Vertigo is a common clinical manifestation in the emergency department (ED). It is important for physicians to determine if the peripheral cause of vertigo is benign paroxysmal positional vertigo (BPPV), a disorder accounting for 20% of all vertigo cases. However, the Dix-Hallpike test—the standard for BPPV diagnosis—is not common in the ED setting. If no central origin of the vertigo is determined, patients in the ED are typically treated with benzodiazepine, antihistamine, or anticholinergic agents. Studies have shown that these pharmaceutical treatment options may not be the best for patients with BPPV.
The authors describe a case of a 38-year-old woman who presented to the ED with complaints of severe, sudden-onset vertigo. The patient's BPPV was diagnosed by means of a Dix-Hallpike test and the patient was acutely treated in the ED with physical therapy using the canalith repositioning maneuver.
Wednesday, June 22, 2011
A multi-institutional quality improvement initiative to transform education for chronic illness care in resident continuity practices
BACKGROUND: There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care.
OBJECTIVE: To improve training for residents who provide chronic illness care in teaching practice settings.
DESIGN: US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure <or=130/80-and three process measures-retinal and foot examinations, and patient self-management goals-were tracked.
PARTICIPANTS: Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives.
INTERVENTIONS: Teaching-practice teams-faculty, residents and staff-participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly.
RESULTS: Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives.
CONCLUSIONS: These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable.
OBJECTIVE: To improve training for residents who provide chronic illness care in teaching practice settings.
DESIGN: US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure <or=130/80-and three process measures-retinal and foot examinations, and patient self-management goals-were tracked.
PARTICIPANTS: Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives.
INTERVENTIONS: Teaching-practice teams-faculty, residents and staff-participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly.
RESULTS: Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives.
CONCLUSIONS: These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable.
Using the Teamlet Model to improve chronic care in an academic primary care practice
BACKGROUND: Team care can improve management of chronic conditions, but implementing a team approach in an academic primary care clinic presents unique challenges.
OBJECTIVES: To implement and evaluate the Teamlet Model, which uses health coaches working with primary care physicians to improve care for patients with diabetes and/or hypertension in an academic practice.
DESIGN: Process and outcome measures were compared before and during the intervention in patients seen with the Teamlet Model and in a comparison patient group.
PARTICIPANTS: First year family medicine residents, medical assistants, health workers, and adult patients with either type 2 diabetes or hypertension in a large public health clinic.
INTERVENTION: Health coaches, in coordination with resident primary care physicians, met with patients before and after clinic visits and called patients between visits.
MEASUREMENTS: Measurement of body mass index, assessment of smoking status, and formulation of a self-management plan prior to and during the intervention period for patients in the Teamlet Model group. Testing for LDL and HbA1C and the proportion of patients at goal for blood pressure, LDL, and HbA1C in the Teamlet Model and comparison groups in the year prior to and during implementation.
RESULTS: Teamlet patients showed improvement in all measures, though improvement was significant only for smoking, BMI, and self-management plan documentation and testing for LDL (p = 0.02), with a trend towards significance for LDL at goal (p = 0.07). Teamlet patients showed a greater, but non-significant, increase in the proportion of patients tested for HbA1C and proportion reaching goal for blood pressure, HgbA1C, and LDL compared to the comparison group patients. The difference for blood pressure was marginally significant (p = 0.06). In contrast, patients in the comparison group were significantly more likely to have had testing for LDL (P = 0.001).
CONCLUSIONS: The Teamlet Model may improve chronic care in academic primary care practices.
OBJECTIVES: To implement and evaluate the Teamlet Model, which uses health coaches working with primary care physicians to improve care for patients with diabetes and/or hypertension in an academic practice.
DESIGN: Process and outcome measures were compared before and during the intervention in patients seen with the Teamlet Model and in a comparison patient group.
PARTICIPANTS: First year family medicine residents, medical assistants, health workers, and adult patients with either type 2 diabetes or hypertension in a large public health clinic.
INTERVENTION: Health coaches, in coordination with resident primary care physicians, met with patients before and after clinic visits and called patients between visits.
MEASUREMENTS: Measurement of body mass index, assessment of smoking status, and formulation of a self-management plan prior to and during the intervention period for patients in the Teamlet Model group. Testing for LDL and HbA1C and the proportion of patients at goal for blood pressure, LDL, and HbA1C in the Teamlet Model and comparison groups in the year prior to and during implementation.
RESULTS: Teamlet patients showed improvement in all measures, though improvement was significant only for smoking, BMI, and self-management plan documentation and testing for LDL (p = 0.02), with a trend towards significance for LDL at goal (p = 0.07). Teamlet patients showed a greater, but non-significant, increase in the proportion of patients tested for HbA1C and proportion reaching goal for blood pressure, HgbA1C, and LDL compared to the comparison group patients. The difference for blood pressure was marginally significant (p = 0.06). In contrast, patients in the comparison group were significantly more likely to have had testing for LDL (P = 0.001).
CONCLUSIONS: The Teamlet Model may improve chronic care in academic primary care practices.
Implementation of a chronic illness model for diabetes care in a family medicine residency program
INTRODUCTION: While the Chronic Care Model (CCM) has been shown to improve the care of patients with chronic illnesses, primary care physicians have been unprepared in its use, and residencies have encountered challenges in introducing it into the academic environment.
AIM: Our residency program has implemented a diabetes management program modeled on the CCM to evaluate its impact on health outcomes of diabetic patients and educational outcomes of residents.
SETTING: University-affiliated, community-based family medicine residency program.
PROGRAM DESCRIPTION: Six residents, two faculty clinicians, and clinic staff formed a diabetes management team. We redesigned the outpatient experience for diabetic patients by incorporating elements of the CCM: multidisciplinary team care through planned and group visits; creation of a diabetes registry; use of guidelines-based flow sheets; and incorporation of self-management goal-setting. Residents received extensive instruction in diabetes management, quality improvement, and patient self-management.
PROGRAM EVALUATION: We achieved overall improvement in all metabolic and process measures for patients, with the percentage achieving HbA1c, LDL, and BP goals simultaneously increasing from 5.7% to 17.1%. Educational outcomes for residents, as measured by compliance with review of provider performance reports and self-management goal-setting with patients, also significantly improved.
DISCUSSION: Through a learning collaborative experience, residency programs can successfully incorporate chronic care training for residents while addressing gaps in care for patients with diabetes.
AIM: Our residency program has implemented a diabetes management program modeled on the CCM to evaluate its impact on health outcomes of diabetic patients and educational outcomes of residents.
SETTING: University-affiliated, community-based family medicine residency program.
PROGRAM DESCRIPTION: Six residents, two faculty clinicians, and clinic staff formed a diabetes management team. We redesigned the outpatient experience for diabetic patients by incorporating elements of the CCM: multidisciplinary team care through planned and group visits; creation of a diabetes registry; use of guidelines-based flow sheets; and incorporation of self-management goal-setting. Residents received extensive instruction in diabetes management, quality improvement, and patient self-management.
PROGRAM EVALUATION: We achieved overall improvement in all metabolic and process measures for patients, with the percentage achieving HbA1c, LDL, and BP goals simultaneously increasing from 5.7% to 17.1%. Educational outcomes for residents, as measured by compliance with review of provider performance reports and self-management goal-setting with patients, also significantly improved.
DISCUSSION: Through a learning collaborative experience, residency programs can successfully incorporate chronic care training for residents while addressing gaps in care for patients with diabetes.
Linking a motivational interviewing curriculum to the chronic care model
BACKGROUND: Unhealthy lifestyle choices frequently cause or worsen chronic diseases. Many internal medicine residents are inadequately trained to provide effective health behavior counseling, in part, due to prioritization of acute care in the traditional model of medical education and to other systemic barriers to teaching psychosocial aspects of patient care.
AIM: To address this gap in training, we developed and piloted a curriculum for a Primary Care Internal Medicine residency program that links a practical form of motivational interviewing (MI) training to the self-management support (SMS) component of the chronic care model.
PARTICIPANTS AND SETTING: All 30 primary care residents at Alameda County Medical Center were trained in the curriculum since it was initiated in 2007 during the California Academic Chronic Care Collaborative.
PROGRAM DESCRIPTION: Residents participated in three modules during which the chronic care model was introduced and motivational interviewing skills were linked to the model's self-management support component. This training was then reinforced in the clinical setting. Case-based interactive instruction, teaching videotapes, group role-plays, faculty demonstration, and observation of resident-patient interactions in the clinical setting were used to teach the curriculum.
PROGRAM ASSESSMENT: A preliminary, qualitative assessment of this curriculum was done from a program standpoint and from the perspective of the learners. Residents reported increased sense of confidence when approaching patients about health behavior change. Faculty directly observed residents during clinical encounters using MI and SMS skills to work more collaboratively with patients and to improve patient readiness for self-management goal setting.
CONCLUSION: A curriculum that links motivational interviewing skills to the chronic care model's self-management support component and is reinforced in the clinical setting is feasible to develop and implement. This curriculum may improve residents' confidence with health behavior counseling and with preparing patients to become active participants in management of their chronic conditions.
AIM: To address this gap in training, we developed and piloted a curriculum for a Primary Care Internal Medicine residency program that links a practical form of motivational interviewing (MI) training to the self-management support (SMS) component of the chronic care model.
PARTICIPANTS AND SETTING: All 30 primary care residents at Alameda County Medical Center were trained in the curriculum since it was initiated in 2007 during the California Academic Chronic Care Collaborative.
PROGRAM DESCRIPTION: Residents participated in three modules during which the chronic care model was introduced and motivational interviewing skills were linked to the model's self-management support component. This training was then reinforced in the clinical setting. Case-based interactive instruction, teaching videotapes, group role-plays, faculty demonstration, and observation of resident-patient interactions in the clinical setting were used to teach the curriculum.
PROGRAM ASSESSMENT: A preliminary, qualitative assessment of this curriculum was done from a program standpoint and from the perspective of the learners. Residents reported increased sense of confidence when approaching patients about health behavior change. Faculty directly observed residents during clinical encounters using MI and SMS skills to work more collaboratively with patients and to improve patient readiness for self-management goal setting.
CONCLUSION: A curriculum that links motivational interviewing skills to the chronic care model's self-management support component and is reinforced in the clinical setting is feasible to develop and implement. This curriculum may improve residents' confidence with health behavior counseling and with preparing patients to become active participants in management of their chronic conditions.
The role for clinician educators in implementing healthcare improvement
Clinician educators-who work at the intersection of patient care and resident education-are well positioned to respond to calls for better, safer patient care and resident education. Explicit lessons that address implementing health care improvement and associated residency training came out of the Academic Chronic Care Collaboratives and include the importance of: (1) redesigning the clinical practice as a core component of the residency curriculum; (2) exploiting the efficiencies of the practice team; (3) replacing "faculty development" with "everyone's a learner;" (4) linking faculty across learning communities to build expertise; and (5) using rigorous methodology to design and evaluate interventions for practice redesign.
There has been progress in addressing three thorny academic faculty issues-professional satisfaction, promotion and publication. For example, consensus criteria have been proposed for both faculty promotion as well as the institutional settings that nurture academic health care improvement careers, and the SQUIRE Publication Guidelines have been developed as a general framework for scholarly improvement publications. Extensive curricular resources exist for developing the expert faculty cadre. Curricula from representative training programs include quantitative and qualitative research methods, statistical methodologies appropriate for measuring systems change, organizational culture, management, leadership and scholarly writing for the improvement literature.
Clinician educators-particularly those in general internal medicine-bear the principal responsibility for both patient care and resident training in academic departments of internal medicine. The intersection of these activities presents a unique opportunity for their playing a central role in implementing health care improvement and associated residency training. However, this role in academic settings will require an unambiguous development strategy both for faculty and their institutions.
There has been progress in addressing three thorny academic faculty issues-professional satisfaction, promotion and publication. For example, consensus criteria have been proposed for both faculty promotion as well as the institutional settings that nurture academic health care improvement careers, and the SQUIRE Publication Guidelines have been developed as a general framework for scholarly improvement publications. Extensive curricular resources exist for developing the expert faculty cadre. Curricula from representative training programs include quantitative and qualitative research methods, statistical methodologies appropriate for measuring systems change, organizational culture, management, leadership and scholarly writing for the improvement literature.
Clinician educators-particularly those in general internal medicine-bear the principal responsibility for both patient care and resident training in academic departments of internal medicine. The intersection of these activities presents a unique opportunity for their playing a central role in implementing health care improvement and associated residency training. However, this role in academic settings will require an unambiguous development strategy both for faculty and their institutions.
Resident education in 2011: three key challenges on the road ahead
Two important changes in the past decade have altered the landscape of graduate medical education (GME) in the U.S. The national restrictions on trainee duty hours mandated by the Accreditation Council for Graduate Medical Education (ACGME) were the most visible and generated much controversy. Equally important is the ACGME Outcome Project, which mandates competency-based training. Both of these changes have unique implications for surgery trainees, who traditionally spent long hours caring for patients in the hospital, and who must be assessed in 2 broad domains: their medical care of pre- and postoperative patients, and their technical skill with procedures in and out of the operating room.
This article summarizes 3 key challenges that lie ahead for surgical educators. First, the changes in duty hours in the past 7 years are summarized, and the conversation about added restrictions planned for July 2011 is reviewed. Next, the current state of the assessment of competency among surgical trainees is reviewed, with an outline of the challenges that need to be overcome to achieve widespread, competency-based training in surgery. Finally, the article summarizes the problems caused by increased reliance on handoffs among trainees as they compensate for decreased time in the hospital, and suggests changes that need to be made to improve safety and efficiency, including how to use handoffs as part of our educational evaluation of residents.
This article summarizes 3 key challenges that lie ahead for surgical educators. First, the changes in duty hours in the past 7 years are summarized, and the conversation about added restrictions planned for July 2011 is reviewed. Next, the current state of the assessment of competency among surgical trainees is reviewed, with an outline of the challenges that need to be overcome to achieve widespread, competency-based training in surgery. Finally, the article summarizes the problems caused by increased reliance on handoffs among trainees as they compensate for decreased time in the hospital, and suggests changes that need to be made to improve safety and efficiency, including how to use handoffs as part of our educational evaluation of residents.
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