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

Danny Mou, MD; Claire DeVries, MD

Residents in General Surgery at Brigham and Women's Hospital 

PGY 3

March 26, 2019 

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

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

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

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

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

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

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

Mauricio F. Villamar, MD

Fellow in Epilepsy at BWH

PGY 5 

March 20, 2019

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

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

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

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

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

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

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

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

Sam Miller, MD

Resident in Internal Medicine at MGH

PGY-2

March 20, 2019 

Project Summary

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

Project Obstacles

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

What are the next steps?

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

What have you learned about engaging in research?

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

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

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

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

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

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

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

Medical education research – a lesson in patience and persistence

Yun Xue, MD and Sherry Yu, MD

Residents in Dermatology Program at MGH

PGY-3

March 20, 2019

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

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

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

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

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

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

Patricia Pringle Bloom MD

Fellow in Gastroenterology at MGH

PGY 6

March 20, 2019

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

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

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

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

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

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

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

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