Medical Education Work Group Updates

On the September 13, 2024 HOMERuN Collaborative Session, the Medical Education Work Group presented updates on their current projects. This Work Group plays a pivotal role in achieving the larger HOMERuN objectives by strategically focusing on the interplay between education, research, and communication to positively impact clinician satisfaction, reduce attrition, and contribute to the transformation of patient care.

Survey of Practices Surrounding Onboarding New Hospital Medicine Faculty

Proposed Title: "You're hired, now what? A survey of onboarding practices for new hospitalist physician faculty."

Study Objective: To capture a broad picture of onboarding practices in Hospital Medicine groups.

Survey Scope: The survey was sent to 68 academic institutions across the US.

Status: The data has been collected and we are drafting the manuscript.

Preliminary Findings:

• 30/68 institutions responded
• A lot of new faculty are being onboarded, around 75% without any hospitalist experience
• Common topics and methods
• Similar topics offered across academic hospitalist divisions
• Methods to deliver content tailored to new faculty needs
• Program evaluation
• Few programs evaluate beyond initial reactions

Next Steps: We will finish the manuscript. We'll also do a workshop about onboarding at SHM Converge 2025!

Faculty and Resident Development Regarding the Performance of Clinical Assessments

Team Members: Greg Leslie, Valerie Lang, Jack Cunningham, Jack Badawy, Amit Pahwa.

Project Goals: Further our understanding of the content and prevalence of training for attending and resident preceptors on the utilization of clinical performance assessments for medical students during their Core Internal Medicine Clerkship. 

Status:

• Drafted questions and submitted to Clerkship Directors of Internal Medicine Survey but was rejected
• May utilize the HOMERuN network for obtaining data

Educators Corner on Evidence-based Teaching Practices in the Hospital

Team Members: Greg Leslie, Valerie Lang, John (Jack) Cunningham, Jack Badawy, Amit Pahwa.

Project Goals: Plan to add a short segment on evidence-based teaching in the hospital setting in HOMERuN's newsletter quarterly.

Status: See in future issues!

IV Fluid Shortage, Challenges, and Best Practices

On October 18, 2024, HOMERuN convened an Emergency Collaborative Session to discuss the IV fluid shortage. The recent nationwide IV fluid shortage has presented significant challenges to health care systems across the United States. This summary outlines the key points discussed during a recent meeting addressing the shortage, its causes, the obstacles faced, and the best practices being implemented to manage the crisis.

Cause of the shortage: The primary cause of the shortage is the closure of Baxter's main plant due to severe flooding from Hurricane Helene. This plant supplies 60% of the US IV solution, and its closure has disrupted the supply chain significantly. Efforts are ongoing to activate global manufacturing and restore operations by the end of the year.

Challenges Faced

1. Supply Chain Disruption:

• Hospitals solely dependent on Baxter's supply are experiencing severe shortages.
• There appears to be a geographical pattern with hospitals closer to the Baxter plant feeling more impact.

2. Operational Strain:

• Managing the shortage requires leadership to divert focus from other initiatives to this issue.
• Some health care systems also appear to be hesitant to implement operational changes that may lead to further strain on health care workers.

3. Staffing and Logistics:

• The shortage has led to increased operational demands on hospital staff, including pharmacy, nursing, and administrative teams.

4. Hospitalist Census:

• As some institutions reschedule elective surgery, hospitalists are finding that the medicine census has increased and so there have been downstream effects from this shortage.

5. Insurance Denials:

• Some institutions have begun facing insurance denials for hospital stays where IV fluids were not administered, adding to the administrative burden.

6. Patient Care Impact:

• There is a concern that over-conservation could have downstream effects in terms of patient outcomes such as kidney injury. 

Best Practices Implemented

1. Leadership and Coordination:

• Establishing strategic work groups comprising physicians, nurses, pharmacists, and operational staff to manage the response. Institutions who receive input from many stakeholders have had the most success in implementation of best practices.
• Utilizing existing systems of routine care, such as interdisciplinary rounds, to respond to urgent issues such as shortages has allowed some health systems to implement changes quickly and optimize fluid usage.

2. Conservation Measures:

• Encouraging the use of oral hydration where possible.
• Switching IV medications to oral forms or IV push when clinically appropriate.
• Adjusting surgical workflows to minimize unnecessary IV fluid usage such as avoiding automatic maintenance fluids or rescheduling elective cases which need large volume IV fluids.
• Using clinical decision support systems in electronic health records (EHRs) to prompt best practices to reduce use of maintenance fluids.
• Adjusting NPO (nothing by mouth) timings to be shorter in duration (2 hours) instead of after midnight.
• Selecting duration of IV fluids to fewest number of days or requiring daily renewal.

3. Nursing Practice Adjustments:

• Eliminating the use of IV fluids to keep veins open (TKO) unless absolutely necessary.
• Not switching out IV bags until completely empty and using smaller IV bags so that the remainder of fluid is not wasted.

4. Communication and Education:

• Communicating the importance of conserving IV fluids through emails, alerts in EHR systems, and team meetings.
• Developing protocols to ensure standard of care is maintained while conserving fluids.
• Communicating with patients and families about best practices so that there is shared understanding.

5. Additional Considerations:

• Collaborating with other health systems to share resources and strategies.
• Developing disease- or scenario-specific rules for IV fluid use and tracking measures of safety to be sure conservation does not cause harm.

Documents Shared:

• IV Fluid Conservation Information Sheet
• IV Shortage Critical Conservation Strategies
• IV Solutions Shortage Patient Facing Flyer

Conclusion

The IV fluid shortage has necessitated rapid adaptation and collaboration across health care systems. By implementing strategic conservation measures, adjusting clinical practices, and leveraging technology, hospitals aim to manage the crisis effectively while ensuring patient care standards are upheld. Continued communication, a multi-disciplinary approach and shared learning will be crucial as the situation evolves. Hopefully, some best practices will be sustained around high value care and utilization of IV fluids.

New Publication

The Workforce Planning Work Group manuscript on hospitalist perspectives on secure messaging was recently published in the Journal of Hospital Medicine!

Secure messaging (SM) is becoming a common way for hospitalists to communicate, but most existing literature focuses on usage patterns and implementation science, without clear understanding of the benefits and challenges users may be encountering. Through a mixed methods approach involving surveys and focus groups with hospitalists from 24 academic institutions, we found that while SM enhances communication efficiency, it also increases multitasking, cognitive load, and alters interpersonal dynamics.

The study underscores the need for clear institutional guidelines for SM use and emphasizes the importance of collaborating with frontline workers to improve communication practices.

Knees M, Keniston A, Yu A, Sakumoto M, Westergaard S, Schwatka N, Peterson R, Kochar A, Auerbach A, Lee T, Burden M. Academic hospitalist perspectives on the benefits and challenges of secure messaging: A mixed methods analysis. J Hosp Med. 2 Oct 2024.

More information about what the HOMERuN Work Groups are working on is available on our Collaborative Work Groups Page.

Our next meeting will be on November 8, 2024.