Centers of Expertise - Funded Research Grants

Text 4 Success in Gestational Diabetes Interim Report: Internal testing and iterative improvements

2020-03-30T08:10:00.002-07:00

Rachel Blair, MD

Fellow in the Division of Endocrinology, Diabetes and Hypertension at Brigham and Women’s Hospital

PGY6

03/13/2020

I am developing a text messaging program for women with gestational diabetes, which is diabetes diagnosed during the 3^rd trimester of pregnancy. The program is designed to provide reminders to check blood sugars, as well as educational and motivational messages. The program also sends encouraging replies when women send in their blood sugars.

Screenshot showing some of
the messages.

I previously designed a novel text message library and obtained feedback from women with gestational diabetes on the wording and content of messages. The current stage of my project, supported by funding from the COE for Health Policy and Management, is performing usability testing. We are working with a vendor to create a text messaging platform with our content. We then plan to enroll women for a two week period followed by interviews to obtain feedback and to determine if it is easy to use and acceptable.

We have been working extensively with our vendor to rigorously test the product before enrolling participants. We have discovered additional scenarios during testing for which we needed to create new messages (such as – what if someone sends in a blood sugar number unprompted?). There have been technical limitations and we’ve come up with some creative solutions (for example, emojis cannot be included in the program, so we are using :-) in one of our messages instead).

Next steps will include having women with gestational diabetes use the program once all technical issues have been resolved. That being said, recruitment will likely need to be postponed because of COVID-19. The findings of our work creating the message library were accepted for a poster presentation at the Endocrine Society Meeting in 2020.

I have learned that there are many unexpected roadblocks and limitations when designing a new intervention, and it is important to be creative when coming up with solutions for those roadblocks.

Improving quality of care for people who inject drugs seeking care at Massachusetts General Hospital

2020-03-30T08:01:00.000-07:00

Dinah P. Applewhite, M.D.

Fellow in Addiction Medicine at Massachusetts General Hospital

PGY-4

03/06/2020

Injection of drugs such as opioids, methamphetamine and cocaine, carries with it many risks, including venous damage, overdose, and infections. When people who inject drugs (PWID) interface with the medical system, there are often are missed opportunities for healthcare workers to facilitate safer injection among PWID. This study aims to better understand injection practices and factors contributing to those practices, such as knowledge, attitudes, access to injection supplies, and structural determinants of health.

Example of safer injection supplies

The survey has been approved by the IRB and we are now piloting it among group of PWID. The timeline is behind schedule by two months due to delays getting the final approval by the IRB. The delay was in large part because of a technical error I made when responding to the initial review. I made the mistake of deleting the original documents, which resulted in a very prolonged and frustrating process consisting of multiple phone calls with IRB staff and resubmissions. Last week when I got the final IRB approval, I felt such a wave of relief. Lesson learned (which seems so obvious in retrospect): Read the IRB instructions--your mistakes will cost you time!

I am excited to administer the survey over the next few months. We have a fantastic team of research staff and volunteers. Ultimately, we will use this data to inform an intervention to improve the quality of care for PWID who seek care at MGH. This intervention will involve facilitating access to safer injection supplies and harm reduction messaging around safer injection techniques.

A PAUSE in Process: Successes and hurdles as we prepare to PAUSE more in the BWH Internal Medicine Residency Program.

2020-03-30T07:49:00.000-07:00

Allison Vise MD

Resident in the Internal Medicine Residency Program at BWH/HVMA

PGY2

03/01/2020

Residents on the inpatient medical service must provide high quality care for acutely ill patients, lead interdisciplinary rounds, communicate with patients and families, and supervise a team of junior residents and students. Residents are expected to be proficient at participation in such high stakes clinical events and sometimes even lead them, without any dedicated training or overt support. Currently, post-event debriefings are happenstance, unstructured, and any debriefing typically focuses on aspects of the clinical setting and management rather than the emotions of clinicians. The emotional burden that accompanies acute patient care, especially among young trainees, is a recipe for consequences associated with burnout.

I am interested in teaching my peers how to facilitate debriefings well, and I am eager to study the effects of such a program. My Partners Center of Expertise-funded medical education research project is called PAUSE, which stands for Prepare, Analyze, Understand, Sentiment, Educate, the five steps of the PAUSE debriefing. PAUSE is an educational program that includes: 1) Creating a brief and interactive educational session about debriefing challenging situations (mistakes, codes, patient deaths, a week of inpatient work, or any other stressful situation), 2) Producing a physical tool that providers can use to facilitate such conversations, 3) Implementing the tool in our residency program and hospital, and 4) Studying the usefulness of the tool through both qualitative and quantitative methods.

Allison facilitating a PAUSE in the new PAUSE training video

Over the past six months since I was awarded the COE grant, I have made progress on developing PAUSE, with the support of my Scholars in Medical Education Pathway co-residents and my mentors in the Departments of Medicine and Palliative Care. Specifically, I announced PAUSE to my residency program in December, to great excitement and support from my co-residents. A co-resident and I wrote and directed a training film, featuring other co-residents as actors who had just been at an imagined Code Blue. This film models a PAUSE, and is part of our training program (see image). And, with COE funding, I have created the physical tool, an easy to carry badge that will conveniently attach to providers’ ID lanyards in the hospital. I have solicited and been given permission by the medical director of the Shapiro Levine Cardiac Intensive Care Unit to roll-out our program there, given the high rate of intense events that occur, and the incredibly intimate work environment between nurses, pharmacists, PCAs, and physicians there. All in the program are excited to start using PAUSE in our hospital.

My biggest obstacle to implementation so far has been IRB approval. I have been waiting to roll-out the tool on the hospital floors until I have IRB final approval, so that I can proceed with surveys and focus groups as planned. I have learned much about the IRB process while working on PAUSE. Specifically, I have learned about the components of an education project IRB proposal that matter most. After several rounds of edits, I recently re-submitted my IRB, and eagerly await its approval.

Going forward, I am looking forward to teaching PAUSE to select groups of Internal Medicine program residents for this pilot phase. And, I am writing a curriculum to teach it to all outgoing Internal Medicine interns at the end of this year during their retreat that prepares them for their PGY-2 year. This will mean that all PGY-2 Internal Medicine residents will be ready to lead PAUSE debriefings when they become team leaders in a few short months.

I am most grateful for the support I have received from the Partners Center of Expertise in Medical Education, and I am excited to implement PAUSE soon.

Effective Senior Residents, as Defined by Their Peers: A Qualitative Assessment

2020-03-30T07:36:00.001-07:00

Taylor Coe, MD

PGY4

General Surgery Resident

Department of Surgery

Massachusetts General Hospital
02/29/2020

Surgical training aims to create doctors who are clinically competent and technically sound; however, there are many nontechnical skills that are imperative to surgical practice as well. These include, and are not limited to, team leadership and management, teaching of all members of the team, such as patients, medical students, advanced care providers and junior residents, communication, and providing feedback. There is a clear change in role and responsibility that occurs as one transitions from being a junior to a senior resident in which these nontechnical skills become more prominent and central to successful patient care and team leadership. Therefore, I plan to use qualitative methods to define what makes an effective senior surgical resident and the current process of leadership and nontechnical skills development in the transition from junior to senior surgical resident.

As all projects begin, first I navigated IRB approval. This was a monumental exercise for me, as it was my first IRB application and my first project of my own generation from start to finish. I drafted my proposal and focus group guide and finally submitted, about two months later than I had initially hoped. My first takeaway from this project is that sometimes, the hardest part is just getting started. This task was intimidating and I delayed submission due to my own fears of sharing my work and navigating a new process. Ultimately, I received approval after a round of revisions and was ready to start my focus groups.

Fellows of the MGH Surgical Education Research Group

Here, my first lesson comes into play again. I had approval to start, but now I had to actually recruit the first residents for a focus group. This task brought up a mix of emotions again. I was intimidated to ask my peers to volunteer one hour of their time and to put my research out in the open and receive feedback about a project that I developed and nurtured. The theme continues, in which it took me two extra months to work up the courage to embark on my first focus groups; however, once I started, I found them to be an incredibly insightful and rewarding experience that was beneficial for my work, but also for the participating residents.

So far, I have completed ten focus groups with 23 residents spanning PGY2 to PGY4 residents. I am scheduling the PGY1 and PGY5 residents and will be finished collecting data by the end of March. From there, my next task is qualitative analysis of over fifteen hours of transcription. On preliminary review of the first few focus groups, there are interesting findings starting to take shape. In an effort to first define a senior resident, it is clear that the senior resident has ‘extreme ownership’ of the team resulting in ‘complete responsibility for the patient experience’. The senior resident is viewed as a role model, teacher, and leader who is responsible for not only clinical and technical excellence, but also for management of team morale and creating opportunities for junior autonomy and junior wellness. These skills are mostly obtained through ‘osmosis’ through the gradual transition from junior to senior, with minimal structured education.

Overall, this project has been a wonderful experience for both my own personal growth as a researcher and in defining an effective senior resident. I look forward to completing the project over the next 3 months and using the findings to create a curriculum to help ease the transition from junior to senior resident. This work will be applicable to other programs and hopefully will help all surgeons understand the role of a senior resident in more detail.

Implementing a Robotics Curriculum in Surgery: Lessons learned from the Experts - An Interim Report.

2020-03-30T07:25:00.001-07:00

Kristen Jogerst, M.D.
Research Fellow in MGH Surgery General
PGY 3
03/01/2020

How does one best train a surgical resident or fellow to become proficient in robotic surgery? What are the best methods for surgical educators to use if they are hoping to teach trainees robotic surgery for the first time? Is simulation necessary? Will this training framework change overtime as general surgery and surgical residencies change? Does a surgical educator’s frame of reference (based on their own training background) affect how they approach these training questions? To answer all of these questions, my research team, led by Dr. Denise Gee, and I developed a phone interview guide to interview experts within robotic surgery and surgical education. We interviewed experts across academic and community general surgery, gynecological surgery, and urology. We are completing this qualitative investigation using a framework analysis. We received approval from our IRB, achieved group consensus on our refined interview guide after several practice interviews, and have 29 out of our 32 intended interviews done. We have completed interviews with robotic surgical experts and surgical educators across four strata: academic general surgery (10), gynecological surgery (9), Urology (6), and community general surgery (4).

Emerging themes and representative quotes from our team's
preliminary analysis of the semi-structures interviews

While the study is ongoing, our team has already learned a lot about what experts think it takes to build an excellent robotic surgical training program as well as pitfalls they wish they would have knew prior to implementing curricula at their home institutions. Give my research participants are all clinical faculty and surgical experts, many of them are quite busy. I have been extremely appreciative of how willing these experts have been to give of their time. One of the major obstacles to completing qualitative research studies is the same barrier faced by many surgical education projects: time. Logistically many of my phone interviews would get cancelled, delayed, or unexpectedly rescheduled for early morning hours, late nights, or weekends. However, these scheduling flexibilities have been worth it, as I have been privileged to gain decades worth of surgical education wisdom, all within a few short months. If anyone reading this has ever attempted a qualitative research study with rigorous methodology, I have much more respect for you after the last few months. I also now know the importance of having a backup recorder and how valuable an accurate transcriptionist can be. The rewards and wisdom imparted from the unique constructivist research perspective makes qualitative investigations worthwhile. However, those rewards must be earned and one should expect the research study timeline to take at least double the original timeline estimates. I am thankful for my co-investigator and second transcript coder, Dr. Taylor Coe. Our preliminary analyses and exciting findings would not have emerged without her diligent efforts and late nights of editing and refining our codebook. This project has taught me that when building new curricula or exploring challenging research questions, it is important to consult the experts and surround yourself with the wisdom and experience of other researchers and surgical educators.

Through these hard efforts, we have already learned that building a successful robotic surgery curriculum requires 5 emerging themes: access, investment/ buy-in, relinquishing control, evaluation, and progressive OR integration (Figure 1). We have several more interviews to complete to finalize our framework analysis and compare across the four strata. In addition to completing the final interviews, finishing our coding of the remaining transcripts using our refined codebook, and writing up our framework analysis, I am happy to report our research team

Excited to present our work at the annual meeting for the
Association of Program Directors in Surgery in Seattle
this Spring

will also have the opportunity to present our findings at the Association of Program Directors in Surgery (APDS) annual meeting in Seattle this April (Figure 2). In addition to sharing our lessons learned during Surgical Education Week, our research team plans to submit a final manuscript following the national meeting in May. We are thankful for the support and resources from the Centers of Expertise Medical Education Research Grant and look forward to sharing our final analysis with you later this spring/ summer.

Smartphone App to Manage Cirrhotic Ascites: Continues to Improve as Program Enrolls Mores.

2019-11-15T04:10:00.001-08:00

Patricia Pringle Bloom, M.D.
Fellow in MGH Transplant Hepatology
PGY 7
09/13/2019

I am leading a team to improve the way we manage cirrhotic ascites. Body weight is an effective proxy for ascites volume; therefore, monitoring daily weights is recommended for optimal ascites management. At present, patients with ascites rarely proactively alert providers with significant weight gains, and there are no widely available technologies specifically designed for ascites monitoring. With support from COE funding, we are performing a pilot study to assess the feasibility of an app created by Partners Connected Health to manage outpatient ascites.

In this pilot study, we are identifying cirrhotic patients with significant ascites requiring specialist management. Each patient is sent home with a Bluetooth-connected scale, which transmits weight data to the PGHD Connect Smartphone app, and then via the cloud into Epic. Weights are monitored every weekday by study staff and alerts are sent to providers if their patients' weight changes by 5lb within a week or since discharge.

Acceptance to a local and exciting technology conference

Thus far, 21 patients have enrolled in the program. Eight patients have been unable to enroll because they did not have a Smartphone and 23 because they were encephalopathic and unable to participate. Each patient is enrolled for 28 days, but several patients have wanted to terminate the program early and several have opted to extend their enrollment.Thus far, the program has transmitted weight data on 70% of days that patients are enrolled. Technology issues are occurring on approximately 10% of days. Twenty weight alerts have been fired, ~60% for weight loss and the remainder for weight gain. 65% of the alerts have been followed with some form of provider response.

We continue to enroll patients in this program, and as we do, we we continue to work with Partners Connect Health to develop new iterations of the app that enhance the program. For example, new iterations of the app are being released that resolve some of the technology glitches. In addition, we are beginning to learn more about the types of patients who do best in this program. Part-way through our study, it appears that patients with less severe disease derive more benefit from the program. It also appears that those discharged to rehab facilities have more technical issues with the program.

Recently, our efforts have been rewarded with an invitation to present our interim results at the 2019 Connected Health Conference. This will be an excellent opportunity to gather feedback on our program and app, as well as network with others working in this space.

On Becoming a Qualitative Medical Education Researcher in the Intensive Care Unit: An Interim Report

2019-07-09T09:23:00.002-07:00

Rebecca Sternschein, MD

Fellow in Pulmonary and Critical Care Medicine at Brigham and Women’s Hospital

PGY6

July 1, 2019

I am interested in understanding and improving medical education in the medical intensive care unit (MICU) at both the graduate medical education (GME) and continuing medical education (CME) levels. To accomplish this, I have been developing a project that focuses on exploring the experiences of clinical teachers in the MICU at BWH for which I was fortunate to receive COE Medical Education Research Grant funding. My study is a qualitative examination of MICU educators’ attitudes about teaching and perceptions of the impact of teaching on professional satisfaction and physician well-being.

I started by conducting a needs assessment survey through REDCap of faculty and fellows working in the BWH MICU. I have also held two separate focus groups (one with faculty and one with fellows) to gain an in-depth understanding of the variety of experiences as a teacher in the MICU. The focus group discussions also addressed individuals’ opinions regarding the potential rewards and challenges of teaching in this environment. One of the obstacles I encountered in this stage of the project was the difficulty of scheduling focus groups with busy pulmonary and critical care physicians. I am now in the early stages of the qualitative analysis of the focus group transcripts, and while this is a time-consuming and challenging process, it is fascinating to identify emerging themes from the transcripts.

So far, I have analyzed the preliminary findings from the needs assessment and the data has been accepted for publication as an abstract and poster at the American Association of Chest Physicians (ACCP/CHEST) 2020 national meeting. These data demonstrate that although most physicians report minimal to no dedicated training on teaching, most identify teaching as a task that is enjoyable, meaningful and essential to their role as an ICU physician. Here I struggled with finding the best way to display the data visually, and ultimately discovered that simplicity is key. (see image) The next step for this project is to complete the qualitative analysis of the focus group transcripts. I will also determine if any additional structured interviews are indicated to address topics or themes that require more in-depth exploration. I am looking forward to writing up the results of the research in the coming months. This project has been extremely educational for me, particularly because this is my first qualitative research experience. The most important lesson that I have learned at this stage of the project is the immeasurable value of helpful, motivating, expert mentors.

Presenting my preliminary research at the American Academy of Neurology Annual Meeting

2019-06-24T09:51:00.000-07:00

James Hillis, M.B.B.S.

Resident in PHS Neurology Residency

PGY 4

May 30, 2019.

Recently I had the opportunity to present my preliminary research at the American Academy of Neurology Annual Meeting in Philadelphia. It is the largest neurology conference with over 14,000 attendees. My poster explained the survey instrument that I have developed to investigate an evidence- and consensus-based approach for the neurologic examination. Other attendees provided constructive feedback on the survey instrument and also offered to distribute the survey at their institutions. My plan is to make the survey live over the coming months. Thank you to the Partners Healthcare Center of Expertise in Medical Education for the Research Grant that has supported this project!

If you build it, will it happen? Designing a project to implement a new clinical service

2019-04-24T05:53:00.001-07:00

Stephanie Sun MD MS

Fellow in Rural Health Leadership at Massachusetts General Hospital

PGY-5

April 10, 2019

Point of care ultrasound puts the ultrasound in the hands of the provider at the bedside of the patient. It is huge in acute care settings like emergency medicine where getting to a timely diagnosis is critical. It’s also been shown to assist with diagnostic uncertainty, in some cases reducing the number of additional studies performed, and improves patient satisfaction. But it’s not only the patients in emergency rooms who might benefit from ultrasound at the bedside.

As a general internist who provides care on a Native American reservation in remote rural South Dakota, point of care ultrasound has the potential to help bridge logistical gaps in care. The next closest hospital to my clinic in South Dakota is 50 miles away. But if patients are requiring specialty services, they will find themselves travelling 220 miles (that’s 3 hours and 42 minutes drive) to the nearest academic center in Sioux Falls – a huge burden on our patients! If a patient is going to be making a trip that far from family and their community of support, we want to make sure that it is necessary with the best clinical certainty possible. With a point of care ultrasound in hand, my ability to screen and triage is taken to the next level.

An ultraportable handheld ultrasound about to be put into action

If point of care ultrasound is so great, why isn’t it already being used in every rural clinic in the country? Great question. The most commonly raised concerns are 1) obtaining training, 2) maintaining skills, and oh yes 3) obtaining an ultrasound. Fortunately, new technologies have led to the release of ultraportable handheld ultrasounds at much lower price points than traditional machines. But even with a machine, patient safety must come first. It would be hard to feel comfortable trying a new skill if you are practicing somewhere where there is no one around who can teach it to you or provide the feedback needed to continue to improve.

As a resident, I was fortunate enough to get to create and build an ultrasound curriculum for general internal medicine residents. Taking many lessons from our emergency medicine colleagues, we learned basic skills to pick up on depressed ejection fractions, pneumothoraxes, and free fluid in the abdomen. Now as someone who mainly practices in the outpatient setting, I wonder which other exams would be the most useful to the primary care provider.

With support from the COE in Healthcare Quality and Patient Safety, I’ll be able to acquire an ultra-portable handheld ultrasound. We’ll be training a few fellow rural physicians affiliated with both MGH and the rural South Dakota clinic in ultrasound skills, and tracking their use in South Dakota. Which exams are they using it for? How often are they using it? Feedback will be provided to them on their interpretations of images to help them continue to hone their skills.

While we work through the IRB process, I’ve held two ultrasound scan sessions where a small group of rural physicians has been learning the ins and outs of point of care ultrasound. We’ve even done some scanning on “healthy volunteers,” that is, each other. We’ll be meeting again to keep building our skills and comfort before heading to the wards to practice more scans.

Along the way I’ve reflected on all the skills we’ve gained along our journey as trainees, and how a skill can go from total unfamiliar territory to the routine. It is exciting to see how a new skill can percolate through a discipline, like point of care ultrasound is through internal medicine. By learning lessons from those who have done it before us, and adapting the tools to suit our unique needs, we’ll continue to push boundaries to provide the best clinical care to all populations.

Comparison of cost-effectiveness of admitting moderately injured patients to trauma intermediate care units vs. surgical intensive care units.

2019-04-24T05:47:00.003-07:00

Naveen Fatima Sangji, MD

Fellow in Burn Surgery at MGH

PGY 8

April 12, 2019

As a surgical critical care fellow, I was interested in comparing the cost-effectiveness of admitting moderately injured patients to a trauma intermediate care unit vs. a surgical intensive care unit. Preparing an application for the COE Quality and Safety grants was a great impetus to get this project off the ground and to see it through. An immediate and tangible benefit of getting funded was that COE staff were able to liaison with the MGH Finance division to help us get access to the cost and reimbursement data we needed. We were also able to utilize the funds to obtain software and educational materials for our research. An intangible but more significant benefit was that the application process gave me an introduction on how to prepare a grant application as a trainee. The experience will serve me well as I prepare to apply for both institutional and extramural grant funding for future endeavors.

With the support of my project mentor Dr. David King, our research team which includes trauma research fellow Majed el-Hechi has made significant progress on the project. We presented our work at the MGH SAC 2019 Research Meeting and were very pleased to receive a “Poster of Distinction” award. We are currently preparing a manuscript to report our findings.

Many thanks to the COE leadership for funding and supporting this project.

Developing an educational video on bariatric surgery for obese patients in the primary care setting

2019-03-27T06:38:00.000-07:00

Danny Mou, MD; Claire DeVries, MD

Residents in General Surgery at Brigham and Women's Hospital

PGY 3

March 26, 2019

Briefly, we hope to develop an educational video obese patients to give them a concise overview of various surgical weight loss options. We originally envisioned that this video would be shown to patients in the waiting rooms of the Jen Center PCP clinic. However, after extensive discussions with the Jen Center PCP leadership and an interview campaign with 8 PCPs, we realized that there will be operational obstacles. Obstacles include how to discreetly provide these iPad videos to only obese patients, how to manage the iPads handling/charging/maintenance, and how to minimize disruptive video noise in the waiting room.

The PCP interview campaign was helpful for us to realize that PCPs would prefer to use this video as a bridge to the bariatric surgery info session. Most PCPs prefer having the flexibility to direct their patients to this video, either in the form of a card with link and QR code, or simply a dot phrase to pull the link into the After Visit Summary printout. From this feedback, we have decided to provide the video on the Center for Metabolic and Bariatric Surgery (CMBS) website, and provide Jen Center PCPs with links to the video on business cards.

Sample screen shot of animated bariatric surgery video (source ASMBS)

As for the development of the video, in discussion with Dr. Ali Tavakkoli and Dr. Matthew Hutter at the Massachusetts General Hospital (MGH), we will use the American Society of Metabolic and Bariatric Surgery (ASMBS) animated videos (Figure 1). A number of these videos will be edited, rearranged, and addended with BWH-specific information on attending a bariatric surgery info-session.

As for next steps, we hope to publish this data so we are applying for an IRB. Primary endpoints will be a pre/post survey before and after the video for patients, PCP feedback on experience with the video, CMBS info session attendance volume, and CMBS referral volume.

From our work so far, we developed an appreciation of the challenges of identifying ways to launch an initiative with minimal impact to existing workflow. We also experienced first-hand how difficult it can be to gather stakeholder agreement over what content is important to include in the video.

Optimizing the timeliness of treatment for patients with status epilepticus – almost ready for protocol implementation

2019-03-21T11:52:00.001-07:00

Mauricio F. Villamar, MD

Fellow in Epilepsy at BWH

PGY 5

March 20, 2019

Shortly after starting my epilepsy fellowship at Brigham and Women’s Hospital, I was privileged to receive a grant from the Partners Center of Expertise in Medical Education. Thanks to their valuable support, we are working to implement a protocol that aims to optimize the inpatient management of status epilepticus.

Status epilepticus is a neurological emergency. Studies have found that delays in the treatment of status epilepticus are associated with increased in-hospital mortality and morbidity. This includes longer duration of convulsive seizures, increased need for continuous infusions, delayed return of consciousness, and poorer functional outcomes. More rapid seizure control has the potential of decreasing these adverse outcomes.

Despite the importance of timely management of status epilepticus, treatment delays occur commonly in clinical practice due to several factors that may vary between institutions. During my neurology residency at the University of Kentucky, we tried to address some of these delays by implementing an alert protocol for inpatient management of status epilepticus. Briefly, this is an alert system that resembles the one used for patients with acute stroke, and it involves the collaborative work of the neurology, pharmacy, and rapid response teams. Its use led to earlier administration of antiseizure medications compared to usual care. When I came to BWH, my goal was to refine the protocol and to adapt it to the specific needs of our hospital.

Being a newcomer, I think that the biggest challenge so far was to understand the practical and logistical differences between BWH and my previous hospital, and to identify BWH’s specific needs when implementing a system of this kind. The support that I have received from Dr. Jong Woo Lee, Director of the Critical Care EEG Monitoring Program at BWH, has been essential in this regard. Jack Donleavy, Neurology Operations Coordinator, is also leading the project and has provided critical logistical and administrative advice. Numerous other physicians, nurses, and pharmacists have shown their interest in the project and provided valuable feedback to optimize the protocol.

After several meetings with members of the BWH Epilepsy and Neurocritical Care Divisions, with the Neurology Quality Assurance Committee, and with Pharmacy Services, we have developed a protocol that we think fits our specific needs. It shares some similarities with the acute stroke protocol that is already being used at BWH. In the coming days we will present the status epilepticus alert protocol to the Patient Safety and Risk Management team, after which it will be ready for implementation.

Finally, we are developing methods to facilitate collection of pertinent clinical data from our electronic medical record to objectively measure the impact of the status epilepticus alert system. We have identified Research Patient Data Registry (RPDR) as a tool to obtain historical data and to assess the variables that need to be collected. We explored the Enterprise Data Warehouse (EDW) system but were unsuccessful in engaging the necessary resources.

After working to implement protocols of this kind at two different institutions, I have learned that the most important factors determining their success are how well they adapt to the local needs, and the team’s ability to establish an interdisciplinary collaboration. I am grateful for the support I have received from the Partners Center of Expertise in Medical Education and look forward to implementing the protocol soon.

Power Struggle: The Quest to Increase the Impact of Significant Preliminary Findings

2019-03-21T11:50:00.000-07:00

Sam Miller, MD

Resident in Internal Medicine at MGH

PGY-2

March 20, 2019

Project Summary

Our project addresses an issue near and dear to the hearts of hospitalists, gastroenterologists, hepatologists, administrators, case managers and nurses at MGH; we are attempting to identify predictors of readmission in cirrhotic patients admitted with hepatic encephalopathy. Our study enrolls cirrhotic patients admitted with hepatic encephalopathy at MGH as they approach discharge. We examine patient demographics (age, education level, gender, etiology of cirrhosis, discharge destination), hospital complications (GI bleed, infection, drug use, kidney injury), treatments prescribed (dose of lactulose, stool frequency, rifaxamin prescription) and scores on a battery of cognitive tests (MOCA, Pscyhometric Hepatic Encephalopathy Score) at the time of discharge, to see if any of these parameters predict readmission within 30 days for hepatic encephalopathy, other liver-related complications, or alternatively, death/hospice/liver transplant.

Project Obstacles

Patient recruitment is a difficult process. This requires bi-weekly chart review of the entire hospitalist service at MGH, and communication with patients’ primary teams to determine discharge timing and confirm a diagnosis of hepatic encephalopathy. Then patients need to be approached for consent, enrolled (an hour-long process), and called for follow-up at 30 days post-discharge. Patients are often “busy” during their time in the hospital, working with PT, nutrition, case management, and consulting services, and this can often delay enrollment. Discharge timing is a constantly moving target, and staying up to date on a patient’s discharge plan requires a great deal of attention. And calling patients for follow-up is no guarantee that they will answer the phone on the first, second, or third try!

What are the next steps?

Our project has enrolled 44 patients to date, and we have found that scores on one specific cognitive test (Number Connection Test A, a component of the Psychometric Hepatic Encephalopathy Score) does predict readmission for hepatic encephalopathy, and death/hospice/transplant in a statistically significant fashion. However, the absolute number of readmissions for hepatic encephalopathy is not as high as we would like, so our next steps are to increase our enrollment in order to increase the power of our study. Fortunately, our significant findings have been collated in an abstract that has been accepted for presentation at a national conference (Digestive Disease Week in May 2019) and we are currently preparing a poster for presentation.

What have you learned about engaging in research?

First and foremost, I have learned the immense difference that a highly-functional team can make in a research project. Our prospective study design and significant administrative burden have made this immediately apparent. Without the work of our highly-motivated and flexible team members, we would not be able to enroll the number of patients we have enrolled to date. Each team member has also made significant intellectual contributions to the project; one team member has utilized their facility with statistics to ensure that our significant findings are adequately reported, while another team member independently had the idea to use a composite endpoint of death/hospice/transplant to make our findings more generalizable and clinically useful.

I have also learned the importance of flexibility when conducting a research project. For example, we had one method of collecting data on stool frequency at discharge for our patient cohort that was simply not feasible. We changed this method and have been able to report results consistently and accurately. We also had to adjust our inclusion criteria in order to capture enough patients for our cohort, and this markedly increased our yield. These small tweaks are not particularly profound, but have had significant implications for our project and have allowed us to discover clinically meaningful data that will hopefully make an impact on future patient care!

Number Connection Test A (connect the numbers in order from 1-25)

Number Connection Test B (connect alternating numbers/letters from 1-13 and A-L)

Digital Symbol Test (copy the symbols associated with each number)

Serial Dotting Test (make a dot in the center of each circle, moving R to L)

Line Tracing Test (complete the maze without touching the black outline.)

Medical education research – a lesson in patience and persistence

2019-03-21T11:40:00.000-07:00

Yun Xue, MD and Sherry Yu, MD

Residents in Dermatology Program at MGH

PGY-3

March 20, 2019

Sherry and I are two third-year residents in a combined dermatology program that spans multiple sites across Boston. Training at multiple sites has its own benefits and drawbacks – one of which is that we are constantly interfacing with rotating attendings. We learn a wide variety of practices, but our time is so short with each attending that, often, trust and autonomy is built at a much slower pace than desired. When we conceived of our research project originally, we were setting out to collect data that we had hoped would bring about more resident autonomy.

Through surveying and interviewing our fellow residents, we hoped to provide a narrative of what resident autonomy means, whether resident felt like autonomy varied between the inpatient and outpatient dermatology practice settings, and ways that resident autonomy can be expanded without compromising patient care. We were excited about the prospect of conducting research with a tangible application to our residency but did not foresee the obstacles that have prevented us from getting to the true data collection and analysis.

Our timeline was ambitious to the say the least. The process of submitting the IRB has been a lesson on coordinating meetings with our mentors, waiting for the review process to occur, and underestimating how days could turn into weeks before the next step forward in the process. We are currently still awaiting our IRB approval after submitting rounds of edits. Little distractions have also cropped up along the way that have made a bid for our time: one of us had a baby, the other became chief resident, both of us have made trips across the world and back – all major new responsibilities we had not expected when writing or accepting the grant.

Despite these unanticipated additions to our lives, we remain committed and excited about seeing this project through to the end. Our next steps are making sure the IRB goes through. The good news is that we already have our questionnaire ready because we had to submit that as part of the IRB. Once we have approval to go ahead with the project, we will plan on distributing the questionnaire and hopefully getting some preliminary data to analyze and reflect on before we embark on interviews.

It’s a difficult but also very rewarding project to see a project through from beginning to end. Often, as college and medical students, we are jumping aboard projects that have already had IRB approval and a plan going forth. It feels much more difficult, but also much more rewarding, when you are the one seeing a project through from beginning to end. Every obstacle and every success is felt a little bit more. Research is a marathon and not a sprint, and we are being taught patience and persistence every day.

Weight is more than a Number: Performing an Outpatient Weight Monitoring Pilot Study.

2019-03-21T11:37:00.000-07:00

Patricia Pringle Bloom MD

Fellow in Gastroenterology at MGH

PGY 6

March 20, 2019

Ascites refers to fluid build-up in the abdomen, and is a common complication of liver cirrhosis. Ascites accumulation leads to both patient discomfort and frequent health care utilization. At MGH, 30% of cirrhotic patients admitted to the hospital for a complication of cirrhosis are re-admitted within 90-days. Nearly 30% of those admissions and readmissions are for ascites management. Major American and European expert groups recommend that ascites treatments be adjusted based on body weight changes, as a surrogate of ascites volume. However, in our current practice, outpatient weight data often does not reach the hepatology provider.

Our team performed an interview study of cirrhotic patients readmitted to the hospital with a cirrhosis complication. We discovered that even in this ill and sometimes under-served group, approximately 80% of patients had a Smartphone and were interested in using an application to help manage their liver disease. We also interviewed several MGH hepatology providers to better understand the root causes of ascites readmissions and to learn about their desired features for an outpatient ascites management program.

Two team members hard at work, bringing a scale to another patient!

Equipped with an understanding of what our patients need and what our hepatology providers want, we built a team at the MGH Liver Center to pilot an existing Partners application, called PGHD Connect, which allows weight data to be transmitted from home scales directly into EPIC. Our team is assessing whether patients weigh themselves regularly at home, and if hepatology providers respond to the weight alerts generated.

The most significant obstacle thus far was obtaining IRB approval, specifically with regards to the safety of patient data as it is transmitted through the PGHD Connect application into EPIC. Even though the application is already available for clinical use, the process to obtain regulatory approval was more detailed and time-intensive than we anticipated.

Another obstacle is the overall severity of medical illness in the patient population we are treating. Rarely does a patient with cirrhosis have ascites alone – they are also often burdened by other cirrhosis complications, co-morbidities, or socioeconomic challenges. Working around those other issues has been a challenge at times to ongoing patient participation.

At present, we have enrolled 3 of our planned 20 patients for the pilot. One patient and his provider have found the monitoring system particularly useful when he lost a large amount of weight after hospital discharge. Our next steps are to focus on patient recruitment and find an application developer to help us design an application even more specific to our target population and problem.

The major lessons I have learned from engaging in this research have been two-fold: 1) When working in a large team, creating a plan for regular communication about study tasks is imperative. Just as important, perhaps, is iteratively changing that plan as needed and making sure the entire team is aware and on board with changes. 2) Every human research study must tackle the important task of maintaining the privacy of patient data. Using digital health tools adds another layer to this task and must be managed thoughtfully and proactively. When in doubt, ask someone who knows more!

See One, Do One, Teach One May Be Traditional, But There’s a Better Way!

2018-11-29T08:02:00.001-08:00

Sakina Sojar,¹Caitlin Li,² and Lauren Goverman³

1) Pediatric Emergency Medicine Fellow, PGY4, Hasbro Children’s Hospital, Brown University

2) Pediatric Resident, PGY3, Massachusetts General Hospital for Children

3) Pediatric Resident, PGY2, Massachusetts General Hospital for Children

See One, Do One, Teach One May Be Traditional, But There’s a Better Way!

Learning how to do procedures as a trainee can be exhilarating but stressful. Not only do you have to remember all the steps of the procedure, which supply closet has the extra LP needles, and what percent lidocaine your attending prefers, it’s also essential to obtain high-quality informed consent. For many skills that residents learn, there’s a standard resource they can use to make sure they’re not letting anything slip—shouldn’t they be equally supported in obtaining informed consent?

Lumbar punctures are one of the most common procedures performed by pediatricians, and we noticed that every resident has their own style for obtaining informed consent. Interns learn from their senior residents and attendings, then adapt the consent process fit their own style. After a literature review, we decided that the best strategy to address this variation in consent quality would be to create an electronic tool that could guide the process and ensure that every family had an equal opportunity to learn about the risks and benefits prior to consenting to the procedure.

As a team, we designed a prototype model that could be displayed on an iPad, then went through cycles of cognitive interviews with families who were visiting the pediatric emergency department. Each cycle, we implemented families’ suggested changes into the tool until we consistently received feedback that they liked the design and felt that it helped them adequately understand the procedure. Like any research project, we ran into delays ranging from IRB submissions to lack of space in the busy emergency department, but in the end we were pleased to have a tool that can improve the quality of care we provide to our patients. We’re looking forward to integrating it into pediatric residents’ clinical work flow!

For us, this project reinforced the importance of teamwork and collaboration. By having multiple residents working together, we were able to move forward even when some of us were on busy clinical rotations, and we were able to see the project through to the end even when our fearless leader moved to another institution to start her fellowship. We also realized what a valuable resource the GME office is, and we’re so grateful to them for supporting this project!

Making life a bit simpler – a voyage of discovery through the IRB

2018-10-10T07:16:00.003-07:00

Yvelynne Kelly, MD

Nephrology

PGY-9

October 10, 2018

Last Fall I was privileged to become a recipient of a prestigious Brigham and Women’s Hospital Centers of Expertise Quality and Safety Research Award for my proposed randomized controlled trial comparing tunneled dialysis catheter to non-tunneled dialysis catheter use for renal replacement therapy in the intensive care unit. I have long had a passion for critical care nephrology and had seen first hand the difficulties that can arise with temporary dialysis catheter use for emergent renal replacement therapy. My mentor, Dr. Mallika Mendu, and I decided that the time was well overdue for a high quality randomized trial to give an evidence-based answer as to whether the complication rate with randomization to non-tunneled dialysis catheter use is greater than that associated with tunneled dialysis catheter insertion.

This was my first foray into designing and initiating a randomized controlled trial. What a journey it has been…and, in a sense, we have not yet really begun. We met with interventional nephrologists and critical care nephrologists to bring about a trial design that would be feasible and sufficiently powered to answer our research question. We registered the trial with www.clinicaltrials.gov. I updated my Good Clinical Practice certification. We applied for a $100,000 grant, got amazing feedback, and then, at the last hurdle, the organization decided that they were not interested in a study that focuses on acute kidney injury, as opposed to chronic kidney disease. Still we continue to battle through the grant minefield… In a sense, however, the greatest obstacle has been getting IRB approval. This finally came through in September 2018 after six months of preparing and submitting three different iterations. Like grant writing itself, gaining ethical approval follows a learning curve of honing and refining critical thinking and writing. In the case of IRB approval, however, it serves as a timely reminder of the need to be truly patient-focused, both as clinicians and researchers. One of my stumbling blocks, in particular, was producing a patient consent form that was, in retrospect, far too detailed and medically orientated. I was more interested in telling them every single little thing that could happen, in complete detail, rather than providing a broad overview and simplifying/clarifying language in a manner that would have been beneficial to all involved.

Here’s the take-home point for now, until the trial starts in earnest and all opportunities for learning begin to multiple exponentially: we need to focus on our patients; their wants, needs, fears and frailties. That way, we can shrink the paperwork and apply ourselves more fully to the true task in hand – providing safe, efficacious and quality care for those whom we serve.