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Bridging the Gap Between Inpatient and Outpatient Care
The Olin E. Teague Veterans’ Center (OETVC) in Temple, Texas, is a teaching hospital with 189 beds that provides patients access to medical, surgical, and specialty care. In 2022, 116,359 veterans received care at OETVC and 5393 inpatient admissions were noted. The inpatient ward consists of 3 teaching teams staffed by an attending physician, a second-year internal medicine resident, and 2 to 3 interns while hospitalists staff the 3 nonteaching teams. OETVC residents receive training on both routine and complex medical problems.
Each day, teaching teams discharge patients. With the complexity of discharges, there is always a risk of patients not following up with their primary care physicians, potential issues with filling medications, confusion about new medication regiments, and even potential postdischarge questions. In 1990, Holloway and colleagues evaluated potential risk factors for readmission among veterans. This study found that discharge from a geriatrics or intermediate care bed, chronic disease diagnosis, ≥ 2 procedures performed, increasing age, and distance from a veterans affairs medical center were risk factors.1
Several community hospital studies have evaluated readmission risk factors. One from 2000 noted that patients with more hospitalizations, lower mental health function, a diagnosis of chronic obstructive pulmonary disorder, and increased satisfaction with access to emergency care were associated with increased readmission in 90 days.2 Due to the readmission risks, OETVC decided to construct a program that would help these patients successfully transition from inpatient to outpatient care while establishing means to discuss their care with a physician for reassurance and guidance.
TRANSITION OF CARE PROGRAM
Transition of care programs have been implemented and evaluated in many institutions. A 2017 systematic review of transition of care programs supported the use of tailored discharge planning and postdischarge phone calls to reduce hospital readmission, noting that 6 studies demonstrated a statistically significant reduction in 30-day readmission rate.3 Another study found that pharmacy involvement in the transition of care reduced medication-related problems following discharge.4
Program Goals
The foundational goal of our program was to bridge the gap between inpatient and outpatient medicine. We hoped to improve patient adherence with their discharge regimens, improve access to primary care physicians, and improve discharge follow-up. Since hospitalization can be overwhelming, we hoped to capture potential barriers to medical care postdischarge when patients return home while decreasing hospital readmissions. Our second- and third-year resident physicians spend as much time as needed going through the patient’s course of illness throughout their hospitalization and treatment plans to ensure their understanding and potential success.
This program benefits residents by providing medical education and patient communication opportunities. Residents must review the patient’s clinical trajectory before calling them. In this process, residents develop an understanding of routine and complex illness scripts, or pathways of common illnesses. They also prepare for potential questions about the hospitalization, new medications, and follow-up care. Lastly, residents can focus on communication skills. Without the time pressures of returning to a busy rotation, the residents spend as much time discussing the hospital course and ensuring patient understanding as needed.
Program Description
At the beginning of each week, second- and third-year residents review the list of discharges from the 3 teaching teams. The list is generated by a medical service management analyst. The residents review patient records for inpatient services, laboratory results, medication changes, and proposed follow-up plans designed by the admission team prior to their phone call. The resident is also responsible for reviewing and reconciling discharge instructions and orders. Then, the resident calls the patient and reviews their hospitalization. If a patient does not answer, the resident leaves a voicemail that complies with the Health Insurance Portability and Accountability Act.
When patients answer the call, the resident follows a script (Appendix). Residents are encouraged to ask patients open-ended questions and address any new needs. They also discuss changes in symptoms, medications, functional status, and remind the patient about follow-up appointments. If imaging or specific orders were missed at discharge, the residents notify the chief resident, lead hospitalist, or deputy associate chief of staff for medical service. If additional laboratory tests need to be ordered, the resident devises a follow-up plan. If needed, specialty referrals can be placed. When residents feel there are multiple items that need to be addressed or if they notice any major concerns, they can recommend the patient present to the emergency department for evaluation. The chief resident, lead hospitalist, and deputy associate chair for medical service are available to assist with discussions about complex medical situations or new concerning symptoms. Residents document their encounters in the Computerized Patient Record System health record and any tests that need follow-up. This differs from the standard of care follow-up programs, which are conducted by primary care medicine nurses and do not fully discuss the hospitalization.
Implementation
This program was implemented as a 1-week elective for interested residents and part of the clinic rotation. The internal medicine medical service analyst pulls all discharges on Friday, which are then provided to the residents. The residents on rotation work through the discharges and find teaching team patients to follow up with and call.
Findings
Implementation of this program has yielded many benefits. The reminder of the importance of a primary care appointment has motivated patients to continue following up on an outpatient basis. Residents were also able to capture lapses in patient understanding. Residents could answer forgotten questions and help patients understand their admission pathology without time pressures. Residents have identified patients with hypoglycemia due to changed insulin regimens, set up specialist follow-up appointments, and provided additional education facilitating adherence. Additionally, several residents have expressed satisfaction with the ability to practice their communication skills. Others appreciated contributing to future patient successes.
While the focus on this article has been to share the program description, we have tabulated preliminary data. In January 2023, there were 239 internal medicine admissions; 158 admissions (66%) were teaching team patients, and 97 patients (61%) were called by a resident and spoken to regarding their care. There were 24 teaching team readmissions within 30 days, and 10 (42%) received a follow-up phone call. Eighty-one admitted patients were treated by nonteaching teams, 10 (12%) of whom were readmissions. Comparing 30-day readmission rates, 10 nonteaching team patients (12%), 10 teaching team patients (6.3%) who talk to a resident in the transition of care program were readmitted, and 24 teaching team patients who did not talk to a resident (10%) were readmitted.
DISCUSSION
The OETVC transition of care program was planned, formulated, and implemented without modeling after any other projects or institutions. This program aimed to utilize our residents as resources for patients.
Transition of care is defined as steps taken in a clinical encounter to assist with the coordination and continuity of patient care transferring between locations or levels of care.5 A 2018 study evaluating the utility of transition of care programs on adults aged ≥ 60 years found a reduction in rehospitalization rates, increased use of primary care services, and potential reduction in home health usage.6
In 2021, Johns Hopkins University School of Medicine implemented a program after polling residents and discovering their awareness of gaps in the transition of care.7 In 2002, pharmacists evaluated the impact of follow-up telephone calls to recently hospitalized patients. This group of pharmacists found that these calls were associated with increased patient satisfaction, resolution of medication-related problems and fewer emergency department returns.8
Our program differs from other transition of care programs in that resident physicians made the follow-up calls to patients. Residents could address all aspects of medical care, including new symptoms, new prescriptions, adverse events, and risk factors for readmission, or order new imaging and medications when appropriate. In the program, residents called all patients discharged after receiving care within their team. Calls were not based on risk assessments. The residents were able to speak with 61% of discharged patients. When readmission rates were compared between patients who received a resident follow-up phone call and those who did not, patients receiving the resident phone call were readmitted at a lower rate: 6.3% vs 10%, respectively.
While our data suggest a potential trend of decreased readmission, more follow-up over a longer period may be needed. We believe this program can benefit patients and our model can act as a template for other institutions interested in starting their own programs.
Challenges
Although our process is efficient, there have been some challenges. The discharge is created by the medical service management analyst and then sent to the chief resident, but there was concern that the list could be missed if either individual was unavailable. The chairperson for the department of medicine and their secretary are now involved in the process. To reduce unanswered telephone calls, residents use OETVC phones. Health Insurance Portability and Accountability Act-compliant voicemails providing a time for a follow-up call were implemented. As a result, veterans have answered their phones more regularly and are more aware of calls. Orders are generally placed by the chief resident, lead hospitalist, or chair of the medical service to ensure follow-up because residents are on rotation for 1 week at a time. Access to a physician also allows patients to discuss items unrelated to their hospitalization, introducing new symptoms, or situations requiring a resident to act with limited data.
CONCLUSIONS
The transition of care follow-up program described in this article may be beneficial for both internal medicine residents and patients. Second- and third-year residents are developing a better understanding of the trajectory of many illnesses and are given the opportunity to retrospectively analyze what they would do differently based on knowledge gained from their chart reviews. They are also given the opportunity to work on communication skills and explain courses of illnesses to patients in an easy-to-understand format without time constraints. Patients now have access to a physician following discharge to discuss any concerns with their hospitalization, condition, and follow-up. This program will continue to address barriers to care and adapt to improve the success of care transitions.
1. Holloway JJ, Medendorp SV, Bromberg J. Risk factors for early readmission among veterans. Health Serv Res. 1990;25(1 Pt 2):213-237.
2. Smith DM, Giobbie-Hurder A, Weinberger M, et al. Predicting non-elective hospital readmissions: a multi-site study. Department of Veterans Affairs Cooperative Study Group on Primary Care and Readmissions. J Clin Epidemiol. 2000;53(11):1113-1118. doi:10.1016/s0895-4356(00)00236-5
3. Kamermayer AK, Leasure AR, Anderson L. The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality: A Systematic Review. Dimens Crit Care Nurs. 2017;36(6):311-316. doi:10.1097/DCC.0000000000000266
4. Daliri S, Hugtenburg JG, Ter Riet G, et al. The effect of a pharmacy-led transitional care program on medication-related problems post-discharge: A before-After prospective study. PLoS One. 2019;14(3):e0213593. Published 2019 Mar 12. doi:10.1371/journal.pone.0213593
5. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51(4):549-555. doi:10.1046/j.1532-5415.2003.51185.x
6. Weeks LE, Macdonald M, Helwig M, Bishop A, Martin-Misener R, Iduye D. The impact of transitional care programs on health services utilization among community-dwelling older adults and their caregivers: a systematic review protocol of quantitative evidence. JBI Database System Rev Implement Rep. 2016;14(3):26-34. doi:10.11124/JBISRIR-2016-2568
7. Sheikh F, Gathecha E, Arbaje AI, Christmas C. Internal Medicine Residents’ Views About Care Transitions: Results of an Educational Intervention. J Med Educ Curric Dev. 2021;8:2382120520988590. Published 2021 Jan 20. doi:10.1177/2382120520988590
8. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Dis Mon. 2002;48(4):239-248. doi:10.1016/s0011-5029(02)90031-3
The Olin E. Teague Veterans’ Center (OETVC) in Temple, Texas, is a teaching hospital with 189 beds that provides patients access to medical, surgical, and specialty care. In 2022, 116,359 veterans received care at OETVC and 5393 inpatient admissions were noted. The inpatient ward consists of 3 teaching teams staffed by an attending physician, a second-year internal medicine resident, and 2 to 3 interns while hospitalists staff the 3 nonteaching teams. OETVC residents receive training on both routine and complex medical problems.
Each day, teaching teams discharge patients. With the complexity of discharges, there is always a risk of patients not following up with their primary care physicians, potential issues with filling medications, confusion about new medication regiments, and even potential postdischarge questions. In 1990, Holloway and colleagues evaluated potential risk factors for readmission among veterans. This study found that discharge from a geriatrics or intermediate care bed, chronic disease diagnosis, ≥ 2 procedures performed, increasing age, and distance from a veterans affairs medical center were risk factors.1
Several community hospital studies have evaluated readmission risk factors. One from 2000 noted that patients with more hospitalizations, lower mental health function, a diagnosis of chronic obstructive pulmonary disorder, and increased satisfaction with access to emergency care were associated with increased readmission in 90 days.2 Due to the readmission risks, OETVC decided to construct a program that would help these patients successfully transition from inpatient to outpatient care while establishing means to discuss their care with a physician for reassurance and guidance.
TRANSITION OF CARE PROGRAM
Transition of care programs have been implemented and evaluated in many institutions. A 2017 systematic review of transition of care programs supported the use of tailored discharge planning and postdischarge phone calls to reduce hospital readmission, noting that 6 studies demonstrated a statistically significant reduction in 30-day readmission rate.3 Another study found that pharmacy involvement in the transition of care reduced medication-related problems following discharge.4
Program Goals
The foundational goal of our program was to bridge the gap between inpatient and outpatient medicine. We hoped to improve patient adherence with their discharge regimens, improve access to primary care physicians, and improve discharge follow-up. Since hospitalization can be overwhelming, we hoped to capture potential barriers to medical care postdischarge when patients return home while decreasing hospital readmissions. Our second- and third-year resident physicians spend as much time as needed going through the patient’s course of illness throughout their hospitalization and treatment plans to ensure their understanding and potential success.
This program benefits residents by providing medical education and patient communication opportunities. Residents must review the patient’s clinical trajectory before calling them. In this process, residents develop an understanding of routine and complex illness scripts, or pathways of common illnesses. They also prepare for potential questions about the hospitalization, new medications, and follow-up care. Lastly, residents can focus on communication skills. Without the time pressures of returning to a busy rotation, the residents spend as much time discussing the hospital course and ensuring patient understanding as needed.
Program Description
At the beginning of each week, second- and third-year residents review the list of discharges from the 3 teaching teams. The list is generated by a medical service management analyst. The residents review patient records for inpatient services, laboratory results, medication changes, and proposed follow-up plans designed by the admission team prior to their phone call. The resident is also responsible for reviewing and reconciling discharge instructions and orders. Then, the resident calls the patient and reviews their hospitalization. If a patient does not answer, the resident leaves a voicemail that complies with the Health Insurance Portability and Accountability Act.
When patients answer the call, the resident follows a script (Appendix). Residents are encouraged to ask patients open-ended questions and address any new needs. They also discuss changes in symptoms, medications, functional status, and remind the patient about follow-up appointments. If imaging or specific orders were missed at discharge, the residents notify the chief resident, lead hospitalist, or deputy associate chief of staff for medical service. If additional laboratory tests need to be ordered, the resident devises a follow-up plan. If needed, specialty referrals can be placed. When residents feel there are multiple items that need to be addressed or if they notice any major concerns, they can recommend the patient present to the emergency department for evaluation. The chief resident, lead hospitalist, and deputy associate chair for medical service are available to assist with discussions about complex medical situations or new concerning symptoms. Residents document their encounters in the Computerized Patient Record System health record and any tests that need follow-up. This differs from the standard of care follow-up programs, which are conducted by primary care medicine nurses and do not fully discuss the hospitalization.
Implementation
This program was implemented as a 1-week elective for interested residents and part of the clinic rotation. The internal medicine medical service analyst pulls all discharges on Friday, which are then provided to the residents. The residents on rotation work through the discharges and find teaching team patients to follow up with and call.
Findings
Implementation of this program has yielded many benefits. The reminder of the importance of a primary care appointment has motivated patients to continue following up on an outpatient basis. Residents were also able to capture lapses in patient understanding. Residents could answer forgotten questions and help patients understand their admission pathology without time pressures. Residents have identified patients with hypoglycemia due to changed insulin regimens, set up specialist follow-up appointments, and provided additional education facilitating adherence. Additionally, several residents have expressed satisfaction with the ability to practice their communication skills. Others appreciated contributing to future patient successes.
While the focus on this article has been to share the program description, we have tabulated preliminary data. In January 2023, there were 239 internal medicine admissions; 158 admissions (66%) were teaching team patients, and 97 patients (61%) were called by a resident and spoken to regarding their care. There were 24 teaching team readmissions within 30 days, and 10 (42%) received a follow-up phone call. Eighty-one admitted patients were treated by nonteaching teams, 10 (12%) of whom were readmissions. Comparing 30-day readmission rates, 10 nonteaching team patients (12%), 10 teaching team patients (6.3%) who talk to a resident in the transition of care program were readmitted, and 24 teaching team patients who did not talk to a resident (10%) were readmitted.
DISCUSSION
The OETVC transition of care program was planned, formulated, and implemented without modeling after any other projects or institutions. This program aimed to utilize our residents as resources for patients.
Transition of care is defined as steps taken in a clinical encounter to assist with the coordination and continuity of patient care transferring between locations or levels of care.5 A 2018 study evaluating the utility of transition of care programs on adults aged ≥ 60 years found a reduction in rehospitalization rates, increased use of primary care services, and potential reduction in home health usage.6
In 2021, Johns Hopkins University School of Medicine implemented a program after polling residents and discovering their awareness of gaps in the transition of care.7 In 2002, pharmacists evaluated the impact of follow-up telephone calls to recently hospitalized patients. This group of pharmacists found that these calls were associated with increased patient satisfaction, resolution of medication-related problems and fewer emergency department returns.8
Our program differs from other transition of care programs in that resident physicians made the follow-up calls to patients. Residents could address all aspects of medical care, including new symptoms, new prescriptions, adverse events, and risk factors for readmission, or order new imaging and medications when appropriate. In the program, residents called all patients discharged after receiving care within their team. Calls were not based on risk assessments. The residents were able to speak with 61% of discharged patients. When readmission rates were compared between patients who received a resident follow-up phone call and those who did not, patients receiving the resident phone call were readmitted at a lower rate: 6.3% vs 10%, respectively.
While our data suggest a potential trend of decreased readmission, more follow-up over a longer period may be needed. We believe this program can benefit patients and our model can act as a template for other institutions interested in starting their own programs.
Challenges
Although our process is efficient, there have been some challenges. The discharge is created by the medical service management analyst and then sent to the chief resident, but there was concern that the list could be missed if either individual was unavailable. The chairperson for the department of medicine and their secretary are now involved in the process. To reduce unanswered telephone calls, residents use OETVC phones. Health Insurance Portability and Accountability Act-compliant voicemails providing a time for a follow-up call were implemented. As a result, veterans have answered their phones more regularly and are more aware of calls. Orders are generally placed by the chief resident, lead hospitalist, or chair of the medical service to ensure follow-up because residents are on rotation for 1 week at a time. Access to a physician also allows patients to discuss items unrelated to their hospitalization, introducing new symptoms, or situations requiring a resident to act with limited data.
CONCLUSIONS
The transition of care follow-up program described in this article may be beneficial for both internal medicine residents and patients. Second- and third-year residents are developing a better understanding of the trajectory of many illnesses and are given the opportunity to retrospectively analyze what they would do differently based on knowledge gained from their chart reviews. They are also given the opportunity to work on communication skills and explain courses of illnesses to patients in an easy-to-understand format without time constraints. Patients now have access to a physician following discharge to discuss any concerns with their hospitalization, condition, and follow-up. This program will continue to address barriers to care and adapt to improve the success of care transitions.
The Olin E. Teague Veterans’ Center (OETVC) in Temple, Texas, is a teaching hospital with 189 beds that provides patients access to medical, surgical, and specialty care. In 2022, 116,359 veterans received care at OETVC and 5393 inpatient admissions were noted. The inpatient ward consists of 3 teaching teams staffed by an attending physician, a second-year internal medicine resident, and 2 to 3 interns while hospitalists staff the 3 nonteaching teams. OETVC residents receive training on both routine and complex medical problems.
Each day, teaching teams discharge patients. With the complexity of discharges, there is always a risk of patients not following up with their primary care physicians, potential issues with filling medications, confusion about new medication regiments, and even potential postdischarge questions. In 1990, Holloway and colleagues evaluated potential risk factors for readmission among veterans. This study found that discharge from a geriatrics or intermediate care bed, chronic disease diagnosis, ≥ 2 procedures performed, increasing age, and distance from a veterans affairs medical center were risk factors.1
Several community hospital studies have evaluated readmission risk factors. One from 2000 noted that patients with more hospitalizations, lower mental health function, a diagnosis of chronic obstructive pulmonary disorder, and increased satisfaction with access to emergency care were associated with increased readmission in 90 days.2 Due to the readmission risks, OETVC decided to construct a program that would help these patients successfully transition from inpatient to outpatient care while establishing means to discuss their care with a physician for reassurance and guidance.
TRANSITION OF CARE PROGRAM
Transition of care programs have been implemented and evaluated in many institutions. A 2017 systematic review of transition of care programs supported the use of tailored discharge planning and postdischarge phone calls to reduce hospital readmission, noting that 6 studies demonstrated a statistically significant reduction in 30-day readmission rate.3 Another study found that pharmacy involvement in the transition of care reduced medication-related problems following discharge.4
Program Goals
The foundational goal of our program was to bridge the gap between inpatient and outpatient medicine. We hoped to improve patient adherence with their discharge regimens, improve access to primary care physicians, and improve discharge follow-up. Since hospitalization can be overwhelming, we hoped to capture potential barriers to medical care postdischarge when patients return home while decreasing hospital readmissions. Our second- and third-year resident physicians spend as much time as needed going through the patient’s course of illness throughout their hospitalization and treatment plans to ensure their understanding and potential success.
This program benefits residents by providing medical education and patient communication opportunities. Residents must review the patient’s clinical trajectory before calling them. In this process, residents develop an understanding of routine and complex illness scripts, or pathways of common illnesses. They also prepare for potential questions about the hospitalization, new medications, and follow-up care. Lastly, residents can focus on communication skills. Without the time pressures of returning to a busy rotation, the residents spend as much time discussing the hospital course and ensuring patient understanding as needed.
Program Description
At the beginning of each week, second- and third-year residents review the list of discharges from the 3 teaching teams. The list is generated by a medical service management analyst. The residents review patient records for inpatient services, laboratory results, medication changes, and proposed follow-up plans designed by the admission team prior to their phone call. The resident is also responsible for reviewing and reconciling discharge instructions and orders. Then, the resident calls the patient and reviews their hospitalization. If a patient does not answer, the resident leaves a voicemail that complies with the Health Insurance Portability and Accountability Act.
When patients answer the call, the resident follows a script (Appendix). Residents are encouraged to ask patients open-ended questions and address any new needs. They also discuss changes in symptoms, medications, functional status, and remind the patient about follow-up appointments. If imaging or specific orders were missed at discharge, the residents notify the chief resident, lead hospitalist, or deputy associate chief of staff for medical service. If additional laboratory tests need to be ordered, the resident devises a follow-up plan. If needed, specialty referrals can be placed. When residents feel there are multiple items that need to be addressed or if they notice any major concerns, they can recommend the patient present to the emergency department for evaluation. The chief resident, lead hospitalist, and deputy associate chair for medical service are available to assist with discussions about complex medical situations or new concerning symptoms. Residents document their encounters in the Computerized Patient Record System health record and any tests that need follow-up. This differs from the standard of care follow-up programs, which are conducted by primary care medicine nurses and do not fully discuss the hospitalization.
Implementation
This program was implemented as a 1-week elective for interested residents and part of the clinic rotation. The internal medicine medical service analyst pulls all discharges on Friday, which are then provided to the residents. The residents on rotation work through the discharges and find teaching team patients to follow up with and call.
Findings
Implementation of this program has yielded many benefits. The reminder of the importance of a primary care appointment has motivated patients to continue following up on an outpatient basis. Residents were also able to capture lapses in patient understanding. Residents could answer forgotten questions and help patients understand their admission pathology without time pressures. Residents have identified patients with hypoglycemia due to changed insulin regimens, set up specialist follow-up appointments, and provided additional education facilitating adherence. Additionally, several residents have expressed satisfaction with the ability to practice their communication skills. Others appreciated contributing to future patient successes.
While the focus on this article has been to share the program description, we have tabulated preliminary data. In January 2023, there were 239 internal medicine admissions; 158 admissions (66%) were teaching team patients, and 97 patients (61%) were called by a resident and spoken to regarding their care. There were 24 teaching team readmissions within 30 days, and 10 (42%) received a follow-up phone call. Eighty-one admitted patients were treated by nonteaching teams, 10 (12%) of whom were readmissions. Comparing 30-day readmission rates, 10 nonteaching team patients (12%), 10 teaching team patients (6.3%) who talk to a resident in the transition of care program were readmitted, and 24 teaching team patients who did not talk to a resident (10%) were readmitted.
DISCUSSION
The OETVC transition of care program was planned, formulated, and implemented without modeling after any other projects or institutions. This program aimed to utilize our residents as resources for patients.
Transition of care is defined as steps taken in a clinical encounter to assist with the coordination and continuity of patient care transferring between locations or levels of care.5 A 2018 study evaluating the utility of transition of care programs on adults aged ≥ 60 years found a reduction in rehospitalization rates, increased use of primary care services, and potential reduction in home health usage.6
In 2021, Johns Hopkins University School of Medicine implemented a program after polling residents and discovering their awareness of gaps in the transition of care.7 In 2002, pharmacists evaluated the impact of follow-up telephone calls to recently hospitalized patients. This group of pharmacists found that these calls were associated with increased patient satisfaction, resolution of medication-related problems and fewer emergency department returns.8
Our program differs from other transition of care programs in that resident physicians made the follow-up calls to patients. Residents could address all aspects of medical care, including new symptoms, new prescriptions, adverse events, and risk factors for readmission, or order new imaging and medications when appropriate. In the program, residents called all patients discharged after receiving care within their team. Calls were not based on risk assessments. The residents were able to speak with 61% of discharged patients. When readmission rates were compared between patients who received a resident follow-up phone call and those who did not, patients receiving the resident phone call were readmitted at a lower rate: 6.3% vs 10%, respectively.
While our data suggest a potential trend of decreased readmission, more follow-up over a longer period may be needed. We believe this program can benefit patients and our model can act as a template for other institutions interested in starting their own programs.
Challenges
Although our process is efficient, there have been some challenges. The discharge is created by the medical service management analyst and then sent to the chief resident, but there was concern that the list could be missed if either individual was unavailable. The chairperson for the department of medicine and their secretary are now involved in the process. To reduce unanswered telephone calls, residents use OETVC phones. Health Insurance Portability and Accountability Act-compliant voicemails providing a time for a follow-up call were implemented. As a result, veterans have answered their phones more regularly and are more aware of calls. Orders are generally placed by the chief resident, lead hospitalist, or chair of the medical service to ensure follow-up because residents are on rotation for 1 week at a time. Access to a physician also allows patients to discuss items unrelated to their hospitalization, introducing new symptoms, or situations requiring a resident to act with limited data.
CONCLUSIONS
The transition of care follow-up program described in this article may be beneficial for both internal medicine residents and patients. Second- and third-year residents are developing a better understanding of the trajectory of many illnesses and are given the opportunity to retrospectively analyze what they would do differently based on knowledge gained from their chart reviews. They are also given the opportunity to work on communication skills and explain courses of illnesses to patients in an easy-to-understand format without time constraints. Patients now have access to a physician following discharge to discuss any concerns with their hospitalization, condition, and follow-up. This program will continue to address barriers to care and adapt to improve the success of care transitions.
1. Holloway JJ, Medendorp SV, Bromberg J. Risk factors for early readmission among veterans. Health Serv Res. 1990;25(1 Pt 2):213-237.
2. Smith DM, Giobbie-Hurder A, Weinberger M, et al. Predicting non-elective hospital readmissions: a multi-site study. Department of Veterans Affairs Cooperative Study Group on Primary Care and Readmissions. J Clin Epidemiol. 2000;53(11):1113-1118. doi:10.1016/s0895-4356(00)00236-5
3. Kamermayer AK, Leasure AR, Anderson L. The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality: A Systematic Review. Dimens Crit Care Nurs. 2017;36(6):311-316. doi:10.1097/DCC.0000000000000266
4. Daliri S, Hugtenburg JG, Ter Riet G, et al. The effect of a pharmacy-led transitional care program on medication-related problems post-discharge: A before-After prospective study. PLoS One. 2019;14(3):e0213593. Published 2019 Mar 12. doi:10.1371/journal.pone.0213593
5. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51(4):549-555. doi:10.1046/j.1532-5415.2003.51185.x
6. Weeks LE, Macdonald M, Helwig M, Bishop A, Martin-Misener R, Iduye D. The impact of transitional care programs on health services utilization among community-dwelling older adults and their caregivers: a systematic review protocol of quantitative evidence. JBI Database System Rev Implement Rep. 2016;14(3):26-34. doi:10.11124/JBISRIR-2016-2568
7. Sheikh F, Gathecha E, Arbaje AI, Christmas C. Internal Medicine Residents’ Views About Care Transitions: Results of an Educational Intervention. J Med Educ Curric Dev. 2021;8:2382120520988590. Published 2021 Jan 20. doi:10.1177/2382120520988590
8. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Dis Mon. 2002;48(4):239-248. doi:10.1016/s0011-5029(02)90031-3
1. Holloway JJ, Medendorp SV, Bromberg J. Risk factors for early readmission among veterans. Health Serv Res. 1990;25(1 Pt 2):213-237.
2. Smith DM, Giobbie-Hurder A, Weinberger M, et al. Predicting non-elective hospital readmissions: a multi-site study. Department of Veterans Affairs Cooperative Study Group on Primary Care and Readmissions. J Clin Epidemiol. 2000;53(11):1113-1118. doi:10.1016/s0895-4356(00)00236-5
3. Kamermayer AK, Leasure AR, Anderson L. The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality: A Systematic Review. Dimens Crit Care Nurs. 2017;36(6):311-316. doi:10.1097/DCC.0000000000000266
4. Daliri S, Hugtenburg JG, Ter Riet G, et al. The effect of a pharmacy-led transitional care program on medication-related problems post-discharge: A before-After prospective study. PLoS One. 2019;14(3):e0213593. Published 2019 Mar 12. doi:10.1371/journal.pone.0213593
5. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51(4):549-555. doi:10.1046/j.1532-5415.2003.51185.x
6. Weeks LE, Macdonald M, Helwig M, Bishop A, Martin-Misener R, Iduye D. The impact of transitional care programs on health services utilization among community-dwelling older adults and their caregivers: a systematic review protocol of quantitative evidence. JBI Database System Rev Implement Rep. 2016;14(3):26-34. doi:10.11124/JBISRIR-2016-2568
7. Sheikh F, Gathecha E, Arbaje AI, Christmas C. Internal Medicine Residents’ Views About Care Transitions: Results of an Educational Intervention. J Med Educ Curric Dev. 2021;8:2382120520988590. Published 2021 Jan 20. doi:10.1177/2382120520988590
8. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Dis Mon. 2002;48(4):239-248. doi:10.1016/s0011-5029(02)90031-3
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<root generator="drupal.xsl" gversion="1.7"> <header> <fileName>0624 FED Transition</fileName> <TBEID>0C02F741.SIG</TBEID> <TBUniqueIdentifier>NJ_0C02F741</TBUniqueIdentifier> <newsOrJournal>Journal</newsOrJournal> <publisherName>Frontline Medical Communications Inc.</publisherName> <storyname/> <articleType>1</articleType> <TBLocation>Copyfitting-FED</TBLocation> <QCDate/> <firstPublished>20240603T111333</firstPublished> <LastPublished>20240603T111333</LastPublished> <pubStatus qcode="stat:"/> <embargoDate/> <killDate/> <CMSDate>20240603T111333</CMSDate> <articleSource/> <facebookInfo/> <meetingNumber/> <byline/> <bylineText>Nikhil Seth, MDa; George Martinez, MDa; Andrew Chapmanb; Nathan Childb; Anika Sikkac; Arshad Ghauri, MDa</bylineText> <bylineFull/> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType/> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:"> <name/> <rightsInfo> <copyrightHolder> <name/> </copyrightHolder> <copyrightNotice/> </rightsInfo> </provider> <abstract/> <metaDescription>The Olin E. Teague Veterans’ Center (OETVC) in Temple, Texas, is a teaching hospital with 189 beds that provides patients access to medical, surgical, and speci</metaDescription> <articlePDF/> <teaserImage/> <title>Bridging the Gap Between Inpatient and Outpatient Care</title> <deck/> <eyebrow>Program Profile</eyebrow> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear>2024</pubPubdateYear> <pubPubdateMonth>June</pubPubdateMonth> <pubPubdateDay/> <pubVolume>41</pubVolume> <pubNumber>6</pubNumber> <wireChannels/> <primaryCMSID/> <CMSIDs> <CMSID>4473</CMSID> <CMSID>3639</CMSID> </CMSIDs> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>FED</publicationCode> <pubIssueName>June 2024</pubIssueName> <pubArticleType>Feature Articles | 3639</pubArticleType> <pubTopics/> <pubCategories/> <pubSections> <pubSection>Program Profile | 4473<pubSubsection/></pubSection> </pubSections> <journalTitle>Fed Pract</journalTitle> <journalFullTitle>Federal Practitioner</journalFullTitle> <copyrightStatement>Copyright 2017 Frontline Medical Communications Inc., Parsippany, NJ, USA. All rights reserved.</copyrightStatement> </publicationData> </publications_g> <publications> <term canonical="true">16</term> </publications> <sections> <term canonical="true">61535</term> </sections> <topics> <term canonical="true">27442</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Bridging the Gap Between Inpatient and Outpatient Care</title> <deck/> </itemMeta> <itemContent> <p class="abstract"><b>Background: </b>The Olin E. Teague Veterans’ Center (OETVC) is a teaching hospital with a medical ward consisting of 189 beds, 3 teaching teams with 1 resident and 2 to 3 interns, and 3 nonteaching teams. Due to the complexity of hospitalization, there are concerns that patients may not follow up with primary care or fill their prescribed medication and may have postdischarge questions. <br/><br/><b>Observations: </b>A program was created at OETVC to bridge the gap between inpatient and outpatient care. Internal medicine residents call all teaching team patients a week following discharge. They discuss medications, changes in symptoms, follow-up plans, and address all questions. The residents also assist with missed orders and make treatment regimen changes if necessary. <br/><br/><b>Conclusions: </b>This new program has proven to be beneficial. Residents are developing a better understanding of illness scripts and are working on communication skills without time constraints. Patients now have access to a physician following discharge to discuss any concerns with their hospitalization, present condition, and follow-up. Data show a decreased 30-day readmission rate at 6% in the transition of care group compared to 10% in all patients who participated in the program. This program will continue to address barriers to care and adapt to improve the success of care transitions. </p> <p><span class="Drop">T</span>he Olin E. Teague Veterans’ Center (OETVC) in Temple, Texas, is a teaching hospital with 189 beds that provides patients access to medical, surgical, and specialty care. In 2022, 116,359 veterans received care at OETVC and 5393 inpatient admissions were noted. The inpatient ward consists of 3 teaching teams staffed by an attending physician, a second-year internal medicine resident, and 2 to 3 interns while hospitalists staff the 3 nonteaching teams. OETVC residents receive training on both routine and complex medical problems. </p> <p>Each day, teaching teams discharge patients. With the complexity of discharges, there is always a risk of patients not following up with their primary care physicians, potential issues with filling medications, confusion about new medication regiments, and even potential postdischarge questions. In 1990, Holloway and colleagues evaluated potential risk factors for readmission among veterans. This study found that discharge from a geriatrics or intermediate care bed, chronic disease diagnosis, ≥ 2 procedures performed, increasing age, and distance from a veterans affairs medical center were risk factors.<sup>1</sup> <br/><br/>Several community hospital studies have evaluated readmission risk factors. One from 2000 noted that patients with more hospitalizations, lower mental health function, a diagnosis of chronic obstructive pulmonary disorder, and increased satisfaction with access to emergency care were associated with increased readmission in 90 days.<sup>2</sup> Due to the readmission risks, OETVC decided to construct a program that would help these patients successfully transition from inpatient to outpatient care while establishing means to discuss their care with a physician for reassurance and guidance. </p> <h2>TRANSITION OF CARE PROGRAM</h2> <p>Transition of care programs have been implemented and evaluated in many institutions. A 2017 systematic review of transition of care programs supported the use of tailored discharge planning and postdischarge phone calls to reduce hospital readmission, noting that 6 studies demonstrated a statistically significant reduction in 30-day readmission rate.<sup>3</sup> Another study found that pharmacy involvement in the transition of care reduced medication-related problems following discharge.<sup>4</sup></p> <h3>Program Goals</h3> <p>The foundational goal of our program was to bridge the gap between inpatient and outpatient medicine. We hoped to improve patient adherence with their discharge regimens, improve access to primary care physicians, and improve discharge follow-up. Since hospitalization can be overwhelming, we hoped to capture potential barriers to medical care postdischarge when patients return home while decreasing hospital readmissions. Our second- and third-year resident physicians spend as much time as needed going through the patient’s course of illness throughout their hospitalization and treatment plans to ensure their understanding and potential success. </p> <p>This program benefits residents by providing medical education and patient communication opportunities. Residents must review the patient’s clinical trajectory before calling them. In this process, residents develop an understanding of routine and complex illness scripts, or<b> </b>pathways of common illnesses.<b> </b>They also prepare for potential questions about the hospitalization, new medications, and follow-up care. Lastly, residents can focus on communication skills. Without the time pressures of returning to a busy rotation, the residents spend as much time discussing the hospital course and ensuring patient understanding as needed. </p> <h3>Program Description</h3> <p>At the beginning of each week, second- and third-year residents review the list of discharges from the 3 teaching teams. The list is generated by a medical service management analyst. The residents review patient records for inpatient services, laboratory results, medication changes, and proposed follow-up plans designed by the admission team prior to their phone call. The resident is also responsible for reviewing and reconciling discharge instructions and orders. Then, the resident calls the patient and reviews their hospitalization. If a patient does not answer, the resident leaves a voicemail that complies with the Health Insurance Portability and Accountability Act. </p> <p>When patients answer the call, the resident follows a script (Appendix). Residents are encouraged to ask patients open-ended questions and address any new needs. They also discuss changes in symptoms, medications, functional status, and remind the patient about follow-up appointments. If imaging or specific orders were missed at discharge, the residents notify the chief resident, lead hospitalist, or deputy associate chief of staff for medical service. If additional laboratory tests need to be ordered, the resident devises a follow-up plan. If needed, specialty referrals can be placed. When residents feel there are multiple items that need to be addressed or if they notice any major concerns, they can recommend the patient present to the emergency department for evaluation. The chief resident, lead hospitalist, and deputy associate chair for medical service are available to assist with discussions about complex medical situations or new concerning symptoms. Residents document their encounters in the Computerized Patient Record System health record and any tests that need follow-up. This differs from the standard of care follow-up programs, which are conducted by primary care medicine nurses and do not fully discuss the hospitalization. </p> <h3>Implementation</h3> <p>This program was implemented as a 1-week elective for interested residents and part of the clinic rotation. The internal medicine medical service analyst pulls all discharges on Friday, which are then provided to the residents. The residents on rotation work through the discharges and find teaching team patients to follow up with and call. </p> <h3>Findings</h3> <p>Implementation of this program has yielded many benefits. The reminder of the importance of a primary care appointment has motivated patients to continue following up on an outpatient basis. Residents were also able to capture lapses in patient understanding. Residents could answer forgotten questions and help patients understand their admission pathology without time pressures. Residents have identified patients with hypoglycemia due to changed insulin regimens, set up specialist follow-up appointments, and provided additional education facilitating adherence. Additionally, several residents have expressed satisfaction with the ability to practice their communication skills. Others appreciated contributing to future patient successes. </p> <p>While the focus on this article has been to share the program description, we have tabulated preliminary data. In January 2023, there were 239 internal medicine admissions; 158 admissions (66%) were teaching team patients, and 97 patients (61%) were called by a resident and spoken to regarding their care. There were 24 teaching team readmissions within 30 days, and 10 (42%) received a follow-up phone call. Eighty-one admitted patients were treated by nonteaching teams, 10 (12%) of whom were readmissions. Comparing 30-day readmission rates, 10 nonteaching team patients (12%), 10<b> </b>teaching team patients (6.3%) who talk to a resident in the transition of care program were readmitted, and 24 teaching team patients who did not talk to a resident (10%) were readmitted. </p> <h2>DISCUSSION</h2> <p>The OETVC transition of care program was planned, formulated, and implemented without modeling after any other projects or institutions. This program aimed to utilize our residents as resources for patients. </p> <p>Transition of care is defined as steps taken in a clinical encounter to assist with the coordination and continuity of patient care transferring between locations or levels of care.<sup>5</sup> A 2018 study evaluating the utility of transition of care programs on adults aged ≥ 60 years found a reduction in rehospitalization rates, increased use of primary care services, and potential reduction in home health usage.<sup>6<br/><br/></sup>In 2021, Johns Hopkins University School of Medicine implemented a program after polling residents and discovering their awareness of gaps in the transition of care.<sup>7</sup> In 2002, pharmacists evaluated the impact of follow-up telephone calls to recently hospitalized patients. This group of pharmacists<b> </b>found that these calls were associated with increased patient satisfaction, resolution of medication-related problems and fewer emergency department returns.<sup>8<br/><br/></sup>Our program differs from other transition of care programs in that resident physicians made the follow-up calls to patients. Residents could address all aspects of medical care, including new symptoms, new prescriptions, adverse events, and risk factors for readmission, or order new imaging and medications when appropriate. In the program, residents called all patients discharged after receiving care within their team. Calls were not based on risk assessments. The residents were able to speak with 61% of discharged patients. When readmission rates were compared between patients who received a resident follow-up phone call and those who did not, patients receiving the resident phone call were readmitted at a lower rate: 6.3% vs 10%, respectively. <br/><br/>While our data suggest a potential trend of decreased readmission, more follow-up over a longer period may be needed. We believe this program can benefit patients and our model can act as a template for other institutions interested in starting their own programs. </p> <h3>Challenges</h3> <p>Although our process is efficient, there have been some challenges. The discharge is created by the medical service management analyst and then sent to the chief resident, but there was concern that the list could be missed if either individual was unavailable. The chairperson for the department of medicine and their secretary are now involved in the process. To reduce unanswered telephone calls, residents use OETVC phones. Health Insurance Portability and Accountability Act-compliant voicemails providing a time for a follow-up call were implemented. As a result, veterans have answered their phones more regularly and are more aware of calls. Orders are generally placed by the chief resident, lead hospitalist, or chair of the medical service to ensure follow-up because residents are on rotation for 1 week at a time. Access to a physician also allows patients to discuss items unrelated to their hospitalization, introducing new symptoms, or situations requiring a resident to act with limited data.</p> <h2>CONCLUSIONS</h2> <p>The transition of care follow-up program described in this article may be beneficial for both internal medicine residents and patients. Second- and third-year residents are developing a better understanding of the trajectory of many illnesses and are given the opportunity to retrospectively analyze what they would do differently based on knowledge gained from their chart reviews. They are also given the opportunity to work on communication skills and explain courses of illnesses to patients in an easy-to-understand format without time constraints. Patients now have access to a physician following discharge to discuss any concerns with their hospitalization, condition, and follow-up. This program will continue to address barriers to care and adapt to improve the success of care transitions. </p> <p class="isub">Author affiliations</p> <p> <em><sup>a</sup>Central Texas Veterans Affairs Hospital, Temple<br/><br/><sup>b</sup>Texas A&M School of Medicine, Bryan<br/><br/><sup>c</sup>Texas A&M University, College Station</em> </p> <p class="isub">Author disclosures</p> <p> <em>The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.</em> </p> <p class="isub">Disclaimer</p> <p> <em>The opinions expressed herein are those of the authors and do not necessarily reflect those of <i>Federal Practitioner</i>, Frontline Medical Communications Inc., the US Government, or any of its agencies.</em> </p> <p class="isub">Ethics and consent</p> <p> <em>Institutional review board approval was not needed for implementation of this program.</em> </p> <p class="isub">References</p> <p class="reference"> 1. Holloway JJ, Medendorp SV, Bromberg J. Risk factors for early readmission among veterans. <i>Health Serv Res</i>. 1990;25(1 Pt 2):213-237.<br/><br/> 2. Smith DM, Giobbie-Hurder A, Weinberger M, et al. Predicting non-elective hospital readmissions: a multi-site study. Department of Veterans Affairs Cooperative Study Group on Primary Care and Readmissions. <i>J Clin Epidemiol</i>. 2000;53(11):1113-1118. doi:10.1016/s0895-4356(00)00236-5 3. Kamermayer AK, Leasure AR, Anderson L. The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality: A Systematic Review. <i>Dimens Crit Care Nurs</i>. 2017;36(6):311-316.doi:10.1097/DCC.0000000000000266 4. Daliri S, Hugtenburg JG, Ter Riet G, et al. The effect of a pharmacy-led transitional care program on medication-related problems post-discharge: A before-After prospective study. <i>PLoS One</i>. 2019;14(3):e0213593. Published 2019 Mar 12. doi:10.1371/journal.pone.0213593<br/><br/> 5. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. <i>J Am Geriatr Soc</i>. 2003;51(4):549-555. doi:10.1046/j.1532-5415.2003.51185.x <br/><br/> 6. Weeks LE, Macdonald M, Helwig M, Bishop A, Martin-Misener R, Iduye D. The impact of transitional care programs on health services utilization among community-dwelling older adults and their caregivers: a systematic review protocol of quantitative evidence. <i>JBI Database System Rev Implement Rep</i>. 2016;14(3):26-34. doi:10.11124/JBISRIR-2016-2568<br/><br/> 7. Sheikh F, Gathecha E, Arbaje AI, Christmas C. Internal Medicine Residents’ Views About Care Transitions: Results of an Educational Intervention. <i>J Med Educ Curric Dev</i>. 2021;8:2382120520988590. Published 2021 Jan 20. doi:10.1177/2382120520988590<br/><br/> 8. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. <i>Dis Mon</i>. 2002;48(4):239-248. doi:10.1016/s0011-5029(02)90031-3</p> </itemContent> </newsItem> </itemSet></root>
The Impact of a Paracentesis Clinic on Internal Medicine Resident Procedural Competency
Competency in paracentesis is an important procedural skill for medical practitioners caring for patients with decompensated liver cirrhosis. Paracentesis is performed to drain ascitic fluid for both diagnosis and/or therapeutic purposes.1 While this procedure can be performed without the use of ultrasound, it is preferable to use ultrasound to identify an area of fluid that is away from dangerous anatomy including bowel loops, the liver, and spleen. After prepping the area, lidocaine is administered locally. A catheter is then inserted until fluid begins flowing freely. The catheter is connected to a suction canister or collection kit, and the patient is monitored until the flow ceases. Samples can be sent for analysis to determine the etiology of ascites, identify concerns for infection, and more.
Paracentesis is a very common procedure. Barsuk and colleagues noted that between 2010 and 2012, 97,577 procedures were performed across 120 academic medical centers and 290 affiliated hospitals.2 Patients undergo paracentesis in a variety of settings including the emergency department, inpatient hospitalizations, and clinics. Some patients may require only 1 paracentesis procedure while others may require it regularly.
Due to the rising need for paracentesis in the Central Texas Veterans Affairs Hospital (CTVAH) in Temple, a paracentesis clinic was started in February 2018. The goal of the paracentesis clinic was multifocal—to reduce hospital admissions, improve access to regularly scheduled procedures, decrease wait times, and increase patient satisfaction.3 Through the CTVAH affiliation with the Texas A&M internal medicine residency program, the paracentesis clinic started involving and training residents on this procedure. Up to 3 residents are on weekly rotation and can perform up to 6 paracentesis procedures in a week. The purpose of this article was to evaluate resident competency in paracentesis after completion of the paracentesis clinic.
Methods
The paracentesis clinic schedules up to 3 patients on Tuesdays and Thursdays between 8
A survey was sent via email to all categorical internal medicine residents across all 3 program years at the time of data collection. Competency for paracentesis sign-off was defined as completing and logging 5 procedures supervised by a competent physician who confirmed that all portions of the procedure were performed correctly. Residents were also asked to answer questions on a scale from 1 to 10, with 1 representing no confidence and 10 representing strong confidence to practice independently (Table).
We also evaluated the number of procedures performed by internal medicine residents 3 years before the clinic was started in 2015 up to the completion of 2022. The numbers were obtained by examining procedural log data for each year for all internal medicine residents.
Results
Thirty-three residents completed the survey: 10 first-year internal medicine residents (PGY1), 12 second-year residents (PGY2), and 11 third-year residents (PGY3). The mean participation was 4.8 paracentesis sessions per person for the duration of the study. The range of paracentesis procedures performed varied based on PGY year: PGY1s performed 1 to > 10 procedures, PGY2s performed 2 to > 10 procedures, and PGY3s performed 5 to > 10 procedures. Thirty-six percent of residents completed > 10 procedures in the paracentesis clinic; 82% of PGY3s had completed > 10 procedures by December of their third year. Twenty-six residents (79%) were credentialed to perform paracentesis procedures independently after performing > 5 procedures, and 7 residents were not yet cleared for procedural independence.
In the survey, residents rated their comfort with performing paracentesis procedures independently at a mean of 7.9. The mean comfort reported by PGY1s was 7.2, PGY2s was 7.3, and PGY3s was 9.3. Residents also rated their opinion on whether or not the paracentesis clinic adequately prepared them for paracentesis procedural independence; the mean was 8.9 across all residents.
The total number of procedures performed by residents at CTVAH also increased. Starting in 2015, 3 years before the clinic was started, 38 procedures were performed by internal medicine residents, followed by 72 procedures in 2016; 76 in 2017; 58 in 2018; 94 in 2019; 88 in 2020; 136 in 2021; and 188 in 2022.
Discussion
Paracentesis is a simple but invasive procedure to relieve ascites, often relieving patients’ symptoms, preventing hospital admission, and increasing patient satisfaction.4 The CTVAH does not have the capacity to perform outpatient paracentesis effectively in its emergency or radiology departments. Furthermore, the use of the emergency or radiology departments for routine paracentesis may not be feasible due to the acuity of care being provided, as these procedures can be time consuming and can draw away critical resources and time from patients that need emergent care. The paracentesis clinic was then formed to provide veterans access to the procedural care they need, while also preparing residents to ably and confidently perform the procedure independently.
Based on our study, most residents were cleared to independently perform paracentesis procedures across all 3 years, with 79% of residents having completed the required 5 supervised procedures to independently practice. A study assessing unsupervised practice standards showed that paracentesis skill declines as soon as 3 months after training. However, retraining was shown to potentially interrupt this skill decline.5 Studies have shown that procedure-driven electives or services significantly improved paracentesis certification rates and total logged procedures, with minimal funding or scheduling changes required.6 Our clinic showed a significant increase in the number of procedures logged starting with the minimum of 38 procedures in 2015 and ending with 188 procedures logged at the end of 2022.
By allowing residents to routinely return to the paracentesis clinic across all 3 years, residents were more likely to feel comfortable independently performing the procedure, with residents reporting a mean comfort score of 7.9. The spaced repetition and ability to work with the clinic during elective time allows regular opportunities to undergo supervised training in a controlled environment and created scheduled retraining opportunities. Future studies should evaluate residents prior to each paracentesis clinic to ascertain if skill decline is occurring at a slower rate.
The inpatient effect of the clinic is also multifocal. Pham and colleagues showed that integrating paracentesis into timely training can reduce paracentesis delay and delays in care.7 By increasing the volume of procedures each resident performs and creating a sense of confidence amongst residents, the clinic increases the number of residents able and willing to perform inpatient procedures, thus reducing the number of unnecessary consultations and hospital resources. One of the reasons the paracentesis clinic was started was to allow patients to have scheduled times to remove fluid from their abdomen, thus cutting down on emergency department procedures and unnecessary admissions. Additionally, the benefits of early paracentesis procedural performance by residents and internal medicine physicians have been demonstrated in the literature. A study by Gaetano and colleagues noted that patients undergoing early paracentesis had reduced mortality of 5.5% vs 7.5% in those undergoing late paracentesis.8 This study also showed the in-hospital mortality rate was decreased with paracentesis (6.3%) vs without paracentesis (8.9%).8 By offering residents a chance to participate in the clinic, we have shown that regular opportunities to perform paracentesis may increase the number of physicians capable of independently practicing, improve procedural competency, and improve patient access to this procedure.
Limitations
Our study was not free of bias and has potential weaknesses. The survey was sent to all current residents who have participated in the paracentesis clinic, but not every resident filled out the survey (55% of all residents across 3 years completed the survey, 68.7% who had done clinic that year completed the survey). There is a possibility that those not signed off avoided doing the survey, but we are unable to confirm this. The survey also depended on resident recall of the number of paracenteses completed or looking at their procedure log. It is possible that some procedures were not documented, changing the true number. Additionally, rating comfortability with procedures is subjective, which may also create a source of potential weakness. Future projects should include a baseline survey for residents, followed by a repeat survey a year later to show changes from baseline competency.
Conclusions
A dedicated paracentesis clinic with internal medicine resident involvement may increase resident paracentesis procedural independence, the number of procedures available and performed, and procedural comfort level.
1. Aponte EM, O’Rourke MC, Katta S. Paracentesis. StatPearls [internet]. September 5, 2022. Accessed December 11, 2023. https://www.ncbi.nlm.nih.gov/books/NBK435998
2. Barsuk JH, Feinglass J, Kozmic SE, Hohmann SF, Ganger D, Wayne DB. Specialties performing paracentesis procedures at university hospitals: implications for training and certification. J Hosp Med. 2014;9(3):162-168. doi:10.1002/jhm.2153
3. Cheng Y-W, Sandrasegaran K, Cheng K, et al. A dedicated paracentesis clinic decreases healthcare utilization for serial paracenteses in decompensated cirrhosis. Abdominal Radiology. 2017;43(8):2190-2197. doi:10.1007/s00261-017-1406-y
4. Wang J, Khan S, Wyer P, et al. The role of ultrasound-guided therapeutic paracentesis in an outpatient transitional care program: A case series. Am J Hospice Palliat Med. 2018;35(9):1256-1260. doi:10.1177/1049909118755378
5. Sall D, Warm EJ, Kinnear B, Kelleher M, Jandarov R, O’Toole J. See one, do one, forget one: early skill decay after paracentesis training. J Gen Int Med. 2020;36(5):1346-1351. doi:10.1007/s11606-020-06242-x
6. Berger M, Divilov V, Paredes H, Kesar V, Sun E. Improving resident paracentesis certification rates by using an innovative resident driven procedure service. Am J Gastroenterol. 2018;113(suppl). doi:10.14309/00000434-201810001-00980
7. Pham C, Xu A, Suaez MG. S1250 a pilot study to improve resident paracentesis training and reduce paracentesis delay in admitted patients with cirrhosis. Am J Gastroenterol. 2022;117(10S). doi:10.14309/01.ajg.0000861640.53682.93
8. Gaetano JN, Micic D, Aronsohn A, et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. J Gastroenterol Hepatol. 2016;31(5):1025-1030. doi:10.1111/jgh.13255
Competency in paracentesis is an important procedural skill for medical practitioners caring for patients with decompensated liver cirrhosis. Paracentesis is performed to drain ascitic fluid for both diagnosis and/or therapeutic purposes.1 While this procedure can be performed without the use of ultrasound, it is preferable to use ultrasound to identify an area of fluid that is away from dangerous anatomy including bowel loops, the liver, and spleen. After prepping the area, lidocaine is administered locally. A catheter is then inserted until fluid begins flowing freely. The catheter is connected to a suction canister or collection kit, and the patient is monitored until the flow ceases. Samples can be sent for analysis to determine the etiology of ascites, identify concerns for infection, and more.
Paracentesis is a very common procedure. Barsuk and colleagues noted that between 2010 and 2012, 97,577 procedures were performed across 120 academic medical centers and 290 affiliated hospitals.2 Patients undergo paracentesis in a variety of settings including the emergency department, inpatient hospitalizations, and clinics. Some patients may require only 1 paracentesis procedure while others may require it regularly.
Due to the rising need for paracentesis in the Central Texas Veterans Affairs Hospital (CTVAH) in Temple, a paracentesis clinic was started in February 2018. The goal of the paracentesis clinic was multifocal—to reduce hospital admissions, improve access to regularly scheduled procedures, decrease wait times, and increase patient satisfaction.3 Through the CTVAH affiliation with the Texas A&M internal medicine residency program, the paracentesis clinic started involving and training residents on this procedure. Up to 3 residents are on weekly rotation and can perform up to 6 paracentesis procedures in a week. The purpose of this article was to evaluate resident competency in paracentesis after completion of the paracentesis clinic.
Methods
The paracentesis clinic schedules up to 3 patients on Tuesdays and Thursdays between 8
A survey was sent via email to all categorical internal medicine residents across all 3 program years at the time of data collection. Competency for paracentesis sign-off was defined as completing and logging 5 procedures supervised by a competent physician who confirmed that all portions of the procedure were performed correctly. Residents were also asked to answer questions on a scale from 1 to 10, with 1 representing no confidence and 10 representing strong confidence to practice independently (Table).
We also evaluated the number of procedures performed by internal medicine residents 3 years before the clinic was started in 2015 up to the completion of 2022. The numbers were obtained by examining procedural log data for each year for all internal medicine residents.
Results
Thirty-three residents completed the survey: 10 first-year internal medicine residents (PGY1), 12 second-year residents (PGY2), and 11 third-year residents (PGY3). The mean participation was 4.8 paracentesis sessions per person for the duration of the study. The range of paracentesis procedures performed varied based on PGY year: PGY1s performed 1 to > 10 procedures, PGY2s performed 2 to > 10 procedures, and PGY3s performed 5 to > 10 procedures. Thirty-six percent of residents completed > 10 procedures in the paracentesis clinic; 82% of PGY3s had completed > 10 procedures by December of their third year. Twenty-six residents (79%) were credentialed to perform paracentesis procedures independently after performing > 5 procedures, and 7 residents were not yet cleared for procedural independence.
In the survey, residents rated their comfort with performing paracentesis procedures independently at a mean of 7.9. The mean comfort reported by PGY1s was 7.2, PGY2s was 7.3, and PGY3s was 9.3. Residents also rated their opinion on whether or not the paracentesis clinic adequately prepared them for paracentesis procedural independence; the mean was 8.9 across all residents.
The total number of procedures performed by residents at CTVAH also increased. Starting in 2015, 3 years before the clinic was started, 38 procedures were performed by internal medicine residents, followed by 72 procedures in 2016; 76 in 2017; 58 in 2018; 94 in 2019; 88 in 2020; 136 in 2021; and 188 in 2022.
Discussion
Paracentesis is a simple but invasive procedure to relieve ascites, often relieving patients’ symptoms, preventing hospital admission, and increasing patient satisfaction.4 The CTVAH does not have the capacity to perform outpatient paracentesis effectively in its emergency or radiology departments. Furthermore, the use of the emergency or radiology departments for routine paracentesis may not be feasible due to the acuity of care being provided, as these procedures can be time consuming and can draw away critical resources and time from patients that need emergent care. The paracentesis clinic was then formed to provide veterans access to the procedural care they need, while also preparing residents to ably and confidently perform the procedure independently.
Based on our study, most residents were cleared to independently perform paracentesis procedures across all 3 years, with 79% of residents having completed the required 5 supervised procedures to independently practice. A study assessing unsupervised practice standards showed that paracentesis skill declines as soon as 3 months after training. However, retraining was shown to potentially interrupt this skill decline.5 Studies have shown that procedure-driven electives or services significantly improved paracentesis certification rates and total logged procedures, with minimal funding or scheduling changes required.6 Our clinic showed a significant increase in the number of procedures logged starting with the minimum of 38 procedures in 2015 and ending with 188 procedures logged at the end of 2022.
By allowing residents to routinely return to the paracentesis clinic across all 3 years, residents were more likely to feel comfortable independently performing the procedure, with residents reporting a mean comfort score of 7.9. The spaced repetition and ability to work with the clinic during elective time allows regular opportunities to undergo supervised training in a controlled environment and created scheduled retraining opportunities. Future studies should evaluate residents prior to each paracentesis clinic to ascertain if skill decline is occurring at a slower rate.
The inpatient effect of the clinic is also multifocal. Pham and colleagues showed that integrating paracentesis into timely training can reduce paracentesis delay and delays in care.7 By increasing the volume of procedures each resident performs and creating a sense of confidence amongst residents, the clinic increases the number of residents able and willing to perform inpatient procedures, thus reducing the number of unnecessary consultations and hospital resources. One of the reasons the paracentesis clinic was started was to allow patients to have scheduled times to remove fluid from their abdomen, thus cutting down on emergency department procedures and unnecessary admissions. Additionally, the benefits of early paracentesis procedural performance by residents and internal medicine physicians have been demonstrated in the literature. A study by Gaetano and colleagues noted that patients undergoing early paracentesis had reduced mortality of 5.5% vs 7.5% in those undergoing late paracentesis.8 This study also showed the in-hospital mortality rate was decreased with paracentesis (6.3%) vs without paracentesis (8.9%).8 By offering residents a chance to participate in the clinic, we have shown that regular opportunities to perform paracentesis may increase the number of physicians capable of independently practicing, improve procedural competency, and improve patient access to this procedure.
Limitations
Our study was not free of bias and has potential weaknesses. The survey was sent to all current residents who have participated in the paracentesis clinic, but not every resident filled out the survey (55% of all residents across 3 years completed the survey, 68.7% who had done clinic that year completed the survey). There is a possibility that those not signed off avoided doing the survey, but we are unable to confirm this. The survey also depended on resident recall of the number of paracenteses completed or looking at their procedure log. It is possible that some procedures were not documented, changing the true number. Additionally, rating comfortability with procedures is subjective, which may also create a source of potential weakness. Future projects should include a baseline survey for residents, followed by a repeat survey a year later to show changes from baseline competency.
Conclusions
A dedicated paracentesis clinic with internal medicine resident involvement may increase resident paracentesis procedural independence, the number of procedures available and performed, and procedural comfort level.
Competency in paracentesis is an important procedural skill for medical practitioners caring for patients with decompensated liver cirrhosis. Paracentesis is performed to drain ascitic fluid for both diagnosis and/or therapeutic purposes.1 While this procedure can be performed without the use of ultrasound, it is preferable to use ultrasound to identify an area of fluid that is away from dangerous anatomy including bowel loops, the liver, and spleen. After prepping the area, lidocaine is administered locally. A catheter is then inserted until fluid begins flowing freely. The catheter is connected to a suction canister or collection kit, and the patient is monitored until the flow ceases. Samples can be sent for analysis to determine the etiology of ascites, identify concerns for infection, and more.
Paracentesis is a very common procedure. Barsuk and colleagues noted that between 2010 and 2012, 97,577 procedures were performed across 120 academic medical centers and 290 affiliated hospitals.2 Patients undergo paracentesis in a variety of settings including the emergency department, inpatient hospitalizations, and clinics. Some patients may require only 1 paracentesis procedure while others may require it regularly.
Due to the rising need for paracentesis in the Central Texas Veterans Affairs Hospital (CTVAH) in Temple, a paracentesis clinic was started in February 2018. The goal of the paracentesis clinic was multifocal—to reduce hospital admissions, improve access to regularly scheduled procedures, decrease wait times, and increase patient satisfaction.3 Through the CTVAH affiliation with the Texas A&M internal medicine residency program, the paracentesis clinic started involving and training residents on this procedure. Up to 3 residents are on weekly rotation and can perform up to 6 paracentesis procedures in a week. The purpose of this article was to evaluate resident competency in paracentesis after completion of the paracentesis clinic.
Methods
The paracentesis clinic schedules up to 3 patients on Tuesdays and Thursdays between 8
A survey was sent via email to all categorical internal medicine residents across all 3 program years at the time of data collection. Competency for paracentesis sign-off was defined as completing and logging 5 procedures supervised by a competent physician who confirmed that all portions of the procedure were performed correctly. Residents were also asked to answer questions on a scale from 1 to 10, with 1 representing no confidence and 10 representing strong confidence to practice independently (Table).
We also evaluated the number of procedures performed by internal medicine residents 3 years before the clinic was started in 2015 up to the completion of 2022. The numbers were obtained by examining procedural log data for each year for all internal medicine residents.
Results
Thirty-three residents completed the survey: 10 first-year internal medicine residents (PGY1), 12 second-year residents (PGY2), and 11 third-year residents (PGY3). The mean participation was 4.8 paracentesis sessions per person for the duration of the study. The range of paracentesis procedures performed varied based on PGY year: PGY1s performed 1 to > 10 procedures, PGY2s performed 2 to > 10 procedures, and PGY3s performed 5 to > 10 procedures. Thirty-six percent of residents completed > 10 procedures in the paracentesis clinic; 82% of PGY3s had completed > 10 procedures by December of their third year. Twenty-six residents (79%) were credentialed to perform paracentesis procedures independently after performing > 5 procedures, and 7 residents were not yet cleared for procedural independence.
In the survey, residents rated their comfort with performing paracentesis procedures independently at a mean of 7.9. The mean comfort reported by PGY1s was 7.2, PGY2s was 7.3, and PGY3s was 9.3. Residents also rated their opinion on whether or not the paracentesis clinic adequately prepared them for paracentesis procedural independence; the mean was 8.9 across all residents.
The total number of procedures performed by residents at CTVAH also increased. Starting in 2015, 3 years before the clinic was started, 38 procedures were performed by internal medicine residents, followed by 72 procedures in 2016; 76 in 2017; 58 in 2018; 94 in 2019; 88 in 2020; 136 in 2021; and 188 in 2022.
Discussion
Paracentesis is a simple but invasive procedure to relieve ascites, often relieving patients’ symptoms, preventing hospital admission, and increasing patient satisfaction.4 The CTVAH does not have the capacity to perform outpatient paracentesis effectively in its emergency or radiology departments. Furthermore, the use of the emergency or radiology departments for routine paracentesis may not be feasible due to the acuity of care being provided, as these procedures can be time consuming and can draw away critical resources and time from patients that need emergent care. The paracentesis clinic was then formed to provide veterans access to the procedural care they need, while also preparing residents to ably and confidently perform the procedure independently.
Based on our study, most residents were cleared to independently perform paracentesis procedures across all 3 years, with 79% of residents having completed the required 5 supervised procedures to independently practice. A study assessing unsupervised practice standards showed that paracentesis skill declines as soon as 3 months after training. However, retraining was shown to potentially interrupt this skill decline.5 Studies have shown that procedure-driven electives or services significantly improved paracentesis certification rates and total logged procedures, with minimal funding or scheduling changes required.6 Our clinic showed a significant increase in the number of procedures logged starting with the minimum of 38 procedures in 2015 and ending with 188 procedures logged at the end of 2022.
By allowing residents to routinely return to the paracentesis clinic across all 3 years, residents were more likely to feel comfortable independently performing the procedure, with residents reporting a mean comfort score of 7.9. The spaced repetition and ability to work with the clinic during elective time allows regular opportunities to undergo supervised training in a controlled environment and created scheduled retraining opportunities. Future studies should evaluate residents prior to each paracentesis clinic to ascertain if skill decline is occurring at a slower rate.
The inpatient effect of the clinic is also multifocal. Pham and colleagues showed that integrating paracentesis into timely training can reduce paracentesis delay and delays in care.7 By increasing the volume of procedures each resident performs and creating a sense of confidence amongst residents, the clinic increases the number of residents able and willing to perform inpatient procedures, thus reducing the number of unnecessary consultations and hospital resources. One of the reasons the paracentesis clinic was started was to allow patients to have scheduled times to remove fluid from their abdomen, thus cutting down on emergency department procedures and unnecessary admissions. Additionally, the benefits of early paracentesis procedural performance by residents and internal medicine physicians have been demonstrated in the literature. A study by Gaetano and colleagues noted that patients undergoing early paracentesis had reduced mortality of 5.5% vs 7.5% in those undergoing late paracentesis.8 This study also showed the in-hospital mortality rate was decreased with paracentesis (6.3%) vs without paracentesis (8.9%).8 By offering residents a chance to participate in the clinic, we have shown that regular opportunities to perform paracentesis may increase the number of physicians capable of independently practicing, improve procedural competency, and improve patient access to this procedure.
Limitations
Our study was not free of bias and has potential weaknesses. The survey was sent to all current residents who have participated in the paracentesis clinic, but not every resident filled out the survey (55% of all residents across 3 years completed the survey, 68.7% who had done clinic that year completed the survey). There is a possibility that those not signed off avoided doing the survey, but we are unable to confirm this. The survey also depended on resident recall of the number of paracenteses completed or looking at their procedure log. It is possible that some procedures were not documented, changing the true number. Additionally, rating comfortability with procedures is subjective, which may also create a source of potential weakness. Future projects should include a baseline survey for residents, followed by a repeat survey a year later to show changes from baseline competency.
Conclusions
A dedicated paracentesis clinic with internal medicine resident involvement may increase resident paracentesis procedural independence, the number of procedures available and performed, and procedural comfort level.
1. Aponte EM, O’Rourke MC, Katta S. Paracentesis. StatPearls [internet]. September 5, 2022. Accessed December 11, 2023. https://www.ncbi.nlm.nih.gov/books/NBK435998
2. Barsuk JH, Feinglass J, Kozmic SE, Hohmann SF, Ganger D, Wayne DB. Specialties performing paracentesis procedures at university hospitals: implications for training and certification. J Hosp Med. 2014;9(3):162-168. doi:10.1002/jhm.2153
3. Cheng Y-W, Sandrasegaran K, Cheng K, et al. A dedicated paracentesis clinic decreases healthcare utilization for serial paracenteses in decompensated cirrhosis. Abdominal Radiology. 2017;43(8):2190-2197. doi:10.1007/s00261-017-1406-y
4. Wang J, Khan S, Wyer P, et al. The role of ultrasound-guided therapeutic paracentesis in an outpatient transitional care program: A case series. Am J Hospice Palliat Med. 2018;35(9):1256-1260. doi:10.1177/1049909118755378
5. Sall D, Warm EJ, Kinnear B, Kelleher M, Jandarov R, O’Toole J. See one, do one, forget one: early skill decay after paracentesis training. J Gen Int Med. 2020;36(5):1346-1351. doi:10.1007/s11606-020-06242-x
6. Berger M, Divilov V, Paredes H, Kesar V, Sun E. Improving resident paracentesis certification rates by using an innovative resident driven procedure service. Am J Gastroenterol. 2018;113(suppl). doi:10.14309/00000434-201810001-00980
7. Pham C, Xu A, Suaez MG. S1250 a pilot study to improve resident paracentesis training and reduce paracentesis delay in admitted patients with cirrhosis. Am J Gastroenterol. 2022;117(10S). doi:10.14309/01.ajg.0000861640.53682.93
8. Gaetano JN, Micic D, Aronsohn A, et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. J Gastroenterol Hepatol. 2016;31(5):1025-1030. doi:10.1111/jgh.13255
1. Aponte EM, O’Rourke MC, Katta S. Paracentesis. StatPearls [internet]. September 5, 2022. Accessed December 11, 2023. https://www.ncbi.nlm.nih.gov/books/NBK435998
2. Barsuk JH, Feinglass J, Kozmic SE, Hohmann SF, Ganger D, Wayne DB. Specialties performing paracentesis procedures at university hospitals: implications for training and certification. J Hosp Med. 2014;9(3):162-168. doi:10.1002/jhm.2153
3. Cheng Y-W, Sandrasegaran K, Cheng K, et al. A dedicated paracentesis clinic decreases healthcare utilization for serial paracenteses in decompensated cirrhosis. Abdominal Radiology. 2017;43(8):2190-2197. doi:10.1007/s00261-017-1406-y
4. Wang J, Khan S, Wyer P, et al. The role of ultrasound-guided therapeutic paracentesis in an outpatient transitional care program: A case series. Am J Hospice Palliat Med. 2018;35(9):1256-1260. doi:10.1177/1049909118755378
5. Sall D, Warm EJ, Kinnear B, Kelleher M, Jandarov R, O’Toole J. See one, do one, forget one: early skill decay after paracentesis training. J Gen Int Med. 2020;36(5):1346-1351. doi:10.1007/s11606-020-06242-x
6. Berger M, Divilov V, Paredes H, Kesar V, Sun E. Improving resident paracentesis certification rates by using an innovative resident driven procedure service. Am J Gastroenterol. 2018;113(suppl). doi:10.14309/00000434-201810001-00980
7. Pham C, Xu A, Suaez MG. S1250 a pilot study to improve resident paracentesis training and reduce paracentesis delay in admitted patients with cirrhosis. Am J Gastroenterol. 2022;117(10S). doi:10.14309/01.ajg.0000861640.53682.93
8. Gaetano JN, Micic D, Aronsohn A, et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. J Gastroenterol Hepatol. 2016;31(5):1025-1030. doi:10.1111/jgh.13255
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<root generator="drupal.xsl" gversion="1.7"> <header> <fileName>0224 FED Paracentesis</fileName> <TBEID>0C02F08F.SIG</TBEID> <TBUniqueIdentifier>NJ_0C02F08F</TBUniqueIdentifier> <newsOrJournal>Journal</newsOrJournal> <publisherName>Frontline Medical Communications Inc.</publisherName> <storyname/> <articleType>1</articleType> <TBLocation>Copyfitting-FED</TBLocation> <QCDate/> <firstPublished>20240201T114729</firstPublished> <LastPublished>20240201T114730</LastPublished> <pubStatus qcode="stat:"/> <embargoDate/> <killDate/> <CMSDate>20240201T114729</CMSDate> <articleSource/> <facebookInfo/> <meetingNumber/> <byline/> <bylineText>Nikhil Seth, MDa; Phi Tran, DOb; Arshad Ghauri, MDa; Anika Sikkac; Austin Metting, MDb; George Martinez, MDa</bylineText> <bylineFull/> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType/> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:"> <name/> <rightsInfo> <copyrightHolder> <name/> </copyrightHolder> <copyrightNotice/> </rightsInfo> </provider> <abstract/> <metaDescription>Competency in paracentesis is an important procedural skill for medical practitioners caring for patients with decompensated liver cirrhosis. Paracentesis is pe</metaDescription> <articlePDF/> <teaserImage/> <title>The Impact of a Paracentesis Clinic on Internal Medicine Resident Procedural Competency</title> <deck/> <eyebrow>Original Research</eyebrow> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear>2024</pubPubdateYear> <pubPubdateMonth>February</pubPubdateMonth> <pubPubdateDay/> <pubVolume>41</pubVolume> <pubNumber>2</pubNumber> <wireChannels/> <primaryCMSID/> <CMSIDs> <CMSID>2951</CMSID> <CMSID>3639</CMSID> </CMSIDs> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>FED</publicationCode> <pubIssueName>February 2024</pubIssueName> <pubArticleType>Feature Articles | 3639</pubArticleType> <pubTopics/> <pubCategories/> <pubSections> <pubSection>Feature | 2951<pubSubsection/></pubSection> </pubSections> <journalTitle>Fed Pract</journalTitle> <journalFullTitle>Federal Practitioner</journalFullTitle> <copyrightStatement>Copyright 2017 Frontline Medical Communications Inc., Parsippany, NJ, USA. All rights reserved.</copyrightStatement> </publicationData> </publications_g> <publications> <term canonical="true">16</term> </publications> <sections> <term canonical="true">104</term> </sections> <topics> <term canonical="true">327</term> <term>27442</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>The Impact of a Paracentesis Clinic on Internal Medicine Resident Procedural Competency</title> <deck/> </itemMeta> <itemContent> <p class="abstract"><b>Background: </b>Competency in paracentesis is an important procedural skill for health care practitioners caring for patients with decompensated cirrhosis. It is estimated that 97,577 paracentesis procedures were performed between 2010 and 2012 across 120 academic medical centers and 290 affiliated hospitals. <br/><br/><b>Methods: </b>Due to limitations of resources at the Central Texas Veterans Affairs Hospital, a paracentesis clinic was created to give patients improved access to this procedure which is staffed by a supervising physician and internal medicine residents. We evaluated resident competency via survey and change in the number of paracentesis procedures performed with the utilization of this clinic. <br/><br/><b>Results:</b> Thirty-three residents completed the survey. The total mean number of paracentesis sessions participated in was 4.8. It was found that during training, 79% met conditional independence in performing this procedure with a high level of comfort by rotating through this clinic. It was also found that the number of procedures performed by internal medicine residents significantly increased with the addition of this clinic.<br/><br/><b>Conclusions: </b>A dedicated paracentesis clinic with internal medicine resident involvement can increase resident paracentesis procedural independence, the number of procedures available and performed, and procedural comfort level by the end of training. </p> <p><span class="Drop">C</span>ompetency in paracentesis is an important procedural skill for medical practitioners caring for patients with decompensated liver cirrhosis. Paracentesis is performed to drain ascitic fluid for both diagnosis and/or therapeutic purposes.<sup>1</sup> While this procedure can be performed without the use of ultrasound, it is preferable to use ultrasound to identify an area of fluid that is away from dangerous anatomy including bowel loops, the liver, and spleen. After prepping the area, lidocaine is administered locally. A catheter is then inserted until fluid begins flowing freely. The catheter is connected to a suction canister or collection kit, and the patient is monitored until the flow ceases. Samples can be sent for analysis to determine the etiology of ascites, identify concerns for infection, and more. </p> <p>Paracentesis is a very common procedure. Barsuk and colleagues noted that between 2010 and 2012, 97,577 procedures were performed across 120 academic medical centers and 290 affiliated hospitals.<sup>2</sup> Patients undergo paracentesis in a variety of settings including the emergency department, inpatient hospitalizations, and clinics. Some patients may require only 1 paracentesis procedure while others may require it regularly.<br/><br/>Due to the rising need for paracentesis in the Central Texas Veterans Affairs Hospital (CTVAH) in Temple, a paracentesis clinic was started in February 2018. The goal of the paracentesis clinic was multifocal—to reduce hospital admissions, improve access to regularly scheduled procedures, decrease wait times, and increase patient satisfaction.<sup>3</sup> Through the CTVAH affiliation with the Texas A&M internal medicine residency program, the paracentesis clinic started involving and training residents on this procedure. Up to 3 residents are on weekly rotation and can perform up to 6 paracentesis procedures in a week. The purpose of this article was to evaluate resident competency in paracentesis after completion of the paracentesis clinic. </p> <h2>Methods</h2> <p>The paracentesis clinic schedules up to 3 patients on Tuesdays and Thursdays between 8 <scaps>am</scaps> and noon. All the necessary equipment is readily available and includes the paracentesis kit, lidocaine, sterile gloves, ultrasound, and albumin if needed. Because this procedure is performed at the hospital, direct access to the emergency department is available. Residents are scheduled weekly. Up to 2 residents are scheduled for the paracentesis clinic during their dedicated clinic week. They are expected to practice obtaining consent, performing the procedure, and documenting the encounter under staff supervision. Additionally, 1 or 2 residents participate in the paracentesis clinic as part of an ultrasound elective twice per year. In this elective, they practice ultrasound skills using a simulation and translate that information in the paracentesis clinic while identifying anatomy and performing the paracentesis procedure under staff supervision. </p> <p>A survey was sent via email to all categorical internal medicine residents across all 3 program years at the time of data collection. Competency for paracentesis sign-off was defined as completing and logging 5 procedures supervised by a competent physician who confirmed that all portions of the procedure were performed correctly. Residents were also asked to answer questions on a scale from 1 to 10, with 1 representing no confidence and 10 representing strong confidence to practice independently (Table). <br/><br/>We also evaluated the number of procedures performed by internal medicine residents 3 years before the clinic was started in 2015 up to the completion of 2022. The numbers were obtained by examining procedural log data for each year for all internal medicine residents. </p> <h2>Results</h2> <p>Thirty-three residents completed the survey: 10 first-year internal medicine residents (PGY1), 12 second-year residents (PGY2), and 11 third-year residents (PGY3). The mean participation was 4.8 paracentesis sessions per person for the duration of the study. The range of paracentesis procedures performed varied based on PGY year: PGY1s performed 1 to > 10 procedures, PGY2s performed 2 to > 10 procedures, and PGY3s performed 5 to > 10 procedures. Thirty-six percent of residents completed > 10 procedures in the paracentesis clinic; 82% of PGY3s had completed > 10 procedures by December of their third year. Twenty-six residents (79%) were credentialed to perform paracentesis procedures independently after performing > 5 procedures, and 7 residents were not yet cleared for procedural independence. </p> <p>In the survey, residents rated their comfort with performing paracentesis procedures independently at a mean of 7.9. The mean comfort reported by PGY1s was 7.2, PGY2s was 7.3, and PGY3s was 9.3. Residents also rated their opinion on whether or not the paracentesis clinic adequately prepared them for paracentesis procedural independence; the mean was 8.9 across all residents. <br/><br/>The total number of procedures performed by residents at CTVAH also increased. Starting in 2015, 3 years before the clinic was started, 38 procedures were performed by internal medicine residents, followed by 72 procedures in 2016; 76 in 2017; 58 in 2018; 94 in 2019; 88 in 2020; 136 in 2021; and 188 in 2022. </p> <h2>Discussion</h2> <p>Paracentesis is a simple but invasive procedure to relieve ascites, often relieving patients’ symptoms, preventing hospital admission, and increasing patient satisfaction.<sup>4</sup> The CTVAH does not have the capacity to perform outpatient paracentesis effectively in its emergency or radiology departments. Furthermore, the use of the emergency or radiology departments for routine paracentesis may not be feasible due to the acuity of care being provided, as these procedures can be time consuming and can draw away critical resources and time from patients that need emergent care. The paracentesis clinic was then formed to provide veterans access to the procedural care they need, while also preparing residents to ably and confidently perform the procedure independently. </p> <p>Based on our study, most residents were cleared to independently perform paracentesis procedures across all 3 years, with 79% of residents having completed the required 5 supervised procedures to independently practice. A study assessing unsupervised practice standards showed that paracentesis skill declines as soon as 3 months after training. However, retraining was shown to potentially interrupt this skill decline.<sup>5</sup> Studies have shown that procedure-driven electives or services significantly improved paracentesis certification rates and total logged procedures, with minimal funding or scheduling changes required.<sup>6</sup> Our clinic showed a significant increase in the number of procedures logged starting with the minimum of 38 procedures in 2015 and ending with 188 procedures logged at the end of 2022. <br/><br/>By allowing residents to routinely return to the paracentesis clinic across all 3 years, residents were more likely to feel comfortable independently performing the procedure, with residents reporting a mean comfort score of 7.9. The spaced repetition and ability to work with the clinic during elective time allows regular opportunities to undergo supervised training in a controlled environment and created scheduled retraining opportunities. Future studies should evaluate residents prior to each paracentesis clinic to ascertain if skill decline is occurring at a slower rate. <br/><br/>The inpatient effect of the clinic is also multifocal. Pham and colleagues showed that integrating paracentesis into timely training can reduce paracentesis delay and delays in care.<sup>7</sup> By increasing the volume of procedures each resident performs and creating a sense of confidence amongst residents, the clinic increases the number of residents able and willing to perform inpatient procedures, thus reducing the number of unnecessary consultations and hospital resources. One of the reasons the paracentesis clinic was started was to allow patients to have scheduled times to remove fluid from their abdomen, thus cutting down on emergency department procedures and unnecessary admissions. Additionally, the benefits of early paracentesis procedural performance by residents and internal medicine physicians have been demonstrated in the literature. A study by Gaetano and colleagues noted that patients undergoing early paracentesis had reduced mortality of 5.5% vs 7.5% in those undergoing late paracentesis.<sup>8</sup> This study also showed the in-hospital mortality rate was decreased with paracentesis (6.3%) vs without paracentesis (8.9%).<sup>8</sup> By offering residents a chance to participate in the clinic, we have shown that regular opportunities to perform paracentesis may increase the number of physicians capable of independently practicing, improve procedural competency, and improve patient access to this procedure. </p> <h3>Limitations</h3> <p>Our study was not free of bias and has potential weaknesses. The survey was sent to all current residents who have participated in the paracentesis clinic, but not every resident filled out the survey (55% of all residents across 3 years completed the survey, 68.7% who had done clinic that year completed the survey). There is a possibility that those not signed off avoided doing the survey, but we are unable to confirm this. The survey also depended on resident recall of the number of paracenteses completed or looking at their procedure log. It is possible that some procedures were not documented, changing the true number. Additionally, rating comfortability with procedures is subjective, which may also create a source of potential weakness. Future projects should include a baseline survey for residents, followed by a repeat survey a year later to show changes from baseline competency. </p> <h2>Conclusions</h2> <p>A dedicated paracentesis clinic with internal medicine resident involvement may increase resident paracentesis procedural independence, the number of procedures available and performed, and procedural comfort level. </p> <p class="isub">Author affiliations</p> <p> <em><sup>a</sup>Central Texas Veterans Affairs Hospital, Temple<sup> <br/><br/>b</sup>Baylor Scott & White Health, Irving, Texas<br/><br/><sup>c</sup>Texas A&M University, College Station</em> </p> <p class="isub">Author disclosures</p> <p> <em>The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.</em> </p> <p class="isub">Disclaimer</p> <p> <em>The opinions expressed herein are those of the authors and do not necessarily reflect those of <i>Federal Practitioner</i>, Frontline Medical Communications Inc., the US Government, or any of its agencies.</em> </p> <p class="isub">Ethics and consent</p> <p> <em>This project did not require institutional review board approval.</em> </p> <h2>References</h2> <p class="reference"> 1. Aponte EM, O’Rourke MC, Katta S. Paracentesis. <i>StatPearls [internet]</i>. September 5, 2022. Accessed December 11, 2023. https://www.ncbi.nlm.nih.gov/books/NBK435998<br/><br/> 2. Barsuk JH, Feinglass J, Kozmic SE, Hohmann SF, Ganger D, Wayne DB. Specialties performing paracentesis procedures at university hospitals: implications for training and certification. <i>J Hosp Med</i>. 2014;9(3):162-168. doi:10.1002/jhm.2153<br/><br/> 3. Cheng Y-W, Sandrasegaran K, Cheng K, et al. A dedicated paracentesis clinic decreases healthcare utilization for serial paracenteses in decompensated cirrhosis. <i>Abdominal Radiology</i>. 2017;43(8):2190-2197. doi:10.1007/s00261-017-1406-y<br/><br/> 4. Wang J, Khan S, Wyer P, et al. The role of ultrasound-guided therapeutic paracentesis in an outpatient transitional care program: A case series. <i>Am J Hospice Palliat Med</i>. 2018;35(9):1256-1260. doi:10.1177/1049909118755378<br/><br/> 5. Sall D, Warm EJ, Kinnear B, Kelleher M, Jandarov R, O’Toole J. See one, do one, forget one: early skill decay after paracentesis training. <i>J Gen Int Med</i>. 2020;36(5):1346-1351. doi:10.1007/s11606-020-06242-x<br/><br/> 6. Berger M, Divilov V, Paredes H, Kesar V, Sun E. Improving resident paracentesis certification rates by using an innovative resident driven procedure service. <i>Am J Gastroenterol</i>. 2018;113(suppl). doi:10.14309/00000434-201810001-00980<br/><br/> 7. Pham C, Xu A, Suaez MG. S1250 a pilot study to improve resident paracentesis training and reduce paracentesis delay in admitted patients with cirrhosis. <i>Am J Gastroenterol</i>. 2022;117(10S). doi:10.14309/01.ajg.0000861640.53682.93<br/><br/> 8. Gaetano JN, Micic D, Aronsohn A, et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. <i>J Gastroenterol Hepatol</i>. 2016;31(5):1025-1030. doi:10.1111/jgh.13255</p> </itemContent> </newsItem> </itemSet></root>
Nightmare on CIL Street: A Simulation Series to Increase Confidence and Skill in Responding to Clinical Emergencies
The Central Texas Veteran’s Health Care System (CTVHCS) in Temple, Texas, is a 189-bed teaching hospital. CTVHCS opened the Center for Innovation and Learning (CIL) in 2022. The CIL has about 279 m2 of simulation space that includes high- and low-fidelity simulation equipment and multiple laboratories, which can be used to simulate inpatient and outpatient settings. The CIL high-fidelity manikins and environment allow learners to be immersed in the simulation for maximum realism. Computer and video systems provide clear viewing of training, which allows for more in-depth debriefing and learning. CIL simulation training is used by CTVHCS staff, medical residents, and medical and physician assistant students.
The utility of technology in medical education is rapidly evolving. As noted in many studies, simulation creates an environment that can imitate real patients in the format of a lifelike manikin, anatomic regions stations, clinical tasks, and many real-life circumstances.1 Task trainers for procedure simulation have been widely used and studied. A 2020 study noted that simulation training is effective for developing procedural skills in surgery and prevents the decay of surgical skills.2
In reviewing health care education curriculums, we noted that most of the rapid response situations are learned through active patient experiences. Rapid responses are managed by the intensive care unit and primary care teams during the day but at night are run primarily by the postgraduate year 2 (PGY2) night resident and intern. Knowing these logistics and current studies, we decided to build a rapid response simulation curriculum to improve preparedness for PGY1 residents, medical students, and physician assistant students.
Curriculum Planning
Planning the simulation curriculum began with the CTVHCS internal medicine chief resident and registered nurse (RN) educator. CTVHCS data were reviewed to identify the 3 most common rapid response calls from the past 3 years; research on the most common systems affected by rapid responses also was evaluated.
A 2019 study by Lyons and colleagues evaluated 402,023 rapid response activations across 360 hospitals and found that respiratory scenarios made up 38% and cardiac scenarios made up 37%.3 In addition, the CTVHCS has limited support in stroke neurology. Therefore, the internal medicine chief resident and RN educator decided to run 3 evolving rapid response scenarios per session that included cardiac, respiratory, and neurological scenarios. Capabilities and limitations of different high-fidelity manikins were discussed to identify and use the most appropriate simulator for each situation. Objectives that met both general medicine and site-specific education were discussed, and the program was formulated.
Program Description
Nightmare on CIL Street is a simulation-based program designed for new internal medicine residents and students to encounter difficult situations (late at night, on call, or when resources are limited; ie, weekends/holidays) in a controlled simulation environment. During the simulation, learners will be unable to transfer the patient and no additional help is available. Each learner must determine a differential diagnosis and make appropriate medical interventions with only the assistance of a nurse. Scenarios are derived from common rapid response team calls and low-volume/high-impact situations where clinical decisions must be made quickly to ensure the best patient outcomes. High-fidelity manikins that have abilities to respond to questions, simulate breathing, reproduce pathological heart and breath sounds and more are used to create a realistic patient environment.
This program aligns with 2 national Veterans Health Administration priorities: (1) connect veterans to the soonest and best care; and (2) accelerate the Veterans Health Administration journey to be a high-reliability organization (sensitivity to operations, preoccupation with failure, commitment to resilience, and deference to expertise). Nightmare on CIL Street has 3 clinical episodes: 2 cardiac (A Tell-Tale Heart), respiratory (Don’t Breathe), and neurologic (Brain Scan). Additional clinical episodes will be added based on learner feedback and assessed need.
Each simulation event encompassed all 3 episodes that an individual or a team of 2 learners rotate through in a round-robin fashion. The overarching theme for each episode was a rapid response team call with minimal resources that the learner would have to provide care and stabilization. A literature search for rapid response team training programs found few results, but the literature assisted with providing a foundation for Nightmare on CIL Street.4,5 The goal was to completely envelop the learners in a nightmare scenario that required a solution.
After the safety brief and predata collection, learners received a phone call with minimal information about a patient in need of care. The learners responded to the requested area and provided treatment to the emergency over 25 minutes with the bedside nurse (who is an embedded participant). At the conclusion of the scenario, a physician subject matter expert who has been observing, provided a personalized 10-minute debriefing to the learner, which presented specific learning points and opportunities for the learner’s educational development. After the debriefing, learners returned to a conference room and awaited the next call. After all learners completed the 3 episodes, a group debriefing was conducted using the gather, analyze, summarize debriefing framework. The debriefing begins with an open-ended forum for learners to express their thoughts. Then, each scenario is discussed and broken down by key learning objectives. Starting with cardiac and ending with neurology, the logistics of the cases are discussed based on the trajectory of the learners during the scenarios. Each objective is discussed, and learners are allowed to ask questions before moving to the next scenario. After the debriefing, postevent data were gathered.
Objectives
The program objective was to educate residents and students on common rapid response scenarios. We devised each scenario as an evolving simulation where various interventions would improve or worsen vital signs and symptoms. Each scenario had an end goal: cardioversion (cardiac), intubation (respiratory), and transfer (neurologic). Objectives were tailored to the trainees present during the specific simulation (Table).
IMPLEMENTATION
The initial run of the simulation curriculum was implemented on February 22, 2023, and ended on May 17, 2023, with 5 events. Participants included internal medicine PGY1 residents, third-year medical students, and fourth-year physician assistant students. Internal medicine residents ran each scenario with a subject matter expert monitoring; the undergraduate medical trainees partnered with another student. Students were pulled from their ward rotations to attend the simulation, and residents were pulled from electives and wards. Each trainee was able to experience each planned scenario. They were then briefed, participated in each scenario, and ended with a debriefing, discussing each case in detail. Two subject matter experts were always available, and occasionally 4 were present to provide additional knowledge transfer to learners. These included board-certified physicians in internal medicine and pulmonary critical care. Most scenarios were conducted on Wednesday afternoon or Thursday.
The CIL provided 6 staff minimum for every event. The staff controlled the manikins and acted as embedded players for the learners to interact and work with at the bedside. Every embedded RN was provided the same script: They were a new nurse just off orientation and did not know what to do. In addition, they were instructed that no matter who the learner wanted to call/page, that person or service was not answering or unavailable. This forced learners to respond and treat the simulated patient on their own.
Survey Responses
To evaluate the effect of this program on medical education, we administered surveys to the trainees before and after the simulation (Appendix). All questions were evaluated on a 10-point Likert scale (1, minimal comfort; 10, maximum comfort). The postsurvey added an additional Likert scale question and an open-ended question.
Sixteen trainees underwent the simulation curriculum during the 2022 to 2023 academic year, 9 internal medicine PGY1 residents, 4 medical students, and 3 physician assistant students. Postsimulation surveys indicated a mean 2.2 point increase in comfort compared with the presimulation surveys across all questions and participants.
DISCUSSION
The simulation curriculum proved to be successful for all parties, including trainees, medical educators, and simulation staff. Trainees expressed gratitude for the teaching ability of the simulation and the challenge of confronting an evolving scenario. Students also stated that the simulation allowed them to identify knowledge weaknesses.
Medical technology is rapidly advancing. A study evaluating high-fidelity medical simulations between 1969 and 2003 found that they are educationally effective and complement other medical education modalities.6 It is also noted that care provided by junior physicians with a lack of prior exposure to emergencies and unusual clinical syndromes can lead to more adverse effects.7 Simulation curriculums can be used to educate junior physicians as well as trainees on a multitude of medical emergencies, teach systematic approaches to medical scenarios, and increase exposure to unfamiliar experiences.
The goals of this article are to share program details and encourage other training programs with similar capabilities to incorporate simulation into medical education. Using pre- and postsimulation surveys, there was a concrete improvement in the value obtained by participating in this simulation. The Nightmare on CIL Street learners experienced a mean 2.2 point improvement from presimulation survey to postsimulation survey. Some notable improvements were the feelings of preparedness for rapid response situations and developing a systematic approach. As the students who participated in our Nightmare on CIL Street simulation were early in training, we believe the improvement in preparation and developing a systematic approach can be key to their success in their practical environments.
From a site-specific standpoint, improvement in confidence working through cardiac, respiratory, and neurological emergencies will be very useful. The anesthesiology service intubates during respiratory failures and there is no stroke neurologist available at the CTVHCS hospital. Giving trainees experience in these conditions may allow them to better understand their role in coordination during these times and potentially improve patient outcomes. A follow-up questionnaire administered a year after this simulation may be useful in ascertaining the usefulness of the simulation and what items may have been approached differently. We encourage other institutions to build in aspects of their site-specific challenges to improve trainee awareness in approaches to critical scenarios.
Challenges
The greatest challenge for Nightmare on CIL Street was the ability to pull internal medicine residents from their clinical duties to participate in the simulation. As there are many moving parts to their clinical scheduling, residents do not always have sufficient coverage to participate in training. There were also instances where residents needed to cover for another resident preventing them from attending the simulation. In the future, this program will schedule residents months in advance and will have the simulation training built into their rotations.
Medical and physician assistant students were pulled from their ward rotations as well. They rotate on a 2-to-4-week basis and often had already experienced the simulation the week prior, leaving out students for the following week. With more longitudinal planning, students can be pulled on a rotating monthly basis to maximize their participation. Another challenge was deciding whether residents should partner or experience the simulation on their own. After some feedback, it was noted that residents preferred to experience the simulation on their own as this improves their learning value. With the limited resources available, only rotating 3 residents on a scenario limits the number of trainees who can be reached with the program. Running this program throughout an academic year can help to reach more trainees.
CONCLUSIONS
Educating trainees on rapid response scenarios by using a simulation curriculum provides many benefits. Our trainees reported improvement in addressing cardiac, respiratory, and neurological rapid response scenarios after experiencing the simulation. They felt better prepared and had developed a better systematic approach for the future.
Acknowledgments
The authors thank Pawan Sikka, MD, George Martinez, MD and Braden Anderson, MD for participating as physician experts and educating our students. We thank Naomi Devers; Dinetra Jones; Stephanie Garrett; Sara Holton; Evelina Bartnick; Tanelle Smith; Michael Lomax; Shaun Kelemen for their participation as nurses, assistants, and simulation technology experts.
1. Guze PA. Using technology to meet the challenges of medical education. Trans Am Clin Climatol Assoc. 2015;126:260-270.
2. Higgins M, Madan C, Patel R. Development and decay of procedural skills in surgery: a systematic review of the effectiveness of simulation-based medical education interventions. Surgeon. 2021;19(4):e67-e77. doi:10.1016/j.surge.2020.07.013
3. Lyons PG, Edelson DP, Carey KA, et al. Characteristics of rapid response calls in the United States: an analysis of the first 402,023 adult cases from the Get With the Guidelines Resuscitation-Medical Emergency Team registry. Crit Care Med. 2019;47(10):1283-1289. doi:10.1097/CCM.0000000000003912
4. McMurray L, Hall AK, Rich J, Merchant S, Chaplin T. The nightmares course: a longitudinal, multidisciplinary, simulation-based curriculum to train and assess resident competence in resuscitation. J Grad Med Educ. 2017;9(4):503-508. doi:10.4300/JGME-D-16-00462.1
5. Gilic F, Schultz K, Sempowski I, Blagojevic A. “Nightmares-Family Medicine” course is an effective acute care teaching tool for family medicine residents. Simul Healthc. 2019;14(3):157-162. doi:10.1097/SIH.0000000000000355
6. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27(1):10-28. doi:10.1080/01421590500046924
7. Datta R, Upadhyay K, Jaideep C. Simulation and its role in medical education. Med J Armed Forces India. 2012;68(2):167-172. doi:10.1016/S0377-1237(12)60040-9
The Central Texas Veteran’s Health Care System (CTVHCS) in Temple, Texas, is a 189-bed teaching hospital. CTVHCS opened the Center for Innovation and Learning (CIL) in 2022. The CIL has about 279 m2 of simulation space that includes high- and low-fidelity simulation equipment and multiple laboratories, which can be used to simulate inpatient and outpatient settings. The CIL high-fidelity manikins and environment allow learners to be immersed in the simulation for maximum realism. Computer and video systems provide clear viewing of training, which allows for more in-depth debriefing and learning. CIL simulation training is used by CTVHCS staff, medical residents, and medical and physician assistant students.
The utility of technology in medical education is rapidly evolving. As noted in many studies, simulation creates an environment that can imitate real patients in the format of a lifelike manikin, anatomic regions stations, clinical tasks, and many real-life circumstances.1 Task trainers for procedure simulation have been widely used and studied. A 2020 study noted that simulation training is effective for developing procedural skills in surgery and prevents the decay of surgical skills.2
In reviewing health care education curriculums, we noted that most of the rapid response situations are learned through active patient experiences. Rapid responses are managed by the intensive care unit and primary care teams during the day but at night are run primarily by the postgraduate year 2 (PGY2) night resident and intern. Knowing these logistics and current studies, we decided to build a rapid response simulation curriculum to improve preparedness for PGY1 residents, medical students, and physician assistant students.
Curriculum Planning
Planning the simulation curriculum began with the CTVHCS internal medicine chief resident and registered nurse (RN) educator. CTVHCS data were reviewed to identify the 3 most common rapid response calls from the past 3 years; research on the most common systems affected by rapid responses also was evaluated.
A 2019 study by Lyons and colleagues evaluated 402,023 rapid response activations across 360 hospitals and found that respiratory scenarios made up 38% and cardiac scenarios made up 37%.3 In addition, the CTVHCS has limited support in stroke neurology. Therefore, the internal medicine chief resident and RN educator decided to run 3 evolving rapid response scenarios per session that included cardiac, respiratory, and neurological scenarios. Capabilities and limitations of different high-fidelity manikins were discussed to identify and use the most appropriate simulator for each situation. Objectives that met both general medicine and site-specific education were discussed, and the program was formulated.
Program Description
Nightmare on CIL Street is a simulation-based program designed for new internal medicine residents and students to encounter difficult situations (late at night, on call, or when resources are limited; ie, weekends/holidays) in a controlled simulation environment. During the simulation, learners will be unable to transfer the patient and no additional help is available. Each learner must determine a differential diagnosis and make appropriate medical interventions with only the assistance of a nurse. Scenarios are derived from common rapid response team calls and low-volume/high-impact situations where clinical decisions must be made quickly to ensure the best patient outcomes. High-fidelity manikins that have abilities to respond to questions, simulate breathing, reproduce pathological heart and breath sounds and more are used to create a realistic patient environment.
This program aligns with 2 national Veterans Health Administration priorities: (1) connect veterans to the soonest and best care; and (2) accelerate the Veterans Health Administration journey to be a high-reliability organization (sensitivity to operations, preoccupation with failure, commitment to resilience, and deference to expertise). Nightmare on CIL Street has 3 clinical episodes: 2 cardiac (A Tell-Tale Heart), respiratory (Don’t Breathe), and neurologic (Brain Scan). Additional clinical episodes will be added based on learner feedback and assessed need.
Each simulation event encompassed all 3 episodes that an individual or a team of 2 learners rotate through in a round-robin fashion. The overarching theme for each episode was a rapid response team call with minimal resources that the learner would have to provide care and stabilization. A literature search for rapid response team training programs found few results, but the literature assisted with providing a foundation for Nightmare on CIL Street.4,5 The goal was to completely envelop the learners in a nightmare scenario that required a solution.
After the safety brief and predata collection, learners received a phone call with minimal information about a patient in need of care. The learners responded to the requested area and provided treatment to the emergency over 25 minutes with the bedside nurse (who is an embedded participant). At the conclusion of the scenario, a physician subject matter expert who has been observing, provided a personalized 10-minute debriefing to the learner, which presented specific learning points and opportunities for the learner’s educational development. After the debriefing, learners returned to a conference room and awaited the next call. After all learners completed the 3 episodes, a group debriefing was conducted using the gather, analyze, summarize debriefing framework. The debriefing begins with an open-ended forum for learners to express their thoughts. Then, each scenario is discussed and broken down by key learning objectives. Starting with cardiac and ending with neurology, the logistics of the cases are discussed based on the trajectory of the learners during the scenarios. Each objective is discussed, and learners are allowed to ask questions before moving to the next scenario. After the debriefing, postevent data were gathered.
Objectives
The program objective was to educate residents and students on common rapid response scenarios. We devised each scenario as an evolving simulation where various interventions would improve or worsen vital signs and symptoms. Each scenario had an end goal: cardioversion (cardiac), intubation (respiratory), and transfer (neurologic). Objectives were tailored to the trainees present during the specific simulation (Table).
IMPLEMENTATION
The initial run of the simulation curriculum was implemented on February 22, 2023, and ended on May 17, 2023, with 5 events. Participants included internal medicine PGY1 residents, third-year medical students, and fourth-year physician assistant students. Internal medicine residents ran each scenario with a subject matter expert monitoring; the undergraduate medical trainees partnered with another student. Students were pulled from their ward rotations to attend the simulation, and residents were pulled from electives and wards. Each trainee was able to experience each planned scenario. They were then briefed, participated in each scenario, and ended with a debriefing, discussing each case in detail. Two subject matter experts were always available, and occasionally 4 were present to provide additional knowledge transfer to learners. These included board-certified physicians in internal medicine and pulmonary critical care. Most scenarios were conducted on Wednesday afternoon or Thursday.
The CIL provided 6 staff minimum for every event. The staff controlled the manikins and acted as embedded players for the learners to interact and work with at the bedside. Every embedded RN was provided the same script: They were a new nurse just off orientation and did not know what to do. In addition, they were instructed that no matter who the learner wanted to call/page, that person or service was not answering or unavailable. This forced learners to respond and treat the simulated patient on their own.
Survey Responses
To evaluate the effect of this program on medical education, we administered surveys to the trainees before and after the simulation (Appendix). All questions were evaluated on a 10-point Likert scale (1, minimal comfort; 10, maximum comfort). The postsurvey added an additional Likert scale question and an open-ended question.
Sixteen trainees underwent the simulation curriculum during the 2022 to 2023 academic year, 9 internal medicine PGY1 residents, 4 medical students, and 3 physician assistant students. Postsimulation surveys indicated a mean 2.2 point increase in comfort compared with the presimulation surveys across all questions and participants.
DISCUSSION
The simulation curriculum proved to be successful for all parties, including trainees, medical educators, and simulation staff. Trainees expressed gratitude for the teaching ability of the simulation and the challenge of confronting an evolving scenario. Students also stated that the simulation allowed them to identify knowledge weaknesses.
Medical technology is rapidly advancing. A study evaluating high-fidelity medical simulations between 1969 and 2003 found that they are educationally effective and complement other medical education modalities.6 It is also noted that care provided by junior physicians with a lack of prior exposure to emergencies and unusual clinical syndromes can lead to more adverse effects.7 Simulation curriculums can be used to educate junior physicians as well as trainees on a multitude of medical emergencies, teach systematic approaches to medical scenarios, and increase exposure to unfamiliar experiences.
The goals of this article are to share program details and encourage other training programs with similar capabilities to incorporate simulation into medical education. Using pre- and postsimulation surveys, there was a concrete improvement in the value obtained by participating in this simulation. The Nightmare on CIL Street learners experienced a mean 2.2 point improvement from presimulation survey to postsimulation survey. Some notable improvements were the feelings of preparedness for rapid response situations and developing a systematic approach. As the students who participated in our Nightmare on CIL Street simulation were early in training, we believe the improvement in preparation and developing a systematic approach can be key to their success in their practical environments.
From a site-specific standpoint, improvement in confidence working through cardiac, respiratory, and neurological emergencies will be very useful. The anesthesiology service intubates during respiratory failures and there is no stroke neurologist available at the CTVHCS hospital. Giving trainees experience in these conditions may allow them to better understand their role in coordination during these times and potentially improve patient outcomes. A follow-up questionnaire administered a year after this simulation may be useful in ascertaining the usefulness of the simulation and what items may have been approached differently. We encourage other institutions to build in aspects of their site-specific challenges to improve trainee awareness in approaches to critical scenarios.
Challenges
The greatest challenge for Nightmare on CIL Street was the ability to pull internal medicine residents from their clinical duties to participate in the simulation. As there are many moving parts to their clinical scheduling, residents do not always have sufficient coverage to participate in training. There were also instances where residents needed to cover for another resident preventing them from attending the simulation. In the future, this program will schedule residents months in advance and will have the simulation training built into their rotations.
Medical and physician assistant students were pulled from their ward rotations as well. They rotate on a 2-to-4-week basis and often had already experienced the simulation the week prior, leaving out students for the following week. With more longitudinal planning, students can be pulled on a rotating monthly basis to maximize their participation. Another challenge was deciding whether residents should partner or experience the simulation on their own. After some feedback, it was noted that residents preferred to experience the simulation on their own as this improves their learning value. With the limited resources available, only rotating 3 residents on a scenario limits the number of trainees who can be reached with the program. Running this program throughout an academic year can help to reach more trainees.
CONCLUSIONS
Educating trainees on rapid response scenarios by using a simulation curriculum provides many benefits. Our trainees reported improvement in addressing cardiac, respiratory, and neurological rapid response scenarios after experiencing the simulation. They felt better prepared and had developed a better systematic approach for the future.
Acknowledgments
The authors thank Pawan Sikka, MD, George Martinez, MD and Braden Anderson, MD for participating as physician experts and educating our students. We thank Naomi Devers; Dinetra Jones; Stephanie Garrett; Sara Holton; Evelina Bartnick; Tanelle Smith; Michael Lomax; Shaun Kelemen for their participation as nurses, assistants, and simulation technology experts.
The Central Texas Veteran’s Health Care System (CTVHCS) in Temple, Texas, is a 189-bed teaching hospital. CTVHCS opened the Center for Innovation and Learning (CIL) in 2022. The CIL has about 279 m2 of simulation space that includes high- and low-fidelity simulation equipment and multiple laboratories, which can be used to simulate inpatient and outpatient settings. The CIL high-fidelity manikins and environment allow learners to be immersed in the simulation for maximum realism. Computer and video systems provide clear viewing of training, which allows for more in-depth debriefing and learning. CIL simulation training is used by CTVHCS staff, medical residents, and medical and physician assistant students.
The utility of technology in medical education is rapidly evolving. As noted in many studies, simulation creates an environment that can imitate real patients in the format of a lifelike manikin, anatomic regions stations, clinical tasks, and many real-life circumstances.1 Task trainers for procedure simulation have been widely used and studied. A 2020 study noted that simulation training is effective for developing procedural skills in surgery and prevents the decay of surgical skills.2
In reviewing health care education curriculums, we noted that most of the rapid response situations are learned through active patient experiences. Rapid responses are managed by the intensive care unit and primary care teams during the day but at night are run primarily by the postgraduate year 2 (PGY2) night resident and intern. Knowing these logistics and current studies, we decided to build a rapid response simulation curriculum to improve preparedness for PGY1 residents, medical students, and physician assistant students.
Curriculum Planning
Planning the simulation curriculum began with the CTVHCS internal medicine chief resident and registered nurse (RN) educator. CTVHCS data were reviewed to identify the 3 most common rapid response calls from the past 3 years; research on the most common systems affected by rapid responses also was evaluated.
A 2019 study by Lyons and colleagues evaluated 402,023 rapid response activations across 360 hospitals and found that respiratory scenarios made up 38% and cardiac scenarios made up 37%.3 In addition, the CTVHCS has limited support in stroke neurology. Therefore, the internal medicine chief resident and RN educator decided to run 3 evolving rapid response scenarios per session that included cardiac, respiratory, and neurological scenarios. Capabilities and limitations of different high-fidelity manikins were discussed to identify and use the most appropriate simulator for each situation. Objectives that met both general medicine and site-specific education were discussed, and the program was formulated.
Program Description
Nightmare on CIL Street is a simulation-based program designed for new internal medicine residents and students to encounter difficult situations (late at night, on call, or when resources are limited; ie, weekends/holidays) in a controlled simulation environment. During the simulation, learners will be unable to transfer the patient and no additional help is available. Each learner must determine a differential diagnosis and make appropriate medical interventions with only the assistance of a nurse. Scenarios are derived from common rapid response team calls and low-volume/high-impact situations where clinical decisions must be made quickly to ensure the best patient outcomes. High-fidelity manikins that have abilities to respond to questions, simulate breathing, reproduce pathological heart and breath sounds and more are used to create a realistic patient environment.
This program aligns with 2 national Veterans Health Administration priorities: (1) connect veterans to the soonest and best care; and (2) accelerate the Veterans Health Administration journey to be a high-reliability organization (sensitivity to operations, preoccupation with failure, commitment to resilience, and deference to expertise). Nightmare on CIL Street has 3 clinical episodes: 2 cardiac (A Tell-Tale Heart), respiratory (Don’t Breathe), and neurologic (Brain Scan). Additional clinical episodes will be added based on learner feedback and assessed need.
Each simulation event encompassed all 3 episodes that an individual or a team of 2 learners rotate through in a round-robin fashion. The overarching theme for each episode was a rapid response team call with minimal resources that the learner would have to provide care and stabilization. A literature search for rapid response team training programs found few results, but the literature assisted with providing a foundation for Nightmare on CIL Street.4,5 The goal was to completely envelop the learners in a nightmare scenario that required a solution.
After the safety brief and predata collection, learners received a phone call with minimal information about a patient in need of care. The learners responded to the requested area and provided treatment to the emergency over 25 minutes with the bedside nurse (who is an embedded participant). At the conclusion of the scenario, a physician subject matter expert who has been observing, provided a personalized 10-minute debriefing to the learner, which presented specific learning points and opportunities for the learner’s educational development. After the debriefing, learners returned to a conference room and awaited the next call. After all learners completed the 3 episodes, a group debriefing was conducted using the gather, analyze, summarize debriefing framework. The debriefing begins with an open-ended forum for learners to express their thoughts. Then, each scenario is discussed and broken down by key learning objectives. Starting with cardiac and ending with neurology, the logistics of the cases are discussed based on the trajectory of the learners during the scenarios. Each objective is discussed, and learners are allowed to ask questions before moving to the next scenario. After the debriefing, postevent data were gathered.
Objectives
The program objective was to educate residents and students on common rapid response scenarios. We devised each scenario as an evolving simulation where various interventions would improve or worsen vital signs and symptoms. Each scenario had an end goal: cardioversion (cardiac), intubation (respiratory), and transfer (neurologic). Objectives were tailored to the trainees present during the specific simulation (Table).
IMPLEMENTATION
The initial run of the simulation curriculum was implemented on February 22, 2023, and ended on May 17, 2023, with 5 events. Participants included internal medicine PGY1 residents, third-year medical students, and fourth-year physician assistant students. Internal medicine residents ran each scenario with a subject matter expert monitoring; the undergraduate medical trainees partnered with another student. Students were pulled from their ward rotations to attend the simulation, and residents were pulled from electives and wards. Each trainee was able to experience each planned scenario. They were then briefed, participated in each scenario, and ended with a debriefing, discussing each case in detail. Two subject matter experts were always available, and occasionally 4 were present to provide additional knowledge transfer to learners. These included board-certified physicians in internal medicine and pulmonary critical care. Most scenarios were conducted on Wednesday afternoon or Thursday.
The CIL provided 6 staff minimum for every event. The staff controlled the manikins and acted as embedded players for the learners to interact and work with at the bedside. Every embedded RN was provided the same script: They were a new nurse just off orientation and did not know what to do. In addition, they were instructed that no matter who the learner wanted to call/page, that person or service was not answering or unavailable. This forced learners to respond and treat the simulated patient on their own.
Survey Responses
To evaluate the effect of this program on medical education, we administered surveys to the trainees before and after the simulation (Appendix). All questions were evaluated on a 10-point Likert scale (1, minimal comfort; 10, maximum comfort). The postsurvey added an additional Likert scale question and an open-ended question.
Sixteen trainees underwent the simulation curriculum during the 2022 to 2023 academic year, 9 internal medicine PGY1 residents, 4 medical students, and 3 physician assistant students. Postsimulation surveys indicated a mean 2.2 point increase in comfort compared with the presimulation surveys across all questions and participants.
DISCUSSION
The simulation curriculum proved to be successful for all parties, including trainees, medical educators, and simulation staff. Trainees expressed gratitude for the teaching ability of the simulation and the challenge of confronting an evolving scenario. Students also stated that the simulation allowed them to identify knowledge weaknesses.
Medical technology is rapidly advancing. A study evaluating high-fidelity medical simulations between 1969 and 2003 found that they are educationally effective and complement other medical education modalities.6 It is also noted that care provided by junior physicians with a lack of prior exposure to emergencies and unusual clinical syndromes can lead to more adverse effects.7 Simulation curriculums can be used to educate junior physicians as well as trainees on a multitude of medical emergencies, teach systematic approaches to medical scenarios, and increase exposure to unfamiliar experiences.
The goals of this article are to share program details and encourage other training programs with similar capabilities to incorporate simulation into medical education. Using pre- and postsimulation surveys, there was a concrete improvement in the value obtained by participating in this simulation. The Nightmare on CIL Street learners experienced a mean 2.2 point improvement from presimulation survey to postsimulation survey. Some notable improvements were the feelings of preparedness for rapid response situations and developing a systematic approach. As the students who participated in our Nightmare on CIL Street simulation were early in training, we believe the improvement in preparation and developing a systematic approach can be key to their success in their practical environments.
From a site-specific standpoint, improvement in confidence working through cardiac, respiratory, and neurological emergencies will be very useful. The anesthesiology service intubates during respiratory failures and there is no stroke neurologist available at the CTVHCS hospital. Giving trainees experience in these conditions may allow them to better understand their role in coordination during these times and potentially improve patient outcomes. A follow-up questionnaire administered a year after this simulation may be useful in ascertaining the usefulness of the simulation and what items may have been approached differently. We encourage other institutions to build in aspects of their site-specific challenges to improve trainee awareness in approaches to critical scenarios.
Challenges
The greatest challenge for Nightmare on CIL Street was the ability to pull internal medicine residents from their clinical duties to participate in the simulation. As there are many moving parts to their clinical scheduling, residents do not always have sufficient coverage to participate in training. There were also instances where residents needed to cover for another resident preventing them from attending the simulation. In the future, this program will schedule residents months in advance and will have the simulation training built into their rotations.
Medical and physician assistant students were pulled from their ward rotations as well. They rotate on a 2-to-4-week basis and often had already experienced the simulation the week prior, leaving out students for the following week. With more longitudinal planning, students can be pulled on a rotating monthly basis to maximize their participation. Another challenge was deciding whether residents should partner or experience the simulation on their own. After some feedback, it was noted that residents preferred to experience the simulation on their own as this improves their learning value. With the limited resources available, only rotating 3 residents on a scenario limits the number of trainees who can be reached with the program. Running this program throughout an academic year can help to reach more trainees.
CONCLUSIONS
Educating trainees on rapid response scenarios by using a simulation curriculum provides many benefits. Our trainees reported improvement in addressing cardiac, respiratory, and neurological rapid response scenarios after experiencing the simulation. They felt better prepared and had developed a better systematic approach for the future.
Acknowledgments
The authors thank Pawan Sikka, MD, George Martinez, MD and Braden Anderson, MD for participating as physician experts and educating our students. We thank Naomi Devers; Dinetra Jones; Stephanie Garrett; Sara Holton; Evelina Bartnick; Tanelle Smith; Michael Lomax; Shaun Kelemen for their participation as nurses, assistants, and simulation technology experts.
1. Guze PA. Using technology to meet the challenges of medical education. Trans Am Clin Climatol Assoc. 2015;126:260-270.
2. Higgins M, Madan C, Patel R. Development and decay of procedural skills in surgery: a systematic review of the effectiveness of simulation-based medical education interventions. Surgeon. 2021;19(4):e67-e77. doi:10.1016/j.surge.2020.07.013
3. Lyons PG, Edelson DP, Carey KA, et al. Characteristics of rapid response calls in the United States: an analysis of the first 402,023 adult cases from the Get With the Guidelines Resuscitation-Medical Emergency Team registry. Crit Care Med. 2019;47(10):1283-1289. doi:10.1097/CCM.0000000000003912
4. McMurray L, Hall AK, Rich J, Merchant S, Chaplin T. The nightmares course: a longitudinal, multidisciplinary, simulation-based curriculum to train and assess resident competence in resuscitation. J Grad Med Educ. 2017;9(4):503-508. doi:10.4300/JGME-D-16-00462.1
5. Gilic F, Schultz K, Sempowski I, Blagojevic A. “Nightmares-Family Medicine” course is an effective acute care teaching tool for family medicine residents. Simul Healthc. 2019;14(3):157-162. doi:10.1097/SIH.0000000000000355
6. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27(1):10-28. doi:10.1080/01421590500046924
7. Datta R, Upadhyay K, Jaideep C. Simulation and its role in medical education. Med J Armed Forces India. 2012;68(2):167-172. doi:10.1016/S0377-1237(12)60040-9
1. Guze PA. Using technology to meet the challenges of medical education. Trans Am Clin Climatol Assoc. 2015;126:260-270.
2. Higgins M, Madan C, Patel R. Development and decay of procedural skills in surgery: a systematic review of the effectiveness of simulation-based medical education interventions. Surgeon. 2021;19(4):e67-e77. doi:10.1016/j.surge.2020.07.013
3. Lyons PG, Edelson DP, Carey KA, et al. Characteristics of rapid response calls in the United States: an analysis of the first 402,023 adult cases from the Get With the Guidelines Resuscitation-Medical Emergency Team registry. Crit Care Med. 2019;47(10):1283-1289. doi:10.1097/CCM.0000000000003912
4. McMurray L, Hall AK, Rich J, Merchant S, Chaplin T. The nightmares course: a longitudinal, multidisciplinary, simulation-based curriculum to train and assess resident competence in resuscitation. J Grad Med Educ. 2017;9(4):503-508. doi:10.4300/JGME-D-16-00462.1
5. Gilic F, Schultz K, Sempowski I, Blagojevic A. “Nightmares-Family Medicine” course is an effective acute care teaching tool for family medicine residents. Simul Healthc. 2019;14(3):157-162. doi:10.1097/SIH.0000000000000355
6. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27(1):10-28. doi:10.1080/01421590500046924
7. Datta R, Upadhyay K, Jaideep C. Simulation and its role in medical education. Med J Armed Forces India. 2012;68(2):167-172. doi:10.1016/S0377-1237(12)60040-9
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<root generator="drupal.xsl" gversion="1.7"> <header> <fileName>1123 FED Simulation</fileName> <TBEID>0C02E792.SIG</TBEID> <TBUniqueIdentifier>NJ_0C02E792</TBUniqueIdentifier> <newsOrJournal>Journal</newsOrJournal> <publisherName>Frontline Medical Communications Inc.</publisherName> <storyname>1123 FED Simulation</storyname> <articleType>1</articleType> <TBLocation>Copyfitting-FED</TBLocation> <QCDate/> <firstPublished>20231103T230256</firstPublished> <LastPublished>20231103T230256</LastPublished> <pubStatus qcode="stat:"/> <embargoDate/> <killDate/> <CMSDate>20231103T230256</CMSDate> <articleSource/> <facebookInfo/> <meetingNumber/> <byline/> <bylineText>Nikhil Seth, MDa; Michael T. Finch, MSN, RN, CNLa</bylineText> <bylineFull/> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType/> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:"> <name/> <rightsInfo> <copyrightHolder> <name/> </copyrightHolder> <copyrightNotice/> </rightsInfo> </provider> <abstract/> <metaDescription>The Central Texas Veteran’s Health Care System (CTVHCS) in Temple, Texas, is a 189-bed teaching hospital. CTVHCS opened the Center for Innovation and Learning (</metaDescription> <articlePDF/> <teaserImage/> <title>Nightmare on CIL Street: A Simulation Series to Increase Confidence and Skill in Responding to Clinical Emergencies</title> <deck/> <eyebrow><hl name="33661"/>Program Profile</eyebrow> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear>2023</pubPubdateYear> <pubPubdateMonth>November</pubPubdateMonth> <pubPubdateDay/> <pubVolume>40</pubVolume> <pubNumber>11</pubNumber> <wireChannels/> <primaryCMSID/> <CMSIDs> <CMSID>2951</CMSID> <CMSID>3639</CMSID> </CMSIDs> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>FED</publicationCode> <pubIssueName>November 2023</pubIssueName> <pubArticleType>Feature Articles | 3639</pubArticleType> <pubTopics/> <pubCategories/> <pubSections> <pubSection>Feature | 2951<pubSubsection/></pubSection> </pubSections> <journalTitle>Fed Pract</journalTitle> <journalFullTitle>Federal Practitioner</journalFullTitle> <copyrightStatement>Copyright 2017 Frontline Medical Communications Inc., Parsippany, NJ, USA. All rights reserved.</copyrightStatement> </publicationData> </publications_g> <publications> <term canonical="true">16</term> </publications> <sections> <term canonical="true">61535</term> </sections> <topics> <term canonical="true">27442</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Nightmare on CIL Street: A Simulation Series to Increase Confidence and Skill in Responding to Clinical Emergencies</title> <deck/> </itemMeta> <itemContent> <p class="abstract"><b>Background:</b> The Central Texas Veterans Health Care System (CTVHCS) in Temple, a 189-bed teaching hospital, recently opened its Center for Innovation and Learning for simulation-based learning. CTVHCS built a rapid response simulation curriculum to improve preparedness for internal medicine residents, medical students, and physician assistant students that exploits newly developed medical education technology.<br/><br/><b>Observations:</b> The Center for Innovation and Learning curriculum was created based on the most common rapid response calls received over the previous 3 years. Cardiac, respiratory, and neurological simulations were implemented. Learners approach each scenario as if they were on night service alone without specialist help. Learners must identify tachyarrhythmia, impending respiratory failure, and a patient with encephalopathy requiring transfer. <br/><br/><b>Conclusions:</b> Sixteen learners were surveyed before the simulation and after addressing each educational objective was completed and showed improvement. Educating trainees on rapid response scenarios by using a simulation curriculum provides many benefits. Trainees reported improvement in addressing cardiac, respiratory, and neurological rapid response scenarios after experiencing the simulation.</p> <p><span class="dropcap">T</span>he Central Texas Veteran’s Health Care System (CTVHCS) in Temple, Texas, is a 189-bed teaching hospital. CTVHCS opened the Center for Innovation and Learning (CIL) in 2022. The CIL has about 279 m<sup>2</sup> of simulation space that includes high- and low-fidelity simulation equipment and multiple laboratories, which can be used to simulate inpatient and outpatient settings. The CIL high-fidelity manikins and environment allow learners to be immersed in the simulation for maximum realism. Computer and video systems provide clear viewing of training, which allows for more in-depth debriefing and learning. CIL simulation training is used by CTVHCS staff, medical residents, and medical and physician assistant students. </p> <p>The utility of technology in medical education is rapidly evolving. As noted in many studies, simulation creates an environment that can imitate real patients in the format of a lifelike manikin, anatomic regions stations, clinical tasks, and many real-life circumstances.<sup>1</sup> Task trainers for procedure simulation have been widely used and studied. A 2020 study noted that simulation training is effective for developing procedural skills in surgery and prevents the decay of surgical skills.<sup>2<br/><br/></sup>In reviewing health care education curriculums, we noted that most of the rapid response situations are learned through active patient experiences. Rapid responses are managed by the intensive care unit and primary care teams during the day but at night are run primarily by the postgraduate year 2 (PGY2) night resident and intern. Knowing these logistics and current studies, we decided to build a rapid response simulation curriculum to improve preparedness for PGY1 residents, medical students, and physician assistant students.</p> <h2>Curriculum Planning</h2> <p>Planning the simulation curriculum began with the CTVHCS internal medicine chief resident and registered nurse (RN) educator. CTVHCS data were reviewed to identify the 3 most common rapid response calls from the past 3 years; research on the most common systems affected by rapid responses also was evaluated. </p> <p>A 2019 study by Lyons and colleagues evaluated 402,023 rapid response activations across 360 hospitals and found that respiratory scenarios made up 38% and cardiac scenarios made up 37%.<sup>3</sup> In addition, the CTVHCS has limited support in stroke neurology. Therefore, the internal medicine chief resident and RN educator decided to run 3 evolving rapid response scenarios per session that included cardiac, respiratory, and neurological scenarios. Capabilities and limitations of different high-fidelity manikins were discussed to identify and use the most appropriate simulator for each situation. Objectives that met both general medicine and site-specific education were discussed, and the program was formulated. </p> <h3>Program Description</h3> <p>Nightmare on CIL Street is a simulation-based program designed for new internal medicine residents and students to encounter difficult situations (late at night, on call, or when resources are limited; ie, weekends/holidays) in a controlled simulation environment. During the simulation, learners will be unable to transfer the patient and no additional help is available. Each learner must determine a differential diagnosis and make appropriate medical interventions with only the assistance of a nurse. Scenarios are derived from common rapid response team calls and low-volume/high-impact situations where clinical decisions must be made quickly to ensure the best patient outcomes. High-fidelity manikins that have abilities to respond to questions, simulate breathing, reproduce pathological heart and breath sounds and more are used to create a realistic patient environment. </p> <p>This program aligns with 2 national Veterans Health Administration priorities: (1) connect veterans to the soonest and best care; and (2) accelerate the Veterans Health Administration journey to be a high-reliability organization (sensitivity to operations, preoccupation with failure, commitment to resilience, and deference to expertise). Nightmare on CIL Street has 3 clinical episodes: 2 cardiac (A Tell-Tale Heart), respiratory (Don’t Breathe), and neurologic (Brain Scan). Additional clinical episodes will be added based on learner feedback and assessed need. <br/><br/>Each simulation event encompassed all 3 episodes that an individual or a team of 2 learners rotate through in a round-robin fashion. The overarching theme for each episode was a rapid response team call with minimal resources that the learner would have to provide care and stabilization. A literature search for rapid response team training programs found few results, but the literature assisted with providing a foundation for Nightmare on CIL Street.<sup>4,5</sup> The goal was to completely envelop the learners in a nightmare scenario that required a solution. <br/><br/>After the safety brief and predata collection, learners received a phone call with minimal information about a patient in need of care. The learners responded to the requested area and provided treatment to the emergency over 25 minutes with the bedside nurse (who is an embedded participant). At the conclusion of the scenario, a physician subject matter expert who has been observing, provided a personalized 10-minute debriefing to the learner, which presented specific learning points and opportunities for the learner’s educational development. After the debriefing, learners returned to a conference room and awaited the next call. After all learners completed the 3 episodes, a group debriefing was conducted using the gather, analyze, summarize debriefing framework. The debriefing begins with an open-ended forum for learners to express their thoughts. Then, each scenario is discussed and broken down by key learning objectives. Starting with cardiac and ending with neurology, the logistics of the cases are discussed based on the trajectory of the learners during the scenarios. Each objective is discussed, and learners are allowed to ask questions before moving to the next scenario. After the debriefing, postevent data were gathered. </p> <h3>Objectives</h3> <p>The program objective was to educate residents and students on common rapid response scenarios. We devised each scenario as an evolving simulation where various interventions would improve or worsen vital signs and symptoms. Each scenario had an end goal: cardioversion (cardiac), intubation (respiratory), and transfer (neurologic). Objectives were tailored to the trainees present during the specific simulation (Table). </p> <h2>IMPLEMENTATION</h2> <p>The initial run of the simulation curriculum was implemented on February 22, 2023, and ended on May 17, 2023, with 5 events. Participants included internal medicine PGY1 residents, third-year medical students, and fourth-year physician assistant students. Internal medicine residents ran each scenario with a subject matter expert monitoring; the undergraduate medical trainees partnered with another student. Students were pulled from their ward rotations to attend the simulation, and residents were pulled from electives and wards. Each trainee was able to experience each planned scenario. They were then briefed, participated in each scenario, and ended with a debriefing, discussing each case in detail. Two subject matter experts were always available, and occasionally 4 were present to provide additional knowledge transfer to learners. These included board-certified physicians in internal medicine and pulmonary critical care. Most scenarios were conducted on Wednesday afternoon or Thursday. </p> <p>The CIL provided 6 staff minimum for every event. The staff controlled the manikins and acted as embedded players for the learners to interact and work with at the bedside. Every embedded RN was provided the same script: They were a new nurse just off orientation and did not know what to do. In addition, they were instructed that no matter who the learner wanted to call/page, that person or service was not answering or unavailable. This forced learners to respond and treat the simulated patient on their own. </p> <h3>Survey Responses</h3> <p>To evaluate the effect of this program on medical education, we administered surveys to the trainees before and after the simulation (Appendix). All questions were evaluated on a 10-point Likert scale (1, minimal comfort; 10, maximum comfort). The postsurvey added an additional Likert scale question and an open-ended question. </p> <p>Sixteen trainees underwent the simulation curriculum during the 2022 to 2023 academic year, 9 internal medicine PGY1 residents, 4 medical students, and 3 physician assistant students. Postsimulation surveys indicated a mean 2.2 point increase in comfort compared with the presimulation surveys across all questions and participants.</p> <h2>DISCUSSION</h2> <p>The simulation curriculum proved to be successful for all parties, including trainees, medical educators, and simulation staff. Trainees expressed gratitude for the teaching ability of the simulation and the challenge of confronting an evolving scenario. Students also stated that the simulation allowed them to identify knowledge weaknesses. </p> <p>Medical technology is rapidly advancing. A study evaluating high-fidelity medical simulations between 1969 and 2003 found that they are educationally effective and complement other medical education modalities.<sup>6</sup> It is also noted that care provided by junior physicians with a lack of prior exposure to emergencies and unusual clinical syndromes can lead to more adverse effects.<sup>7</sup> Simulation curriculums can be used to educate junior physicians as well as trainees on a multitude of medical emergencies, teach systematic approaches to medical scenarios, and increase exposure to unfamiliar experiences. <br/><br/>The goals of this article are to share program details and encourage other training programs with similar capabilities to incorporate simulation into medical education. Using pre- and postsimulation surveys, there was a concrete improvement in the value obtained by participating in this simulation. The Nightmare on CIL Street learners experienced a mean 2.2 point improvement from presimulation survey to postsimulation survey. Some notable improvements were the feelings of preparedness for rapid response situations and developing a systematic approach. As the students who participated in our Nightmare on CIL Street simulation were early in training, we believe the improvement in preparation and developing a systematic approach can be key to their success in their practical environments. <br/><br/>From a site-specific standpoint, improvement in confidence working through cardiac, respiratory, and neurological emergencies will be very useful. The anesthesiology service intubates during respiratory failures and there is no stroke neurologist available at the CTVHCS hospital. Giving trainees experience in these conditions may allow them to better understand their role in coordination during these times and potentially improve patient outcomes. A follow-up questionnaire administered a year after this simulation may be useful in ascertaining the usefulness of the simulation and what items may have been approached differently. We encourage other institutions to build in aspects of their site-specific challenges to improve trainee awareness in approaches to critical scenarios. </p> <h3>Challenges</h3> <p>The greatest challenge for Nightmare on CIL Street was the ability to pull internal medicine residents from their clinical duties to participate in the simulation. As there are many moving parts to their clinical scheduling, residents do not always have sufficient coverage to participate in training. There were also instances where residents needed to cover for another resident preventing them from attending the simulation. In the future, this program will schedule residents months in advance and will have the simulation training built into their rotations. </p> <p>Medical and physician assistant students were pulled from their ward rotations as well. They rotate on a 2-to-4-week basis and often had already experienced the simulation the week prior, leaving out students for the following week. With more longitudinal planning, students can be pulled on a rotating monthly basis to maximize their participation. Another challenge was deciding whether residents should partner or experience the simulation on their own. After some feedback, it was noted that residents preferred to experience the simulation on their own as this improves their learning value. With the limited resources available, only rotating 3 residents on a scenario limits the number of trainees who can be reached with the program. Running this program throughout an academic year can help to reach more trainees. </p> <h2>CONCLUSIONs</h2> <p>Educating trainees on rapid response scenarios by using a simulation curriculum provides many benefits. Our trainees reported improvement in addressing cardiac, respiratory, and neurological rapid response scenarios after experiencing the simulation. They felt better prepared and had developed a better systematic approach for the future. </p> <h3> Acknowledgments </h3> <p> <em>The authors thank Pawan Sikka, MD, George Martinez, MD and Braden Anderson, MD for participating as physician experts and educating our students. We thank Naomi Devers; Dinetra Jones; Stephanie Garrett; Sara Holton; Evelina Bartnick; Tanelle Smith; Michael Lomax; Shaun Kelemen for their participation as nurses, assistants, and simulation technology experts. </em> </p> <h3> Author affiliations </h3> <p> <em><sup>a</sup>Central Texas Veterans Health Care System, Temple</em> </p> <h3> Author disclosures </h3> <p> <em>The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.</em> </p> <h3> Disclaimer </h3> <p> <em>The opinions expressed herein are those of the authors and do not necessarily reflect those of<i> Federal Practitioner, </i>Frontline Medical Communications Inc., the US Government, or any of its agencies.</em> </p> <h3> Ethics and consent </h3> <p> <em>Not applicable</em> </p> <h3> References </h3> <p class="reference"> 1. Guze PA. Using technology to meet the challenges of medical education. <i>Trans Am Clin Climatol Assoc. </i>2015;126:260-270. <br/><br/> 2. Higgins M, Madan C, Patel R. Development and decay of procedural skills in surgery: a systematic review of the effectiveness of simulation-based medical education interventions. <i>Surgeon.</i> 2021;19(4):e67-e77. doi:10.1016/j.surge.2020.07.013<br/><br/> 3. Lyons PG, Edelson DP, Carey KA, et al. Characteristics of rapid response calls in the United States: an analysis of the first 402,023 adult cases from the Get With the Guidelines Resuscitation-Medical Emergency Team registry. <i>Crit Care Med.</i> 2019;47(10):1283-1289. doi:10.1097/CCM.0000000000003912<br/><br/> 4. McMurray L, Hall AK, Rich J, Merchant S, Chaplin T. The nightmares course: a longitudinal, multidisciplinary, simulation-based curriculum to train and assess resident competence in resuscitation. <i>J Grad Med Educ. </i>2017;9(4):503-508. doi:10.4300/JGME-D-16-00462.1<br/><br/> 5. Gilic F, Schultz K, Sempowski I, Blagojevic A. “Nightmares-Family Medicine” course is an effective acute care teaching tool for family medicine residents. <i>Simul Healthc. </i>2019;14(3):157-162. doi:10.1097/SIH.0000000000000355<br/><br/> 6. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. <i>Med Teach.</i> 2005;27(1):10-28. doi:10.1080/01421590500046924<br/><br/> 7. Datta R, Upadhyay K, Jaideep C. Simulation and its role in medical education. <i>Med J Armed Forces India.</i> 2012;68(2):167-172. doi:10.1016/S0377-1237(12)60040-9</p> </itemContent> </newsItem> </itemSet></root>
Gastrointestinal Bleeding Caused by Large Intestine Amyloidosis
Gastrointestinal (GI) bleeding is a common cause of hospital admissions. The yearly incidence of upper GI bleeding is 80 to 150/100,000 people and lower GI bleeding is 87/100,000 people.1,2 The differential tends to initially be broad but narrows with good history followed by endoscopic findings. Getting an appropriate history can be difficult at times, which leads health care practitioners to rely more on interventional results.
Amyloidosis is a rare disorder of abnormal protein folding, leading to the deposition of insoluble fibrils that disrupt normal tissues and cause disease.3 There are 2 main types of amyloidosis, systemic and transthyretin, and 4 subtypes. Systemic amyloidosis includes amyloid light-chain (AL) deposition, caused by plasma cell dyscrasia, and amyloid A (AA) protein deposition, caused by systemic autoimmune illness or infections. Transthyretin amyloidosis is caused by changes and deposition of the transthyretin protein consisting of either unstable, mutant protein or wild type protein. Biopsy-proven amyloidosis of the GI tract is rare.4 About 60% of patients with AA amyloidosis and 8% with AL amyloidosis have GI involvement.5
We present a case of nonspecific symptoms that ultimately lined up perfectly with the official histologic confirmation of intestinal amyloidosis.
Case Presentation
A 79-year-old man with a history of type 2 diabetes mellitus, congestive heart failure, hyperlipidemia, obstructive sleep apnea, hypothyroidism, hypertension, coronary artery disease status postcoronary artery bypass grafting, and stent placements presented for 3 episodes of large, bright red bowel movements. He reported past bleeding and straining with stools, but bleeding of this amount had not been noted prior. He also reported dry heaves, lower abdominal pain, constipation with straining, early satiety with dysphagia, weakness, and decreased appetite. Lastly, he mentioned intentionally losing about 35 to 40 pounds in the past 3 to 4 months and over the past several months increased abdominal distention. However, he stated he had no history of alcohol misuse, liver or intestinal disease, cirrhosis, or other autoimmune diseases. His most recent colonoscopy was more than a decade prior and showed no acute process. The patient never had an esophagogastroduodenoscopy (EGD).
On initial presentation, the patient’s vital signs showed no acute findings. His physical examination noted a chronically ill–appearing male with decreased breath sounds to the bases bilaterally and noted abdominal distention with mild generalized tenderness. Laboratory findings were significant for a hemoglobin level, 9.4 g/dL (reference range, 11.6-15.3); iron, 23 ug/dL (reference range, 45-160); transferrin saturation, 8% (reference range, 15-50); ferritin level, 80 ng/mL (reference range, 30-300); and carcinoembryonic antigen level, 1.5 ng/mL (reference range, 0-2.9). Aspartate aminotransferase level was 54 IU/L (reference range, 0-40); alanine transaminase, 24 IU/L (reference range, 7-52); albumin, 2.7 g/dL (reference range, 3.4-5.7); international normalized ratio, 1.3 (reference range, 0-1.1); creatinine, 1.74 mg/dL (reference range, 0.44-1.27); alkaline phosphatase, 369 IU/L (reference range, 39-117). White blood cell count was 15.5 × 109/L (reference range, 3.5-10.3), and lactic acid was 2.5 mmol/L (reference range, 0.5-2.2). He was started on piperacillin/tazobactam in the emergency department and transitioned to ciprofloxacin and metronidazole for presumed intra-abdominal infection. Paracentesis showed a serum ascites albumin gradient of > 1.1 g/dL with no signs of spontaneous bacterial peritonitis. Computed tomography of the abdomen and pelvis with contrast was suspicious for colitis involving the proximal colon, and colonic mass could not be excluded. Also noted was hepatosplenomegaly with abdominopelvic ascites.
Based on these findings, an EGD and colonoscopy were done. The EGD showed mild portal hypertensive gastropathy. 
After the biopsy results, the patient was officially diagnosed with intestinal amyloidosis (Figure 2). 
He returned to the gastroenterology clinic 2 months later. At that point, he had worsening symptoms, liver function test results, and international normalized ratio. He was admitted for further investigation. A bone biopsy was done to confirm the histology and define the underlying disorder. The biopsy returned showing Waldenstrom macroglobulinemia, and he was started on bortezomib. Unfortunately, his clinical status rapidly worsened, leading to acute renal and hepatic failure and the development of encephalopathy. He eventually died under palliative care services.
Discussion
Amyloidosis is a rare disorder of abnormal protein folding, leading to the deposition of insoluble fibrils that disrupt normal tissues and cause disease.3 There are several variations of amyloid, but the most common type is AL amyloidosis, which affects several organs, including the heart, kidney, liver, nervous system, and GI tract. When AL amyloidosis involves the liver, the median survival time is about 8.5 months.6 There are different ways to diagnose the disease, but a tissue biopsy and Congo Red staining can confirm specific organ involvement as seen in our case.
This case adds another layer to our constantly expanding differential as health care practitioners and proves that atypical patient presentations may not be atypical after all. GI amyloidosis tends to present similarly to our patient with bleeding, malabsorption, dysmotility, and protein-losing gastroenteropathy as ascites, edema, pericardial effusions, and laboratory evidence of hypoalbuminemia.7 Because amyloidosis is a systemic illness, early recognition is important as intestinal complications tend to present as symptoms, but mortality is more often caused by renal failure, cardiomyopathy, or ischemic heart disease, making early multispecialty involvement very important.8
Conclusions
Health care practitioners in all specialties should be aware of and include intestinal amyloidosis in their differential diagnosis when working up GI bleeds with the hope of identifying the disease early. With early recognition, rapid biopsy identification, and early specialist involvement, patients will get the opportunity for expedited multidisciplinary treatment and potentially delay rapid decompensation as shown by the evidence in this case.
1. Antunes C, Copelin II EL. Upper gastrointestinal bleeding. StatPearls [internet]. Updated July 18, 2022. Accessed May 25, 2023. https://www.ncbi.nlm.nih.gov/books/NBK470300
2. Almaghrabi M, Gandhi M, Guizzetti L, et al. Comparison of risk scores for lower gastrointestinal bleeding: a systematic review and meta-analysis. JAMA Netw Open. 2022;5(5):e2214253. doi:10.1001/jamanetworkopen.2022.14253
3. Pepys MB. Pathogenesis, diagnosis and treatment of systemic amyloidosis. Philos Trans R Soc Lond B Biol Sci. 2001;356(1406):203-211. doi:10.1098/rstb.2000.0766
4. Cowan AJ, Skinner M, Seldin DC, et al. Amyloidosis of the gastrointestinal tract: a 13-year, single-center, referral experience. Haematologica. 2013;98(1):141-146. doi:10.3324/haematol.2012.068155
5. Lee BS, Chudasama Y, Chen AI, Lim BS, Taira MT. Colonoscopy leading to the diagnosis of AL amyloidosis in the gastrointestinal tract mimicking an acute ulcerative colitis flare. ACG Case Rep J. 2019;6(11):e00289. doi:10.14309/crj.0000000000000289
6. Zhao L, Ren G, Guo J, Chen W, Xu W, Huang X. The clinical features and outcomes of systemic light chain amyloidosis with hepatic involvement. Ann Med. 2022;54(1):1226-1232. doi:10.1080/07853890.2022.2069281
7. Rowe K, Pankow J, Nehme F, Salyers W. Gastrointestinal amyloidosis: review of the literature. Cureus. 2017;9(5):e1228. doi:10.7759/cureus.1228
8. Kyle RA, Greipp PR, O’Fallon WM. Primary systemic amyloidosis: multivariate analysis for prognostic factors in 168 cases. Blood. 1986;68(1):220-224.
Gastrointestinal (GI) bleeding is a common cause of hospital admissions. The yearly incidence of upper GI bleeding is 80 to 150/100,000 people and lower GI bleeding is 87/100,000 people.1,2 The differential tends to initially be broad but narrows with good history followed by endoscopic findings. Getting an appropriate history can be difficult at times, which leads health care practitioners to rely more on interventional results.
Amyloidosis is a rare disorder of abnormal protein folding, leading to the deposition of insoluble fibrils that disrupt normal tissues and cause disease.3 There are 2 main types of amyloidosis, systemic and transthyretin, and 4 subtypes. Systemic amyloidosis includes amyloid light-chain (AL) deposition, caused by plasma cell dyscrasia, and amyloid A (AA) protein deposition, caused by systemic autoimmune illness or infections. Transthyretin amyloidosis is caused by changes and deposition of the transthyretin protein consisting of either unstable, mutant protein or wild type protein. Biopsy-proven amyloidosis of the GI tract is rare.4 About 60% of patients with AA amyloidosis and 8% with AL amyloidosis have GI involvement.5
We present a case of nonspecific symptoms that ultimately lined up perfectly with the official histologic confirmation of intestinal amyloidosis.
Case Presentation
A 79-year-old man with a history of type 2 diabetes mellitus, congestive heart failure, hyperlipidemia, obstructive sleep apnea, hypothyroidism, hypertension, coronary artery disease status postcoronary artery bypass grafting, and stent placements presented for 3 episodes of large, bright red bowel movements. He reported past bleeding and straining with stools, but bleeding of this amount had not been noted prior. He also reported dry heaves, lower abdominal pain, constipation with straining, early satiety with dysphagia, weakness, and decreased appetite. Lastly, he mentioned intentionally losing about 35 to 40 pounds in the past 3 to 4 months and over the past several months increased abdominal distention. However, he stated he had no history of alcohol misuse, liver or intestinal disease, cirrhosis, or other autoimmune diseases. His most recent colonoscopy was more than a decade prior and showed no acute process. The patient never had an esophagogastroduodenoscopy (EGD).
On initial presentation, the patient’s vital signs showed no acute findings. His physical examination noted a chronically ill–appearing male with decreased breath sounds to the bases bilaterally and noted abdominal distention with mild generalized tenderness. Laboratory findings were significant for a hemoglobin level, 9.4 g/dL (reference range, 11.6-15.3); iron, 23 ug/dL (reference range, 45-160); transferrin saturation, 8% (reference range, 15-50); ferritin level, 80 ng/mL (reference range, 30-300); and carcinoembryonic antigen level, 1.5 ng/mL (reference range, 0-2.9). Aspartate aminotransferase level was 54 IU/L (reference range, 0-40); alanine transaminase, 24 IU/L (reference range, 7-52); albumin, 2.7 g/dL (reference range, 3.4-5.7); international normalized ratio, 1.3 (reference range, 0-1.1); creatinine, 1.74 mg/dL (reference range, 0.44-1.27); alkaline phosphatase, 369 IU/L (reference range, 39-117). White blood cell count was 15.5 × 109/L (reference range, 3.5-10.3), and lactic acid was 2.5 mmol/L (reference range, 0.5-2.2). He was started on piperacillin/tazobactam in the emergency department and transitioned to ciprofloxacin and metronidazole for presumed intra-abdominal infection. Paracentesis showed a serum ascites albumin gradient of > 1.1 g/dL with no signs of spontaneous bacterial peritonitis. Computed tomography of the abdomen and pelvis with contrast was suspicious for colitis involving the proximal colon, and colonic mass could not be excluded. Also noted was hepatosplenomegaly with abdominopelvic ascites.
Based on these findings, an EGD and colonoscopy were done. The EGD showed mild portal hypertensive gastropathy.
After the biopsy results, the patient was officially diagnosed with intestinal amyloidosis (Figure 2).
He returned to the gastroenterology clinic 2 months later. At that point, he had worsening symptoms, liver function test results, and international normalized ratio. He was admitted for further investigation. A bone biopsy was done to confirm the histology and define the underlying disorder. The biopsy returned showing Waldenstrom macroglobulinemia, and he was started on bortezomib. Unfortunately, his clinical status rapidly worsened, leading to acute renal and hepatic failure and the development of encephalopathy. He eventually died under palliative care services.
Discussion
Amyloidosis is a rare disorder of abnormal protein folding, leading to the deposition of insoluble fibrils that disrupt normal tissues and cause disease.3 There are several variations of amyloid, but the most common type is AL amyloidosis, which affects several organs, including the heart, kidney, liver, nervous system, and GI tract. When AL amyloidosis involves the liver, the median survival time is about 8.5 months.6 There are different ways to diagnose the disease, but a tissue biopsy and Congo Red staining can confirm specific organ involvement as seen in our case.
This case adds another layer to our constantly expanding differential as health care practitioners and proves that atypical patient presentations may not be atypical after all. GI amyloidosis tends to present similarly to our patient with bleeding, malabsorption, dysmotility, and protein-losing gastroenteropathy as ascites, edema, pericardial effusions, and laboratory evidence of hypoalbuminemia.7 Because amyloidosis is a systemic illness, early recognition is important as intestinal complications tend to present as symptoms, but mortality is more often caused by renal failure, cardiomyopathy, or ischemic heart disease, making early multispecialty involvement very important.8
Conclusions
Health care practitioners in all specialties should be aware of and include intestinal amyloidosis in their differential diagnosis when working up GI bleeds with the hope of identifying the disease early. With early recognition, rapid biopsy identification, and early specialist involvement, patients will get the opportunity for expedited multidisciplinary treatment and potentially delay rapid decompensation as shown by the evidence in this case.
Gastrointestinal (GI) bleeding is a common cause of hospital admissions. The yearly incidence of upper GI bleeding is 80 to 150/100,000 people and lower GI bleeding is 87/100,000 people.1,2 The differential tends to initially be broad but narrows with good history followed by endoscopic findings. Getting an appropriate history can be difficult at times, which leads health care practitioners to rely more on interventional results.
Amyloidosis is a rare disorder of abnormal protein folding, leading to the deposition of insoluble fibrils that disrupt normal tissues and cause disease.3 There are 2 main types of amyloidosis, systemic and transthyretin, and 4 subtypes. Systemic amyloidosis includes amyloid light-chain (AL) deposition, caused by plasma cell dyscrasia, and amyloid A (AA) protein deposition, caused by systemic autoimmune illness or infections. Transthyretin amyloidosis is caused by changes and deposition of the transthyretin protein consisting of either unstable, mutant protein or wild type protein. Biopsy-proven amyloidosis of the GI tract is rare.4 About 60% of patients with AA amyloidosis and 8% with AL amyloidosis have GI involvement.5
We present a case of nonspecific symptoms that ultimately lined up perfectly with the official histologic confirmation of intestinal amyloidosis.
Case Presentation
A 79-year-old man with a history of type 2 diabetes mellitus, congestive heart failure, hyperlipidemia, obstructive sleep apnea, hypothyroidism, hypertension, coronary artery disease status postcoronary artery bypass grafting, and stent placements presented for 3 episodes of large, bright red bowel movements. He reported past bleeding and straining with stools, but bleeding of this amount had not been noted prior. He also reported dry heaves, lower abdominal pain, constipation with straining, early satiety with dysphagia, weakness, and decreased appetite. Lastly, he mentioned intentionally losing about 35 to 40 pounds in the past 3 to 4 months and over the past several months increased abdominal distention. However, he stated he had no history of alcohol misuse, liver or intestinal disease, cirrhosis, or other autoimmune diseases. His most recent colonoscopy was more than a decade prior and showed no acute process. The patient never had an esophagogastroduodenoscopy (EGD).
On initial presentation, the patient’s vital signs showed no acute findings. His physical examination noted a chronically ill–appearing male with decreased breath sounds to the bases bilaterally and noted abdominal distention with mild generalized tenderness. Laboratory findings were significant for a hemoglobin level, 9.4 g/dL (reference range, 11.6-15.3); iron, 23 ug/dL (reference range, 45-160); transferrin saturation, 8% (reference range, 15-50); ferritin level, 80 ng/mL (reference range, 30-300); and carcinoembryonic antigen level, 1.5 ng/mL (reference range, 0-2.9). Aspartate aminotransferase level was 54 IU/L (reference range, 0-40); alanine transaminase, 24 IU/L (reference range, 7-52); albumin, 2.7 g/dL (reference range, 3.4-5.7); international normalized ratio, 1.3 (reference range, 0-1.1); creatinine, 1.74 mg/dL (reference range, 0.44-1.27); alkaline phosphatase, 369 IU/L (reference range, 39-117). White blood cell count was 15.5 × 109/L (reference range, 3.5-10.3), and lactic acid was 2.5 mmol/L (reference range, 0.5-2.2). He was started on piperacillin/tazobactam in the emergency department and transitioned to ciprofloxacin and metronidazole for presumed intra-abdominal infection. Paracentesis showed a serum ascites albumin gradient of > 1.1 g/dL with no signs of spontaneous bacterial peritonitis. Computed tomography of the abdomen and pelvis with contrast was suspicious for colitis involving the proximal colon, and colonic mass could not be excluded. Also noted was hepatosplenomegaly with abdominopelvic ascites.
Based on these findings, an EGD and colonoscopy were done. The EGD showed mild portal hypertensive gastropathy.
After the biopsy results, the patient was officially diagnosed with intestinal amyloidosis (Figure 2).
He returned to the gastroenterology clinic 2 months later. At that point, he had worsening symptoms, liver function test results, and international normalized ratio. He was admitted for further investigation. A bone biopsy was done to confirm the histology and define the underlying disorder. The biopsy returned showing Waldenstrom macroglobulinemia, and he was started on bortezomib. Unfortunately, his clinical status rapidly worsened, leading to acute renal and hepatic failure and the development of encephalopathy. He eventually died under palliative care services.
Discussion
Amyloidosis is a rare disorder of abnormal protein folding, leading to the deposition of insoluble fibrils that disrupt normal tissues and cause disease.3 There are several variations of amyloid, but the most common type is AL amyloidosis, which affects several organs, including the heart, kidney, liver, nervous system, and GI tract. When AL amyloidosis involves the liver, the median survival time is about 8.5 months.6 There are different ways to diagnose the disease, but a tissue biopsy and Congo Red staining can confirm specific organ involvement as seen in our case.
This case adds another layer to our constantly expanding differential as health care practitioners and proves that atypical patient presentations may not be atypical after all. GI amyloidosis tends to present similarly to our patient with bleeding, malabsorption, dysmotility, and protein-losing gastroenteropathy as ascites, edema, pericardial effusions, and laboratory evidence of hypoalbuminemia.7 Because amyloidosis is a systemic illness, early recognition is important as intestinal complications tend to present as symptoms, but mortality is more often caused by renal failure, cardiomyopathy, or ischemic heart disease, making early multispecialty involvement very important.8
Conclusions
Health care practitioners in all specialties should be aware of and include intestinal amyloidosis in their differential diagnosis when working up GI bleeds with the hope of identifying the disease early. With early recognition, rapid biopsy identification, and early specialist involvement, patients will get the opportunity for expedited multidisciplinary treatment and potentially delay rapid decompensation as shown by the evidence in this case.
1. Antunes C, Copelin II EL. Upper gastrointestinal bleeding. StatPearls [internet]. Updated July 18, 2022. Accessed May 25, 2023. https://www.ncbi.nlm.nih.gov/books/NBK470300
2. Almaghrabi M, Gandhi M, Guizzetti L, et al. Comparison of risk scores for lower gastrointestinal bleeding: a systematic review and meta-analysis. JAMA Netw Open. 2022;5(5):e2214253. doi:10.1001/jamanetworkopen.2022.14253
3. Pepys MB. Pathogenesis, diagnosis and treatment of systemic amyloidosis. Philos Trans R Soc Lond B Biol Sci. 2001;356(1406):203-211. doi:10.1098/rstb.2000.0766
4. Cowan AJ, Skinner M, Seldin DC, et al. Amyloidosis of the gastrointestinal tract: a 13-year, single-center, referral experience. Haematologica. 2013;98(1):141-146. doi:10.3324/haematol.2012.068155
5. Lee BS, Chudasama Y, Chen AI, Lim BS, Taira MT. Colonoscopy leading to the diagnosis of AL amyloidosis in the gastrointestinal tract mimicking an acute ulcerative colitis flare. ACG Case Rep J. 2019;6(11):e00289. doi:10.14309/crj.0000000000000289
6. Zhao L, Ren G, Guo J, Chen W, Xu W, Huang X. The clinical features and outcomes of systemic light chain amyloidosis with hepatic involvement. Ann Med. 2022;54(1):1226-1232. doi:10.1080/07853890.2022.2069281
7. Rowe K, Pankow J, Nehme F, Salyers W. Gastrointestinal amyloidosis: review of the literature. Cureus. 2017;9(5):e1228. doi:10.7759/cureus.1228
8. Kyle RA, Greipp PR, O’Fallon WM. Primary systemic amyloidosis: multivariate analysis for prognostic factors in 168 cases. Blood. 1986;68(1):220-224.
1. Antunes C, Copelin II EL. Upper gastrointestinal bleeding. StatPearls [internet]. Updated July 18, 2022. Accessed May 25, 2023. https://www.ncbi.nlm.nih.gov/books/NBK470300
2. Almaghrabi M, Gandhi M, Guizzetti L, et al. Comparison of risk scores for lower gastrointestinal bleeding: a systematic review and meta-analysis. JAMA Netw Open. 2022;5(5):e2214253. doi:10.1001/jamanetworkopen.2022.14253
3. Pepys MB. Pathogenesis, diagnosis and treatment of systemic amyloidosis. Philos Trans R Soc Lond B Biol Sci. 2001;356(1406):203-211. doi:10.1098/rstb.2000.0766
4. Cowan AJ, Skinner M, Seldin DC, et al. Amyloidosis of the gastrointestinal tract: a 13-year, single-center, referral experience. Haematologica. 2013;98(1):141-146. doi:10.3324/haematol.2012.068155
5. Lee BS, Chudasama Y, Chen AI, Lim BS, Taira MT. Colonoscopy leading to the diagnosis of AL amyloidosis in the gastrointestinal tract mimicking an acute ulcerative colitis flare. ACG Case Rep J. 2019;6(11):e00289. doi:10.14309/crj.0000000000000289
6. Zhao L, Ren G, Guo J, Chen W, Xu W, Huang X. The clinical features and outcomes of systemic light chain amyloidosis with hepatic involvement. Ann Med. 2022;54(1):1226-1232. doi:10.1080/07853890.2022.2069281
7. Rowe K, Pankow J, Nehme F, Salyers W. Gastrointestinal amyloidosis: review of the literature. Cureus. 2017;9(5):e1228. doi:10.7759/cureus.1228
8. Kyle RA, Greipp PR, O’Fallon WM. Primary systemic amyloidosis: multivariate analysis for prognostic factors in 168 cases. Blood. 1986;68(1):220-224.
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<root generator="drupal.xsl" gversion="1.7"> <header> <fileName>0823 FED Large Int Amyloidosis</fileName> <TBEID>0C02D561.SIG</TBEID> <TBUniqueIdentifier>NJ_0C02D561</TBUniqueIdentifier> <newsOrJournal>Journal</newsOrJournal> <publisherName>Frontline Medical Communications Inc.</publisherName> <storyname/> <articleType>1</articleType> <TBLocation>Copyfitting-FED</TBLocation> <QCDate/> <firstPublished>20230814T170957</firstPublished> <LastPublished>20230814T170957</LastPublished> <pubStatus qcode="stat:"/> <embargoDate/> <killDate/> <CMSDate>20230814T170957</CMSDate> <articleSource/> <facebookInfo/> <meetingNumber/> <byline/> <bylineText>Nikhil Seth, MDa; Victoria A. Jaeger, DOb; Namisha Thapa, DOb; James T. Sing, DOb; Christopher R. Naumann, MDb</bylineText> <bylineFull/> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType/> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:"> <name/> <rightsInfo> <copyrightHolder> <name/> </copyrightHolder> <copyrightNotice/> </rightsInfo> </provider> <abstract/> <metaDescription>Gastrointestinal (GI) bleeding is a common cause of hospital admissions. The yearly incidence of upper GI bleeding is 80 to 150/100,000 people and lower GI blee</metaDescription> <articlePDF/> <teaserImage/> <title>Gastrointestinal Bleeding Caused by Large Intestine Amyloidosis</title> <deck/> <eyebrow>Case in Point</eyebrow> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear>2023</pubPubdateYear> <pubPubdateMonth>August</pubPubdateMonth> <pubPubdateDay/> <pubVolume>40</pubVolume> <pubNumber>8</pubNumber> <wireChannels/> <primaryCMSID/> <CMSIDs> <CMSID>2953</CMSID> <CMSID>3639</CMSID> </CMSIDs> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>FED</publicationCode> <pubIssueName>August 2023</pubIssueName> <pubArticleType>Feature Articles | 3639</pubArticleType> <pubTopics/> <pubCategories/> <pubSections> <pubSection>Case in Point | 2953<pubSubsection/></pubSection> </pubSections> <journalTitle>Fed Pract</journalTitle> <journalFullTitle>Federal Practitioner</journalFullTitle> <copyrightStatement>Copyright 2017 Frontline Medical Communications Inc., Parsippany, NJ, USA. All rights reserved.</copyrightStatement> </publicationData> </publications_g> <publications> <term canonical="true">16</term> </publications> <sections> <term canonical="true">45</term> </sections> <topics> <term canonical="true">27442</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Gastrointestinal Bleeding Caused by Large Intestine Amyloidosis</title> <deck/> </itemMeta> <itemContent> <p class="abstract"><b>Background:</b> Amyloidosis is a rare disorder caused by abnormal folding of proteins, leading to the dysfunction of normal tissues. Amyloid deposition can affect several organs, but deposition in the large intestine is rare.<br/><br/><b>Case Presentation: </b>A 79-year-old man presented with gastrointestinal bleeding and nonspecific symptoms of weight loss, dry heaves, dysphagia, and weakness. The patient underwent esophagogastroduodenoscopy and colonoscopy and a biopsy confirmed the diagnosis of intestinal amyloidosis.<br/><br/><b>Conclusions: </b>This case report highlights the importance of a strong differential when working up gastrointestinal bleeding that includes amyloidosis. Early identification and multidisciplinary involvement are crucial for management and tailored care to each patient’s needs.</p> <p><span class="Drop">G</span>astrointestinal (GI) bleeding is a common cause of hospital admissions. The yearly incidence of upper GI bleeding is 80 to 150/100,000 people and lower GI bleeding is 87/100,000 people.<sup>1,2</sup> The differential tends to initially be broad but narrows with good history followed by endoscopic findings. Getting an appropriate history can be difficult at times, which leads health care practitioners to rely more on interventional results. </p> <p>Amyloidosis is a rare disorder of abnormal protein folding, leading to the deposition of insoluble fibrils that disrupt normal tissues and cause disease.<sup>3</sup> There are 2 main types of amyloidosis, systemic and transthyretin, and 4 subtypes. Systemic amyloidosis includes amyloid light-chain (AL) deposition, caused by plasma cell dyscrasia, and amyloid A (AA) protein deposition, caused by systemic autoimmune illness or infections. Transthyretin amyloidosis is caused by changes and deposition of the transthyretin protein consisting of either unstable, mutant protein or wild type protein. Biopsy-proven amyloidosis of the GI tract is rare.<sup>4</sup> About 60% of patients with AA amyloidosis and 8% with AL amyloidosis have GI involvement.<sup>5<br/><br/></sup>We present a case of nonspecific symptoms that ultimately lined up perfectly with the official histologic confirmation of intestinal amyloidosis. </p> <h2>Case Presentation</h2> <p>A 79-year-old man with a history of type 2 diabetes mellitus, congestive heart failure, hyperlipidemia, obstructive sleep apnea, hypothyroidism, hypertension, coronary artery disease status postcoronary artery bypass grafting, and stent placements presented for 3 episodes of large, bright red bowel movements. He reported past bleeding and straining with stools, but bleeding of this amount had not been noted prior. He also reported dry heaves, lower abdominal pain, constipation with straining, early satiety with dysphagia, weakness, and decreased appetite. Lastly, he mentioned intentionally losing about 35 to 40 pounds in the past 3 to 4 months and over the past several months increased abdominal distention. However, he stated he had no history of alcohol misuse, liver or intestinal disease, cirrhosis, or other autoimmune diseases. His most recent colonoscopy was more than a decade prior and showed no acute process. The patient never had an esophagogastroduodenoscopy (EGD). </p> <p>On initial presentation, the patient’s vital signs showed no acute findings. His physical examination noted a chronically ill–appearing male with decreased breath sounds to the bases bilaterally and noted abdominal distention with mild generalized tenderness. Laboratory findings were significant for a hemoglobin level, 9.4 g/dL (reference range, 11.6-15.3); iron, 23 ug/dL (reference range, 45-160); transferrin saturation, 8% (reference range, 15-50); ferritin level, 80 ng/mL (reference range, 30-300); and carcinoembryonic antigen level, 1.5 ng/mL (reference range, 0-2.9). Aspartate aminotransferase level was 54 IU/L (reference range, 0-40); alanine transaminase, 24 IU/L (reference range, 7-52); albumin, 2.7 g/dL (reference range, 3.4-5.7); international normalized ratio, 1.3 (reference range, 0-1.1); creatinine, 1.74 mg/dL (reference range, 0.44-1.27); alkaline phosphatase, 369 IU/L (reference range, 39-117). White blood cell count was 15.5 × 10<sup>9</sup>/L (reference range, 3.5-10.3), and lactic acid was 2.5 mmol/L (reference range, 0.5-2.2). He was started on piperacillin/tazobactam in the emergency department and transitioned to ciprofloxacin and metronidazole for presumed intra-abdominal infection. Paracentesis showed a serum ascites albumin gradient of > 1.1 g/dL with no signs of spontaneous bacterial peritonitis. Computed tomography of the abdomen and pelvis with contrast was suspicious for colitis involving the proximal colon, and colonic mass could not be excluded. Also noted was hepatosplenomegaly with abdominopelvic ascites. <br/><br/>Based on these findings, an EGD and colonoscopy were done. The EGD showed mild portal hypertensive gastropathy. The coloscopy showed patchy colitis in the cecum, ascending colon, and transverse colon with a mass vs clot adherent to the mucosa and areas of ulceration next to the masslike structures with oozing (Figure 1).<br/><br/>After the biopsy results, the patient was officially diagnosed with intestinal amyloidosis (Figure 2). His hemoglobin level stabilized, he was to complete his antibiotic treatment outpatient, and there were plans to follow up with gastroenterology, hematology/oncology, nephrology, and his primary care physician for further management. <br/><br/>He returned to the gastroenterology clinic 2 months later. At that point, he had worsening symptoms, liver function test results, and international normalized ratio. He was admitted for further investigation. A bone biopsy was done to confirm the histology and define the underlying disorder. The biopsy returned showing Waldenstrom macroglobulinemia, and he was started on bortezomib. Unfortunately, his clinical status rapidly worsened, leading to acute renal and hepatic failure and the development of encephalopathy. He eventually died under palliative care services. </p> <h2>Discussion</h2> <p>Amyloidosis is a rare disorder of abnormal protein folding, leading to the deposition of insoluble fibrils that disrupt normal tissues and cause disease.<sup>3</sup> There are several variations of amyloid, but the most common type is AL amyloidosis, which affects several organs, including the heart, kidney, liver, nervous system, and GI tract. When AL amyloidosis involves the liver, the median survival time is about 8.5 months.<sup>6</sup> There are different ways to diagnose the disease, but a tissue biopsy and Congo Red staining can confirm specific organ involvement as seen in our case.</p> <p>This case adds another layer to our constantly expanding differential as health care practitioners and proves that atypical patient presentations may not be atypical after all. GI amyloidosis tends to present similarly to our patient with bleeding, malabsorption, dysmotility, and protein-losing gastroenteropathy as ascites, edema, pericardial effusions, and laboratory evidence of hypoalbuminemia.<sup>7</sup> Because amyloidosis is a systemic illness, early recognition is important as intestinal complications tend to present as symptoms, but mortality is more often caused by renal failure, cardiomyopathy, or ischemic heart disease, making early multispecialty involvement very important.<sup>8</sup> </p> <h2>Conclusions</h2> <p>Health care practitioners in all specialties should be aware of and include intestinal amyloidosis in their differential diagnosis when working up GI bleeds with the hope of identifying the disease early. With early recognition, rapid biopsy identification, and early specialist involvement, patients will get the opportunity for expedited multidisciplinary treatment and potentially delay rapid decompensation as shown by the evidence in this case.</p> <h3> Author affiliations </h3> <p> <em><sup>a</sup>Central Texas Veterans Affairs Health Care System, Temple<br/><br/><sup>b</sup>Baylor Scott and White Medical Center, Temple, Texas</em> </p> <h3> Author disclosures </h3> <p> <em>The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.</em> </p> <h3> Disclaimer </h3> <p> <em>The opinions expressed herein are those of the authors and do not necessarily reflect those of <i>Federal Practitioner</i>, Frontline Medical Communications Inc., the US Government, or any of its agencies. </em> </p> <h3> Ethics and consent </h3> <p> <em>Consent was obtained by the patient’s next of kin. </em> </p> <h3> References </h3> <p class="reference"> 1. Antunes C, Copelin II EL. Upper gastrointestinal bleeding. <i>StatPearls</i> [internet]. Updated July 18, 2022. Accessed May 25, 2023. https://www.ncbi.nlm.nih.gov/books/NBK470300<br/><br/> 2. Almaghrabi M, Gandhi M, Guizzetti L, et al. Comparison of risk scores for lower gastrointestinal bleeding: a systematic review and meta-analysis. <i>JAMA Netw Open</i>. 2022;5(5):e2214253. doi:10.1001/jamanetworkopen.2022.14253<br/><br/> 3. Pepys MB. Pathogenesis, diagnosis and treatment of systemic amyloidosis. <i>Philos Trans R Soc Lond B Biol Sci</i>. 2001;356(1406):203-211. doi:10.1098/rstb.2000.0766<br/><br/> 4. Cowan AJ, Skinner M, Seldin DC, et al. Amyloidosis of the gastrointestinal tract: a 13-year, single-center, referral experience. <i>Haematologica</i>. 2013;98(1):141-146. doi:10.3324/haematol.2012.068155<br/><br/> 5. Lee BS, Chudasama Y, Chen AI, Lim BS, Taira MT. Colonoscopy leading to the diagnosis of AL amyloidosis in the gastrointestinal tract mimicking an acute ulcerative colitis flare. <i>ACG Case Rep J</i>. 2019;6(11):e00289. doi:10.14309/crj.0000000000000289<br/><br/> 6. Zhao L, Ren G, Guo J, Chen W, Xu W, Huang X. The clinical features and outcomes of systemic light chain amyloidosis with hepatic involvement. <i>Ann Med</i>. 2022;54(1):1226-1232. doi:10.1080/07853890.2022.2069281<br/><br/> 7. Rowe K, Pankow J, Nehme F, Salyers W. Gastrointestinal amyloidosis: review of the literature. <i>Cureus</i>. 2017;9(5):e1228. doi:10.7759/cureus.1228<br/><br/> 8. Kyle RA, Greipp PR, O’Fallon WM. Primary systemic amyloidosis: multivariate analysis for prognostic factors in 168 cases. <i>Blood</i>. 1986;68(1):220-224.</p> </itemContent> </newsItem> </itemSet></root>