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Wellness Wednesday: Utilization of Strategic Duty-free Hours by OB/GYN Residents

Purpose: To detail the specifics of how OB/GYN residents utilize a monthly duty-free afternoon for wellness activities. 

 

Background: Much attention is paid to burnout and high rates of depression among physicians. Some speculate these difficulties may start in medical school but that they become cemented and sometimes problematic in residency. Studies have made implications that interventions, specifically promotion of self-care and work-family balance, and work hour restrictions, early in residency can decrease burnout and depression levels.  

 

Methods: Starting in 2016, all residents of an OB/GYN program were allowed to have the first Wednesday afternoon of each month free from clinical duties. Faculty members covered all clinical services from noon to 5pm. Residents were then permitted to use the time for whatever they felt promoted their well-being. Two years of data were collected through surveys to determine the specific activities completed by the residents. 

 

Results: The commonly reported activities included health care visits, financial planning activities, leisure time with family/friends, community or church group events, every day errands, home chores, and fitness. Additionally, the residents also used the time away from clinical responsibilities to study and fulfill administrative requirements. 

 

Discussions: By better understanding what residents choose to do to promote their own well-being, programs can then tailor structured wellness activities to those choices.  Alternatively, programs can look at an open-ended wellness day as a possible intervention for fostering excellent overall health and welfare of their residents. More research is needed to validate this approach to wellness promotion.

 

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Professionalism, Systems-Based Practice & Improvement, GME, CME, UME, Quality & Safety,

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Trends in Off-Service Rotations in Ob/Gyn Residencies Before and After Duty Hour Restrictions

Purpose: To establish trends in off-service rotations in OB/GYN residencies before and after duty hour restrictions.

 

Background: As co-morbidities in our patient population increases, the skills required of OB/GYNs are changing, we sought to determine the characteristics of off service rotations.

 

Methods: We searched websites of ACGME accredited OB/GYN residency programs. We collected data on off service rotations: services, number of rotations, and PGY year of rotations. Surveys were emailed to programs regarding off service rotations in 2018 and before duty hour changes in 2003.

 

Results: 92% (n=259) of programs had information available on off-service rotations, of these, 24% (n=62) had no off-service rotations, 26% (n=67) had 1, 25% (n=66) had 2, 13% (n=34) had 3, 12% (n=30) had 4 or more. The majority (84%) of rotations were in PGY1. The most common rotations were ER (47%, n=122), SICU (24%, n=62), IM (25%, n=66), MICU (9%, n=23). We received 53 responses to the survey (19% response rate). Of those who responded, the most common rotations for 2018 and before 2003 were ER & SICU. The number of programs with SICU rotations remained stable from 2003 to 2018 (43% vs 47%) compared to 1.4 fold decrease in programs with ER rotations. The number of programs with IM rotations decreased 2.5 fold from before 2003 to 2018.

 

Discussions: Duty hour restrictions have affected off-service rotations. A quarter of all programs have no off-service rotations, with a decrease in ER and IM exposure during residency. This does not reflect the breadth of knowledge required of OB/GYNs today.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Residency Director, Residency Coordinator, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Quality & Safety, General Ob-Gyn, CREOG & APGO Annual Meeting, 2019, Student, Resident, Clerkship Director, Residency Director, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, UME, Team-Based Learning,

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Simulation Training for Operative Vaginal Delivery Among Obstetrics and Gynecology Residents: A Systematic Review

Purpose: To evaluate the impact of simulation training of operative vaginal delivery (OVD) on learner technique, operator comfort, and patient-centered outcomes.

 

Background: Obstetric simulation affords learners opportunities to acquire and to refine clinical skills in a low-stress environment while potentially improving patient outcomes.  However, the effect of simulation on OVD training is less clear. 

 

Methods: A systematic research protocol was constructed a priori for the conduct of the literature search, study selection, data abstraction and data synthesis.  Electronic databases were searched for educational randomized trials and observational studies assessing OVD simulation training for OBGYN residents.   The educational domains of knowledge, skills and attitudes were evaluated.  The Medical Education Research Study Quality Instrument (MERSQI) was used to assess study quality.  The review was prospectively registered with PROSPERO.

 

Results: The search strategy yielded 30,812 articles, with 7 articles eligible for analysis (2 cohort studies, 1 case-control study, 4 cross-sectional studies).  No randomized trials were identified.  Studies demonstrated simulation to improve learners’ skill with forceps placement and generated force during extraction.  While forceps simulation had no change in procedure failure rates, there were significant decreases in rates of maternal lacerations, neonatal injury, and special-care nursery admission.  Only one study evaluated the effect of simulation on provider comfort, demonstrating increased provider comfort with vacuum-assisted delivery. The median MERSQI score was 9.5 (range 9.0-13.5), indicating low-to-moderate quality.

 

Discussions: The available evidence suggests improvement in technique, comfort, and patient outcomes with OVD simulation, but additional studies are required to further characterize such benefits for both forceps and vacuum.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Osteopathic Faculty, Residency Director, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Assessment, Simulation, Quality & Safety, Maternal-Fetal Medicine, General Ob-Gyn,

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Saving Lives: Students Enhancing Patient Health Literacy Regarding Hypertension in Pregnancy and Prenatal Aspirin

Purpose: To increase medical student’s knowledge, behavior and belief systems regarding hypertension (HTN) in pregnancy and prenatal aspirin (PNA). To increase patient\'s understanding regarding the complications of HTN in pregnancy and the benefits of PNA.

 

Background: Prenatal aspirin (81 mg) has been recommended by ACOG for high-risk women and women with >1 moderate risk factor. Its use reduces the rate of preeclampsia, preterm birth, intrauterine growth restriction and fetal death in at-risk patients. In a survey conducted at Boston Medical Center, the incidence of hypertension in pregnancy is 30%, with only 15% of patient having heard of PNA, demonstrating high prevalence and low patient literacy regarding the topic.

 

Methods: Ob/Gyn clerkship students are instructed to educate patients regarding: knowledge of HTN in pregnancy, warning signs of preeclampsia, and efficacy of PNA in pregnancy. The student educational intervention was evaluated regarding: satisfaction, knowledge, confidence, and belief systems by surveys at the beginning and end of the clerkship. Patient education was evaluated by pre and post intervention metrics.

 

Results: Student knowledge of PNA and HTN increased 35%, confidence 45% and belief systems 14%. They gave the project a 72% satisfaction rating. Patient’s knowledge about HTN increased 48%, warning signs 80%, and understanding of efficacy of PNA 65%.

 

Discussions: Medical student health counseling increased patient knowledge regarding HTN and PNA. By educating patients, students also increased their knowledge and confidence in the subject. We plan to continue implementing this QI project throughout the year to augment a departmental QI initiative and evaluate its benefit to patients and students.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, UME, Quality & Safety, Advocacy,

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Perceptions Regarding Medical Students Performing Pelvic Examinations on Anesthetized Female Patients

Purpose: The purpose of this study was to determine perceptions regarding medical students performingpelvic examinations on anesthetized female patients.

 

Background: Pelvic exams performed under anesthesia continues to be a controversial topic, but studies looking at medical staff are lacking.

 

Methods: An internet based survey was distributed to OB/GYNs, OR nurses/techs,anesthesiologists/CRNAs, and medical students at multiple hospitals and medical schools.Demographic data were collected. Non-demographic answers to questions were recorded on a 5-point scale. Characteristics between the respondent groups were statistically compared usingChi-squared test for independence and the Fisher’s Exact Test.

 

Results: 337surverys were completed. 72% of respondents believed permission should be obtained from patientsprior to the performance of EUAs by medical students on anesthetized femalepatients. 30% of respondents believed prior consent was usually obtained. 50% believed patients would agree to have the exams performed. 80% thought patients would be upset if an EUA by a medical student was performed on them  without their prior consent. 32% of nurses believed medical students should be allowed to examine anesthetized patients.  Medical students were less likely to believe it was appropriate for a student to examine a patient, there was an educational benefit, and that patients would consent. 

 

Discussions: Despite the perception of all OB/GYN OR team members that consent should be obtained beforemedical students perform pelvic examinations on anesthetized female patients, this does notusually occur. Almost 50% of medical students would not encourage their female relatives toconsent to medical students performing such pelvic examinations.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Patient Care, Professionalism, GME, Quality & Safety, Advocacy,

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Pain Perception in Cervical Biopsy- Variations by Patient and Provider Characteristics in an Academic Teaching Clinic

Purpose: We aim to identify factors which dependably predict patients’ experience of pain during colposcopy, and to evaluate if providers, stratified by level of training, are capable of anticipating procedural pain.

 

Background: Cervical biopsy procedures, including colposcopy and loop electrosurgical excision procedure (LEEP), are considered non-invasive office procedures and efforts to codify their use emphasize logistics and ability to detect disease. A significant gap exists for mitigating psychological distress and procedural pain. Previous research suggests that physician assessment of procedural discomfort varies by years of experience.

 

Methods: Patients presenting to an academic gynecology practice for colposcopy with cervical biopsy or LEEP completed Pre- and Post-Procedure surveys (14- and 3-item surveys, respectively), assessing demographics, past cervical procedures, menstrual pain, and anticipated biopsy pain, among other metrics. Post-Procedure surveys assessed a numerical level of pain experienced during the biopsy. The health care provider (HCP) and procedural assistant were surveyed for perceptions of patient pain. Pain scores were evaluated using a 100mm visual analog scale.  Data analysis was performed using Spearman rank correlation, and coefficients for relevant variables were calculated.

Results: 80 patients were enrolled and 62 underwent cervical biopsy. Patients with higher anticipated pain gave higher ratings for post-procedure pain (p=0.024). Women reporting more intense periods predicted and experienced more procedural pain (p<0.001, p=0.058). From the provider perspective, HCPs correctly estimated patients’ pain when compared with the patients’ perceptions (p=0.066). However, only PGY3 and PGY4 OB/GYN residents did so with statistical significance (p=0.014) and PGY1 and PGY2 residents rated lower pain scores (p=0.039).  Male assistants rated pain lower than female assistants (p=0.037). 

 

Discussions: Providers accurately estimated patients’ pain with variation by years of training. Patient characteristics of age, anxiety, and dysmenorrhea were reliable predictors of pain levels. Our findings suggest that pre-procedure screening of patients may be helpful in directing pain reduction interventions. Additionally, years of experience may provide enhanced pain perception, suggesting future research into pain management training for junior resident physicians and medical students.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Patient Care, Practice-Based Learning & Improvement, GME, CME, Quality & Safety, General Ob-Gyn,

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Magnesium Toxicity and Medical Errors: A Multidisciplinary Simulation for Debriefing an Obstetric Emergency

Purpose: To create a simulation that improves communication during obstetric emergency and promotes a safe learning environment to debrief and evaluate medical errors.

 

Background: Simulation is known to improve communication and comfort in obstetric emergency. Little data exist regarding simulation for enhancing expertise in debriefing and evaluating system errors.

 

Methods: The simulation highlights an unresponsive patient shortly following a preterm delivery at 30 weeks gestation. The team discovers an accidental bolus of intravenous magnesium was given instead of postpartum oxytocin. Following conclusion of the simulation, participants were asked to lead a debrief session. Surveys were performed to assess participant comfort with magnesium toxicity, debriefing, evaluating a medical error, and communication during an emergency. 

 

Results: Participants felt the simulation was (1) a realistic scenario that allowed practice debriefing a medical error within a large multidisciplinary team, (2) a place to practice high acuity care and communication, and (3) a safe place to receive and provide feedback. On average, residents reported an increase in comfort with management of magnesium toxicity from little comfort(2/5) tomoderate comfort(4/5). In general, participants (90%; N=10) felt like they learned advanced management of acute magnesium toxicity. All participants (100%; N=10) reported they would recommend this simulation to others in their profession. 

 

Discussions: We have designed a simple model that highlights the importance of (1) communication during an obstetric emergency and (2) debriefing and evaluating errors from systems perspective. This model increased participant knowledge and comfort with magnesium toxicity and promoted a safe culture to discuss medical errors and practice debriefing.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Residency Director, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, CME, Simulation, Quality & Safety, Team-Based Learning,

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Keeping Residents Well: How Important Are Perceptions of Program Support and Psycholocical Safety to Resident Wellness?

Purpose: We aimed to test whether measures of resident well-being correlated with perceptions of program support and psychological safety.

 

Background: Trainee well-being is a crucial component of developing competent and skilled OB/GYN physicians. While there are several measures of well-being collected at the national-level, there is little insight in the role of individual programs to foster trainee well-being. Perceived organizational and psychological safety are two constructs that can help identify cultural aspects of the clinical learning environment that may relate to trainee well-being.

 

Methods: OBGYN residents in a training program were recruited to complete an IRB-approved survey through paper and electronic methods between May-June 2018. Measures included the Survey of Perceived Organizational Support (POS), Psychological Safety Scale (PS), Perceived Stress Scale (PSS), Wayne State Wellness Scale (RWS) and Physician Well-Being Index (PWBI); all demonstrate validity and reliability evidence to assess factors of well-being and cultural aspects of the training program.

 

Results: 20 OBGYN residents completed our survey. Results indicated a strong relationship between perceived organizational support and wellness  (r= .62, P<.01 for RWS, r=.50, P<.05 for PWB)., suggesting greater perceptions of support relate to better wellness. Similarly, psychological safety also had a strong relationship with wellness (r=.56, p<.05 for RWS;  r= -.72, p<.01 for PWB)

Discussions:  
Our findings suggest that there is a strong relationship between trainee wellness and the cultural measures of support and safety, especially between psypschological safety and negative indicators of well-being (e.g,. feeling burnt out from work, feelings of irritation). Further research should include interventions to improve percpetions of suport and safety.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Residency Coordinator, Professionalism, Interpersonal & Communication Skills, GME, Quality & Safety, Advocacy, CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Residency Director, Residency Coordinator, Professionalism, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, Lecture, Advocacy,

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Improving Tetanus, Diphtheria, Pertussis Vaccination Rates in an Academic Center Through Resident-driven Education

Purpose: To improve rates of prenatal Tetanus, Diphtheria, Pertussis (Tdap) vaccination for clinic patients in an academic training center.

 

Background: The United States is experiencing a resurgence of pertussis, which can cause serious complications for infants, especially within the first six months of life. To maximize maternal antibody response to Tdap and antibody transfer to the newborn, vaccination between 27-36 weeks of gestation is recommended.

 

Methods: A pre-post survey study design was used to evaluate OBGYN residents at the University of Tennessee during the 2017-2018 academic year. The primary outcome was Tdap vaccination rate. Secondary outcomes were resident-reported Tdap counseling and resident understanding of the appropriate gestational age for administration. The following educational methods were utilized: resident-lead lecture, provider handouts, English and Spanish patient education posters throughout the clinic. Direct comparison of pre and post-surveys was used to analyze results.

 

Results: Five Tdap vaccinations were given in the four months prior to pre-survey administration (0.33 vaccines/resident). Following the Tdap educational program, forty-three vaccinations were given in four months (2.86 vaccines/resident). Pre-surveys indicated eleven residents (73%) provided Tdap counseling, while post-surveys revealed fifteen residents (100%) provided counseling. On pre-surveys, the majority of residents (33%) incorrectly answered that Tdap was indicated between 27 weeks gestation until delivery. In post-surveys, thirteen residents (87%) correctly answered that Tdap was indicated between 27-36 weeks gestation.

 

Discussions: Tdap vaccination rate increased by 767% after implementation of the educational tools. Additionally, resident-driven counseling about Tdap increased by 36% and resident understanding of appropriate gestational age for vaccine administration improved by 225%.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Patient Care, Medical Knowledge, GME, Lecture, Quality & Safety, Public Health, Advocacy,

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Evaluation of Neonatal Resuscitation Program (NRP) Knowledge Among OB/GYN Residents

Purpose: To determine OB/GYN resident retention of neonatal resuscitation program (NRP) knowledge following their intern NICU rotation and NRP course.   

 

Background: NRP training has been utilized to teach birth attendees evidence-based approaches to care for the newborn at birth.  OB/GYN trainees undergo NRP training and rotate in the NICU as interns.  It is unclear how much NRP knowledge is retained as OB/GYN residents advance in training.

 

Methods: A survey was distributed amongst the 41 OB/GYN residents at Indiana University during the 2017-2018 academic year.  The survey was completed anonymously and included the resident’s year in training (PGY1-4) and date of their NRP course and NICU rotation.   A 10-question abbreviated NRP quiz was administered to participants.  Correlation analysis was performed to test for associations between quiz scores and elapsed time (months) between quiz and the intern NRP course and NICU rotation.

 

Results: 37 of 41 residents completed the survey.  The average test score was 76%.  There was no significant difference between abbreviated NRP quiz score and PGY level (p=0.30).  There was also no difference between time since NRP course (p=0.21) or time since NICU rotation (p=0.50).  Greater time since NICU rotation correlated with lower quiz scores in the PGY2 class (p<0.05).  No significant correlation was seen in other classes.

 

Discussions: Overall, there was no significance between test scores based on training year.  With this information, OB/GYN residents may be able to do an accelerated certification course while in a training setting instead of the traditional course completion every 2 years. 

Topics: CREOG & APGO Annual Meeting, 2019, Residency Director, Medical Knowledge, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Assessment, Simulation, Quality & Safety, General Ob-Gyn,

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Evaluating the Rates of Visualized IUD Strings Following Immediate Post-Partum Placement by Ob/Gyn Residents

Purpose: Compare the incidence of visualized IUD strings at follow up by mode of postpartum IUD placement by residents

 

Background: Immediately postpartum contraception decreases maternal mortality, low birth weight, preterm births and infant mortality.  Missing strings in the setting of a well positioned IUD are more common following postpartum placement as compared to interval placement. This difference may be explained by variation in residents’ techniques for placement in the postpartum setting.

 

Methods: A retrospective chart review of 306 women receiving immediate postpartum IUD insertion by residents was performed between July 1, 2017-February 15th, 2018.  Variables analyzed included: type of IUD, length of strings prior to placement, method of insertion (applicator, ring-forceps, manual), and delivery type. 

 

Results: Sixty-two (20%) women attended postpartum follow-up between four to six weeks after delivery.  Eleven of 14 (79%) post-cesarean section and 39 of 48 (81%) post-vaginal delivery had strings visualized.  Insertion via the IUD applicator was associated with significantly more IUD strings visualized at the postpartum visit  when compared to manual insertion (p <0.05) and ring forceps (p <0.05). There was no difference in string visualization between IUD types or after cutting the string to 10 cm. 

 

Discussions: Mode of placement affects postpartum IUD string visibility. Future research will include developing a protocol for best practices for post-placental IUD placement to improve string visibility at the postpartum visit. Additional research is needed on the low postpartum follow up rate in this subset of the population.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Patient Care, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Quality & Safety, Public Health, Contraception or Family Planning, General Ob-Gyn,

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Evaluating Patient Understanding of the “diagnosis of Pregnancy of Unknown Location”

Purpose: To evaluate health literacy in an inner city population among a high risk group of resident-managed patients with a diagnosis of pregnancy of unknown location.

 

Background: Low health literacy is associated with poor reproductive health outcomes. Previous research on patient compliance with methotrexate protocols as treatment for ectopic pregnancy has shown poor compliance (as low as 10%).  Rates of follow up after diagnosis with pregnancy of unknown location are not well described.

 

Methods: A chart review was performed to identify of all patients seen in an inner city hospital with the diagnosis of pregnancy of unknown location. Patients meeting inclusion criteria were contacted by phone to survey understanding of the rationale for close follow up. Patients who never followed up after initial contact were excluded.

 

Results: Eighty seven patients with the diagnosis of pregnancy of unknown location were identified between January – April 2018.  Twenty nine patients met inclusion criteria and twenty agreed to participate. Only 40% of patients correctly explained that there was a concern for ectopic pregnancy. The remaining patients identified their diagnosis as an “abnormal pregnancy” (10%), “miscarriage” (10%); “I don’t know” (15%), and other (25%). 

 

Discussions: Although the patients surveyed were compliant with follow up, nearly half of the patients showed poor comprehension of their clinical condition. It may be that poor understanding is a major underlying cause for noncompliance for the many patients who never followed up. This should be evaluated in future research.  

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, GME, Quality & Safety, Public Health, General Ob-Gyn,

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Developing a Culture of Continual Process Improvement: A Pilot Kaizen Event in an OB/GYN Resident Clinic

Purpose: To apply Lean Six Sigma concepts and foster a culture of continual process improvement.

 

Background: Quality improvement is an ACGME Obstetrics and Gynecology Milestones sub-competency. However, the 2016 CLER National Report demonstrated that most residents have little working knowledge of basic quality improvement concepts. In 2017, Lean Six Sigma certification was incorporated into Summa Health’s resident education. To apply these concepts, a resident-designed pilot Kaizen event was executed in the resident clinic.

 

Methods: Three-day Lean Six Sigma training began in 2017; the pilot Kaizen event was planned for June 2018. Preparation included a brainstorming session and the creation of interprofessional teams and project area assignments. During the half-day event, house staff (residents and attendings) and office staff identified workplace process inefficiencies and implemented solutions within five assigned project areas: scheduling, patient flow, room setup, patient consent and instrument stocking.  Teams then presented their improvements to the larger group and 22 participants completed a post-event survey.

 

Results: Six (46%) house staff completed Yellow Belt certification prior to the event and all rated the training “very helpful” in identifying and improving processes during the event. Eight (72%) house and 6 (75%) office staff reported the improvements “very positively” impacted the clinic. Seven (54%) house and 8 (100%) office staff responded that the event should be repeated at least biannually.

 

Discussions: Residents found Yellow Belt training and the Kaizen event to be beneficial and have a positive impact on daily workflow.  These activities will be repeated in the future to foster a culture of continual process improvement.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Osteopathic Faculty, Residency Director, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, GME, Quality & Safety,

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Decreasing the incidence of hospital-acquired venous thromboembolism (VTE) through inter-disciplinary educational methods

Purpose: This study explored the knowledge of a venous thromboembolism (VTE) prevention protocol among residents, fellows and nurses and the impact of an educational module in an effort to improve adherence to this protocol and subsequently decrease the incidence of hospital-acquired VTE.

 

Background: VTE significantly contributes to morbidity and mortality in hospitalized patients. Patients with gynecologic cancers are at high risk primarily due to malignancy, increased age, and recent surgery and immobility. Several evidence-based interventions are used to decrease the risk of hospital-acquired VTE commonly leading to institutional policies. The division of Gynecologic Oncology at University Hospitals Cleveland Medical Center  standardized VTE prevention guidelines in 2015.

 

Methods: Participants included OB-GYN residents, Gynecologic Oncology fellows and nurses on the Gynecologic Oncology floor. Participants received a fifteen question pre-test immediately followed by an educational presentation describing the venous thromboembolism prevention guidelines. They then received the same fifteen question post-test. The participants were re-tested in six months to gauge knowledge retention. The scores were compared using an unpaired T test.

 

Results: There were seventy-five eligible participants. The survey response rates were: pretest 68%, post-test 35%, follow up pretest 28% and follow up posttest 21%.Of the participants who identified their role, 62% were nurses, 33% were residents and 5% were fellows. There was a statistically significant difference between the test scores before and after the educational intervention during the initial intervention and the six month follow up (p= 0.0001). During the initial survey, the mean pre-test and post-test scores were 54.5% (95% CI 49.7-59.3) and 80.2% (95% CI 73.4-87.1) respectively. At the six month follow up, the mean pre-test and post-test scores were 62.2% (95% CI 56.5-67.9) and 82.1% (95% CI 75.3-88.9) respectively. There was no significant difference between the post-test scores at zero and six months (p= 0.7).

 

Discussions: These findings suggest that knowledge of the VTE prevention guidelines improved following an educational module. Further studies can elucidate the impact of this knowledge on compliance with the VTE protocol and incidence of hospital-acquired VTE.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, GME, Quality & Safety, Gynecologic Oncology,

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Bring Back the Tubal: An Intervention to Provide Postpartum Bilateral Tubal Ligation in the Underserved Population

Purpose: Improve educational awareness and receptiveness to the PPBTL procedure.

 

Background: 50% of women requesting a PPBTL undergo the procedure. Barriers exist to obtain the PPBTL, including lack of available operating rooms and concern for patient regret. Half of pregnancies in the U.S. are unintended, occurring disproportionately higher in low-income and minority populations. Children resulting from unintended pregnancies are at risk for poor health outcomes including low birth weight and developmental delay. Additionally, the U.S. financial burden of unintended pregnancy accounted for approximately 21 billion dollars in 2010.

 

Methods: A retrospective chart review was conducted from 2015-2016 to document the baseline prevalence of PPBTLs performed at IFMC. Educational sessions with pre- and post-session questionnaires were conducted for departments of OB/GYN, Anesthesia, and Nursing. Data was collected from April 2017 - April 2018 regarding patients desiring the procedure, those completing the procedure, and reasons for unsuccessful procedure completion. A pre-post comparison was performed to assess the impact of the educational sessions and the overall prevalence of PPBTLs.

 

Results: Fifty-one multidisciplinary staff members at IFMC participated in the educational sessions. All departments showed significant improvement in knowledge of the PPBTL (OB/GYN p=0.0117, Anesthesia p=0.0002, Nursing p=0.0001). A baseline prevalence of three PPBTLs were performed from 2015-2016, which increased to fifty-six from 2017-2018. Comparing pre-post intervention, the percentage of PPBTLs requested and ultimately performed increased from 39% to 60%.

 

Discussions: Targeted multidisciplinary educational sessions were effective in identifying barriers and increasing educational awareness. Overall, this resulted in increased access to and performance of sterilization in the underserved population.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Residency Director, Patient Care, Professionalism, Interpersonal & Communication Skills, GME, Quality & Safety, Team-Based Learning, Advocacy, Contraception or Family Planning,

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An Interprofessional Fais Do-Do: Medical Student Field Notes on a New Integrated Practice Unit

Purpose: - To gauge medical students’ perspectives on integrated care using an experiential learning approach

 - To provide a clinical application of interprofessional learning

 - To inform continuous quality improvement

 

Background: Dell Medical School students attain the Basic Certificate in Quality & Safety through the IHI Open School online course in year two of our interprofessional integration curriculum. Recently, our institution opened a Complex Gynecology Integrated Practice Unit (CGIPU), which also serves as an interprofessional clinical site for students on the Women’s Health (OB/GYN) clerkship.

 

Methods: Students followed CGIPU team members and composed field notes on the provision of high-quality, patient-centric care.  They used a truncated list of the IOM Six Aims for Healthcare on which to base their notes: Timeliness, Efficiency, Equity, and Patient-centeredness.  At the end of each clerkship block, they submitted a group report based on individual experiences.  Reports were qualitatively analyzed to identify key questions and recommendations emerging from their observations.   

 

Results: 100% of students completed individual field notes (N=50).  Six group reports were evaluated.  Results revealed positive Patient-centered observations, specifically the desire to attain patients’ goals, time allotted for visits, and interprofessional coordination of care. Under Equity, psychosocial determinants of health and access to care were routinely addressed. Appointments were lengthy due to the delivery of personalized care. Recommendations included a better balance of time (Timeliness). Efficiency focused on technical operations including improved integration of the EHR and facilitation of online language interpretation.

 

Discussions: Reports were submitted to leadership to consider recommendations for quality improvement.  The assignment achieved its purposes.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Residency Director, Patient Care, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, UME, Assessment, Quality & Safety, Problem-Based Learning,

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A Triple Aim Curriculum That Addresses Health Care Inequity: A Resident Driven Patient Centered QI Project That Improves Postpartum Care Utilization for a High Risk Population

Purpose: To describe the design and implementation of a resident driven QI initiative which addresses the low percentage of patients returning for a 6-week postpartum visit in a resident obstetrics clinic.

 

Background: The postpartum period or the “fourth trimester of pregnancy” is a critical period for women’s health and well-being.  At our resident clinic (2014-2016), only 21% of patients presented to their 6-week postpartum visits compared to 80-93% in other practices.  As part of a new, mentored experiential approach to QI education, our residents completed a QI project based on an identified clinically relevant patient care issue.

 

Methods: 12 Ob/Gyn residents (single institution) completed the IHI QI Online modules as part of a GME supported Health Systems Science initiative focused on operationalizing a Triple Aim targeted curriculum.  Applying the Model for Improvement, the residents designed and implemented a QI project with the aim of 100% of postpartum patients discharged from the resident service during a 6-month period to receive a 2-week post-discharge check-in call.   The % of discharged patients attending their 6-week postpartum visit was calculated and compared to the % attendance 2014-16. Data analysis: independent t test, P<0.05

 

Results: 6 months after implementation, 97%(37/38) of patients received a 2-week check-in call.   Of those contacted, there was a 45% increase in patients who returned for a 6-week postpartum visit (p<0.01).

 

Discussions: An educational intervention can directly improve patient care.  An experiential approach to QI can facilitate knowledge application and result in improved postpartum care utilization for high risk patients.  

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Residency Director, Residency Coordinator, Systems-Based Practice & Improvement, GME, CME, UME, Quality & Safety, Problem-Based Learning,

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Resident Self-Entrustment and Expectations of Autonomy: OB > GYN?

Purpose: The goal of this study was to identify the definition and expectations of autonomy from residents’ perspective, as well as the self-entrustment of their surgical competencies in obstetrics (OB) and gynecologic (GYN) procedures.  

 

Background: Entrustment in the operating room (OR) is a two-way street. Resident self-entrustment of their surgical competencies closely associates with their OR training experience and granted autonomy. Some recent studies have investigated how attending surgeons determined and entrusted OB/GYN residents in the OR. There is little to no data, however, in examining these issues from the resident perspective.

 

Methods: We conducted three focus group interviews with 20 OB/GYN residents across four post-graduate year (PGY) levels.  Audio recordings of each interview were transcribed, iteratively analyzed, and emergent themes identified, using a framework method. 

 

Results: A total of 123 minutes of interviews were recorded. Eight junior residents (PGY1-2) and twelve senior residents (PGY3-4) participated.  Our data illustrated that 1) the definition of autonomy shifted significantly throughout residency training; 2) residents demonstrated higher expectations and self-entrustment for OB surgical procedures than for GYN surgical procedures upon graduation; 3) case volume, modalities of OR teaching (e.g. teaching style, attending experience, rotation site) and mutual communication are three factors influencing resident self-entrustment of their surgical competencies.

 

Discussions: Residents showed disparities in their self-entrustment and expectations of autonomy between OB and GYN surgical procedures. Better understanding these differences and the three influencing factors could help programs develop a potential solution for improvement in resident entrustment and autonomy upon graduation.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, Assessment, Quality & Safety,

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Increasing Access to Emergency Contraception, Non-emergent Contraception, and LARC Referrals in the Emergency Room: A Resident-based Educational Intervention

 

Purpose: The aim of this study is to determine whether an educational intervention improves emergency medicine residents\' knowledge of and personal comfort with prescribing EC, offering non-emergent contraception, and referring patients for LARCs.

 

Background: Approximately 50% of pregnancies in the United States are unintended. Increasing access to emergency contraception (EC), non-emergent contraception, and long-acting reversible contraception methods (LARCs) is one way of decreasing unintended pregnancies. Emergency rooms enable physicians to assess a woman\'s risk of unintended pregnancy and afford an opportunity to intervene, if appropriate. Previous studies have found that emergency medicine physicians do not always offer EC, even in cases of sexual assault. Barriers to prescribing EC have been identified and include time constraints, lack of clinical resources, concern about discouraging regular birth control, and concern about birth defects.

 

Methods: Emergency medicine residents were given an interactive lecture on contraception with emphasis on EC. They were also given a pocketbook on contraception to keep. Pre- and post-lecture surveys were given in person, along with another 6 months later. The surveys assessed knowledge, comfort level, and prescribing/referring practices with both quantitative data and qualitative data. Data will also be extracted from the electronic medical record to assess if there was an increase in prescriptions for contraception and/or referrals to family planning.

 

Results: The preliminary data analysis is currently being conducted. Twenty-three emergency medicine residents completed the pre- and post-test surveys. Additional information from prescriptions and referrals will provide objective data to assess whether the educational intervention changed behavior.

 

Discussions: There are two hypotheses for this study. First, it is hypothesized that an educational intervention will increase emergency medicine residents\' knowledge of and comfort with EC, non-emergent contraception, and LARCs. Second, there will be a significant increase in prescriptions for EC, non-emergent contraception, and referrals for LARCs one year after the educational intervention takes place. If the hypotheses are correct, residency programs and hospitals should consider developing educational strategies and policies to improve access to contraception in the emergency room and prevent unintended pregnancy.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, GME, CME, Assessment, Lecture, Quality & Safety, Contraception or Family Planning,

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Wellness Challenges and Burnout Contributors: A Systematic Approach to Issue Identification & Program Development

Purpose: To implement an institutionally-specific process to: A: Identify wellness challenges/burnout contributors. B: Develop a systematic approach to wellness programming prioritized by Maslow need level

 

Background: Addressing wellness challenges/burnout contributors (WC/BC) is critically important to both providers and the patients they treat.

 

Methods: A representative task force was assembled.  Using mind-mapping, members developed a comprehensive list of WC/BC issues and related factors.  These were then mapped by members to Maslow need levels ranging from physiologic (level 1) to transcendence (level 8). PDs were then queried regarding wellness programming in their residencies to generate a “menu” of institutionally-available programming. Gaps were then identified by mapping WC/BC issues to available PD-reported programming.  Highest priority was given to program development for WC/BC issues with lowest Maslow levels for which there was no programming available.

 

Results: From October, 2016-May, 2017, the task forced include 20 representatives from 7 departments and the GME Office and included residency/fellowship PDs, residents, and staff.  Through mind-mapping work, 12 categories of WC/BC issues and 38 related factors were identified. While all GME program directors reported having WC/BC programming in place, the majority (57%) of this was informal support around “healthy lifestyles”.  For 34 of 38 factors (89%) identified, no programming was reported. Notably, when mapping factors to Maslow need level, 30 of 38 (80%) mapped to basic Maslow levels 1-4.  Program development was recommended for WC/BC factors with lowest Maslow levels for which no institutional programming was in place.

 

Discussions: An institutionally-specific approach to identifying WC/BC issues and prioritizing them for resource development by Maslow level was successfully implemented.

Topics: CREOG & APGO Annual Meeting, 2018, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Professionalism, Systems-Based Practice & Improvement, GME, CME, UME, Quality & Safety, Problem-Based Learning, General Ob-Gyn,

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