Here - American Geriatrics Society

P OSTER
A BSTRACTS
B64
Residency Training in Optimizing Hospital to Nursing Home
Transitions.
A. Nazir, A. K. Chakka, M. Tegeler, A. D. Graves,
G. R. Westmoreland. Medicine, Indiana University, Indianapolis, IN.
Supported By: 1. Dr. Arif Nazir was funded by the Geriatric
Academic Career Award sponsoerd by Health Resources and
Services Adminsitration.
Background: Selecting an appropriate Post-Acute Care (PAC)
venue and ensuring a seamless transition are critical for the recovery
of older hospitalized patients. We implemented a course for Internal
Medicine and Medicine/Pediatrics residents on selection of PAC venues,
best practices in transitional care, and PAC insurance coverage.
Methods: A formal needs assessment helped structure the aims
that included teaching: 1) various PAC options and Medicare and
Medicaid coverage, 2) strategies to help patients and families select
the most appropriate skilled nursing facility (SNF), and 3) best practices
in transitional care. Course pre-work included an online self-efficacy
survey, a pretest and assigned readings. Sessions 1 and 2 of the
course were conducted by geriatricians in 2 local SNFs. Session 1 included
case-based discussions and role-play in a mock family meeting
focusing on description and insurance coverage of various PAC options,
and the physician’s role in helping families select the most appropriate
SNF. In session 2 residents used a formal tool to assess the
quality of patient transitions and patient awareness of their diseases
and PAC goals. The course concluded with residents repeating the online
self-efficacy survey, a posttest and course evaluation.
Results: Twelve residents have taken the course. Preliminary
survey results show that after taking the course the residents who
were ‘aware OR very much aware’ of ‘available PAC options’ increased
from 3 to 12; those who were ‘knowledgeable OR very
knowledgeable’ about PAC insurance coverage increased from 0 to 7;
and those who were ‘familiar OR very familiar’ with ‘transitional care
issues in elders increased from 2 to 11. Similarly, more residents felt
‘confident OR very confident’ to ‘carry out a family meeting regarding
appropriate PAC venue’, ‘facilitate successful transition for an
older patient’, and ‘help a family to select the best SNF’. There was a
16% mean gain in posttest vs. pretest scores and 85% would recommend
this course to others. Most felt the course will impact their practice.
One learner said, “I will check discharge summaries, look up
(star) rating information on facilities and have early discussions
about goals of care.”
Conclusion: Early findings show that a structured course may
improve residents’ knowledge, skills and attitudes about their role in
patient selection of appropriate PAC options and transitional care.
B65
Inadequate Understanding of Code Status Improved by Case-Based
Learning.
A. Sangarlangkarn, M. Drickamer. Geriatrics, Yale School of
Medicine, New Haven, CT.
Multiple studies show continued deficiencies in education on
end-of-life care. However, there is limited literature on whether
providers have an adequate understanding of DNR/DNI, which is essential
in end-of-life care. Our study evaluates the understanding of
DNR/DNI among physicians in training and the efficacy of casebased
learning in code status education.
In Fall 2011, we surveyed medical students and residents at Yale
School of Medicine before and after a course on challenging end-oflife
cases. Constructed using the same standards as the nationally utilized
Yale Office-Based Medicine Curriculum, the course focused on
DNI/not DNR patients, reversibility of code status, and futility of
care. Mcnemar test was used to evaluate changes in responses.
Results from 44 surveys are shown in attached image. After the
course, participants were 9 times more likely to correctly forego
amiodarone in coding DNR patients (p=0.02), and 11 times more
likely to correctly offer ambu-bag in DNI patients (p=0.01). When
asked if participants possess adequate understanding of DNR/DNI
on a scale of 1 (disagree) to 5 (agree), there was a 0.93 point increase
after the course (before=3.26, after=4.19, p=0.00). Ninety-three percent
would recommend the course to others.
Surveys showed that many participants would provide contraindicated
interventions to DNR patients while failing to offer appropriate
interventions to DNI patients. After the course, more participants reported
having an adequate understanding of DNR/DNI. A significant
number appropriately offered manual lung inflation to DNI patients
and correctly withheld antiarrhythmics in coding DNR patients. Our
study showed that physicians in training may benefit from code status
education, particularly case-based learning which may improve their
understanding of DNR/DNI and the quality of end-of-life care.
B66
Development of an Ambulatory Geriatrics Exam for Internal
Medicine Residents.
J. L. Kalender-Rich, 1,2 J. D. Mahnken, 4 I. Dong, 4 A. M. Paolo, 3
S. K. Rigler. 1,2 1. Internal Medicine, University of Kansas School of
Medicine, Overland Park, KS; 2. Landon Center on Aging, University
of Kansas School of Medicine, Overland Park, KS; 3. Office of
Medical Education, University of Kansas School of Medicine,
Overland Park, KS; 4. Department of Biostatistics, University of
Kansas School of Medicine, Overland Park, KS.
Background
Internal Medicine residents must complete geriatric-specific
training. Ambulatory care is now increasingly emphasized in Internal
Medicine residency which has traditionally focused on inpatient care.
Two widely used geriatrics knowledge exams focus mainly on nonambulatory
topics. Our goal was to create a valid ambulatory-focused
geriatrics knowledge exam for residents.
Methods
We created exam questions that cover common clinical topics
likely to be tested on in-training and board exams. Questions were reviewed
by experts in Internal Medicine, Geriatric Medicine, and
Medical Education for content and structure. The exam was administered
to 55 interns and residents after which item analysis was performed
to assess discrimination and level of difficulty; five questions
were discarded based on poor item performance, creating a final 25
question exam. It was also completed by 20 fourth year medical students,
11 general medicine faculty, and 10 geriatrics fellowshiptrained
faculty. We compared the mean correct score for each group
with one-way ANOVA, and also treated group as ordinal and tested
for a trend using simple linear regression.
Results
The mean correct scores for the four groups were 65%, 59%,
60%, 70% and 80% for students, interns, residents, general medicine
faculty and geriatric medicine faculty, respectively. The test of equal
mean scores across groups was rejected (p