Kalliainen L, Adebayo L, et al. Venous thromboembolism prophylaxis. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012. Available at: http://www.guideline.gov/content.aspx?id=39350. Accessed September 7, 2015.

PubMed: http://www.ncbi.nlm.nih.gov/pubmed/16300419
Journal Free Full Text: http://amcp.org/data/jmcp/contemporary_755-762.pdf
MeSH *Major* terms: Health Personnel/education; Heparin, Low-Molecular-Weight/therapeutic use; Inservice Training; Thromboembolism/prevention & control; Venous Thrombosis/prevention & control

Mixed-Methods Study Improves Team Communication After Non-Didactic Interprofessional Education on Cardiac Surgical Crisis

It would be hard to imagine a more crucial setting for effective interdisciplinary clinical interactions than the cardiac surgery operating theater. Stevens and colleagues published this 2012 pilot study on interprofessional education to “sharpen performance of experienced cardiac surgical teams in acute crisis management.”

The educational methods support existing effectiveness research for non-didactic education, incorporating both interactive workshops for an entire care unit and computer-based, crisis-case simulations (whose “high-realism” scenarios improved over time). Researchers found that 82% of the 79 participants recommended repetition of case simulations every 6 – 12 months. Workshop participants identified priorities in “encouraging speaking up about critical information and interprofessional information sharing,” particularly early communication of the surgical plan.

The mixed-methods outcomes assessment methodology is also noteworthy because of its appropriateness to this study of human communications and behaviors during a patient crisis: the structured interviews with study participants added context and insights to the quantitative data that could be gathered from periodic surveys. The surveys that were administered before, just after, and 6 months after the educational activities noted that the “concept of working as a team improved between surveys,” as well as “trends for improvement in gaining common understanding of the plan before a procedure and appropriate resolution of disagreements.” The qualitative arm of the study found that interviewees valued the initiative’s “positive effect on their personal behaviors and patient care, including speaking up more readily and communicating more clearly.”

In the continuing medical education field, we often see the Canadians leading educational research, standards, and innovative methods. In fact, looking only at the U. S. National Library of Medicine’s assignment of Medical Subject Headings (MeSH terms) to this indexed article shows the relevance of this study for medical education methods for promoting competence in decision-making, performance-in-practice change, and quality improvement (see “major” MeSH terms listed below, and others on the PubMed page). One hopes to see a follow-up on this pilot study at the Centre Hospitalier Universitaire de Montréal (Quebec, Canada).

PubMed: http://www.ncbi.nlm.nih.gov/pubmed/22502966

MeSH *Major* terms: Cardiac Surgical Procedures/education; Clinical Competence; Critical Care/standards; Education, Medical, Continuing/methods; Patient Care Team/organization & administration

Saturday, September 5, 2015

ACEhp’s President Ed Dellert Co-Authored COPD CME Mayo Clinic Article With Robust Follow-Up Data

Mayo Clinic Proceedings published this free 2012 article by SG Adams (University of Texas Health Science Center) and colleagues on an educational change intervention on chronic obstructive pulmonary disease (COPD) among primary care clinic. What’s more, our own Alliance for CE in the Health Professions president, Ed Dellert, is a co-author!

There was a clear educational gap among target clinicians: The authors report that, “before the program, 173 of 320 participants (54.1%) had never used the Global Initiative for Chronic Obstructive Lung Disease recommendations for COPD.” Those of us who collect educational outcomes data can applaud the tremendous follow-up survey’s response rate of 48.7% of the 313 participants. We all struggle with the problematic use of self reported performance data in CEhp outcomes articles; the authors even acknowledge this, stating, “physician self assessment is unreliable” (Methods). Yet, this article is impressive because of its inclusion of the word “completely: “Of the follow-up survey respondents, 92 of 132 (69.7%) reported completely implementing at least one clinical practice change.” This helps us appreciate the knowledge and comprehension data reported as increasing significantly, as well as the value of improved self-confidence developed through CME/CEhp. Confidence is a measure of competence (Moore’s Level 4), and competence is, to me, “the glue that sticks” knowledge to performance-in-practice.

The initiative featured systematic instructional design methods using the Analysis, Design, Development, Implementation, and Evaluation (ADDIE) approach. This construct was followed by a team of educators and medical experts from multiple disciplines, particularly from the American College of Chest Physicians and American Academy of Nurse Practitioners. Especially interesting for us instructional designers, the team used “self-directed learning” and “case and problem-based learning” before ever beginning “lecture-based learning” (Table 1), indicating that they incorporated the benefits of exploration in scientific learning that ideally occurs before the didactic introduction of terms (per the Learning Cycle teaching model).

To challenge medical educators, I ask that we all continue to look for and share CEhp studies that feature professional instructional design that other clinical sites and educational teams can reproduce. This will help us highlight Why We Matter. So I close with the image that my educational outcomes colleague, Wendy Turell, tweeted (@WTevalu8), showing Ed Dellert discussing Why We Matter at the Alliance Industry Summit in May 2015.

PubMed: http://www.ncbi.nlm.nih.gov/pubmed/22958990
PubMed Central: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538496/
MeSH *Major* terms: Clinical Competence; Education, Medical, Continuing; Physicians, Primary Care/education; Pulmonary Disease, Chronic Obstructive/diagnosis; Pulmonary Disease, Chronic Obstructive/therapy

Wednesday, September 2, 2015

Open-Access Article on Interprofessional Care and Team Learning for Delirium in Hospital

A few years ago, I asked a nurse practicing in the hospital in my neighborhood whether she would be interested in continuing education on any particular topic. Given such an opening, her response probably had the benefit of the being the topmost concern in her daily practice, although one might disagree that this is the case. What CE did she request? Diagnosing and managing DELIRIUM.

This article by Peterson et al features interprofessional education and team-based learning on delirium in patients recovering from hip fracture surgery at Eisenhower Medical Center. With an aging population and hip fracture as a potentially fatal injury within the first 30 days, this study informs us on a topic that is relevant to hospital care providers with education that also could widely improve patient health outcomes in this practice setting.

Even better … CE Measure is a peer-reviewed, open-access journal, so you can link to the full article here and now.

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