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.

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

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.

Problem definition

Performance feedback, in which clinicians are given data on select metrics, is widely used in the context of quality improvement. However, there is a lack of practical guidance describing the process of developing performance feedback systems.

Initial approach

This study took place at the University of California, San Francisco (UCSF) with hospitalist physicians. Participatory design methodology was used to develop a performance dashboard and feedback system. Twenty hospitalist physicians participated in a series of six design sessions and two surveys. Each design session and survey systematically addressed key components of the feedback system, including design, metric selection, data delivery, and incentives. The Capability Opportunity Motivation and Behavior (COM-B) model was then used to identify behavior change interventions to facilitate engagement with the dashboard during a pilot implementation.

Key insights, lessons learned

In regard to performance improvement, physicians preferred collaboration over competition and internal motivation over external incentives. Physicians preferred that the dashboard be used as a tool to aid in clinical practice improvement and not punitively by leadership. Metrics that were clinical or patient-centered were perceived as more meaningful and more likely to motivate behavior change.

Next steps

The performance dashboard has been introduced to the entire hospitalist group, and evaluation of implementation continues by monitoring engagement and physician attitudes. This will be followed by targeted feedback interventions to attempt to improve performance.

Background

Following up on patients' clinical courses after hospital discharge may enhance physicians' learning and care of future patients. Barriers to this practice for residents include time constraints, discontinuous training environments, and difficulty accessing patient information.

Objective

We designed an educational intervention facilitating informed self-assessment and reflection through structured postdischarge follow-up of patients' longitudinal clinical courses. We then examined the experience of interns who received this intervention in a mixed methods study.

Methods

Internal medicine interns on a 4-week patient safety rotation received lists of hospitalized patients they had cared for earlier in the year. They selected patients for chart review and completed a guided reflection worksheet for each patient reviewed. Interns then discussed lessons learned in a faculty-led group debrief session.

Results

Of 62 eligible interns, 62 (100%) participated in this intervention and completed 293 reflection worksheets. We analyzed worksheets and transcripts from 6 debrief sessions. Interns reported that postdischarge patient follow-up was valuable for their professional development, and helped them understand the natural history of disease and patients' illness experiences. After reviewing their patients' clinical courses, interns stated that they would advocate for earlier end-of-life counseling, improve care transitions, and adjust their clinical decision-making for similar patients in the future.

Conclusions

Our educational intervention created the time, space, and structure for postdischarge patient follow-up. It was well received by participants, and is an opportunity for experiential learning.

It is unclear whether previously developed frameworks for effective consultation apply to requests initiated by alphanumeric text page. We assessed a random sample of 210 text paged consult requests for communication of previously described 'essential elements' for effective consultation: reason for consult, level of urgency and requester contact information. Overall page quality was evaluated on a 5-point Likert scale. Over 90% of text paged consult requests included contact information and reason for consult; 14% indicated level of urgency. In ordinal logistic regression, reason for consult was most strongly associated with quality (OR 22.4; 95% CI 8.1 to 61.7), followed by callback number (OR 6.2; 95% CI 0.8 to 49.5), caller's name (OR 5.0; 95% CI 1.9 to 13.1) and level of urgency (OR 3.3; 95% CI 1.6 to 6.7). Results suggest that text paged consult requests often include most informational elements, and that urgency, often missing, may not be as 'essential' for text pages as it was once thought to be.

Background

Several care transition interventions propose that post-discharge phone calls can reduce adverse events and decrease costly return visits to the hospital. However, given the multi-faceted nature of most care transitions interventions, the true relationship between post-discharge phone calls and readmissions in a real world setting is uncertain.

Objective

To determine the effect of receiving a post-discharge telephone call on all-cause 30-day readmission in a general medicine population.

Design

Retrospective observational study.

Participants

Patients discharged home from the Medicine Service at a tertiary care academic medical center between November 2010 and May 2012.

Intervention

Patients received two telephone call attempts by a nurse within 72 h of discharge. Nurses followed a standard script to address issues associated with readmission.

Main outcome and measures

Billing data captured readmissions. We used logistic regression-adjusted patient and clinical covariates as well as a propensity score representing likelihood of being called to determine the association between call receipt and risk for readmission.

Key results

There were 5,507 eligible patients. In unadjusted analyses, patients who received a call and completed the intervention were significantly less likely to be readmitted compared to those who did not [155 (5.8 %) vs 123 (8.6 %), p < 0.01]. In multivariable models adjusting for socio-demographic and clinical covariates alone, completing a post-discharge telephone call intervention was associated with lower odds for readmission (AOR 0.71; 95 % CI: 0.55-0.91). However, when models adjusted for the likelihood of receiving the phone call using the propensity score, no association between call receipt and readmission was observed (AOR 0.91; 95%CI: 0.69-1.20).

Conclusions

Effectiveness of post-discharge phone call programs may be more related to whether patients are able to answer a phone call than to the care delivered by the phone call. Programs would benefit from improving their ability to perform phone outreach while simultaneously improving on the care delivered during the calls.

Background

Effective pain management among hospitalized patients is an important aspect of providing quality care and achieving optimal clinical outcomes and patient satisfaction. Common pharmacologic approaches for pain, though effective, have serious side effects and are not appropriate for all inpatients. Findings from randomized controlled trials (RCTs) support the efficacy of acupuncture for many symptoms relevant to inpatients including postoperative pain, cancer-related pain, nausea and vomiting, and withdrawal from narcotic use. However, the extent to which findings from RCTs translate to real-world implementation of acupuncture in typical hospital settings is unknown.

Methods/design

In partnership with the launch of a clinical program offering acupuncture services to inpatients at the University of California San Francisco's Mount Zion Hospital, we are conducting a pilot study using a hybrid effectiveness-implementation design to: (1) assess the effectiveness of acupuncture to manage pain and other symptoms and improve patient satisfaction; and (2) evaluate the barriers and facilitators to implementing an on-going acupuncture service for inpatients. During a two-month pre-randomization phase, we evaluated and adapted clinical scheduling and treatment protocols with acupuncturists and hospital providers and pretested study procedures including enrollment, consent, and data collection. During a six-month randomization phase, we used a two-tiered consent process in which inpatients were first consented into a study of symptom management, randomized to be offered acupuncture, and consented for acupuncture if they accepted. We are also conducting in-depth interviews and focus groups to assess evidence, context, and facilitators of key provider and hospital administration stakeholders.

Discussion

Effectiveness research in "real-world" practice settings is needed to inform clinical decision-making and guide implementation of evidence-based acupuncture practices. To successfully provide clinical acupuncture services and maintain a rigorous research design, practice-based trials of acupuncture require careful planning and attention to setting-specific, contextual factors.

Trial registration

This trial has been registered in ClinicalTrials.gov. The identifier is NCT01988194, registered on November 5, 2013.