CHAMP (Curriculum for the Hospitalized Aging Medical Patient)—
the faculty develpoment program materials/methods overview/User’s
Guide
University of Chicago, Section of Geriatrics
Paula Podrazik MD
The CHAMP core working group:
Paula M. Podrazik, MD (CHAMP program director, Teaching on Today’s Wards); Aliza Baron, MA (CHAMP project manager); Core working group—Stacie Levine MD(Program evaluation), Don Scott, MD (Observed Standardized Teaching Experience (OSTE)/Medical Students & CHAMP), Catherine DuBeau MD, Sandy Cook, PhD(Program evaluation), Sandy Smith, PhD (Program evaluation), Julie Mohr, PhD (Teaching on Today’s Wards), Chad Whelan, MD (Teaching on Today’s Wards), Vineet Arora, MD (Assessing care of vulnerable elders (ACOVE)/Outcomes), David Meltzer, MD, PhD (ACOVE/ Outcomes), and Greg A. Sachs MD (Principle Investigator)
Supported by the Donald W. Reynolds Foundation
CHAMP—An overview:
1. Teaching in the inpatient setting—Challenges and Importance:
The inpatient setting is the main training site for residents and medical students. The hospital, with potential iatrogenic events, challenging transitions, mortality risk, is likewise a crucial setting for older patients. Changes in residency work rules and new Accreditation Council for Graduate Medical Education (ACGME) core competencies have added to the challenge of teaching in this busy setting. Addressing these challenges and demands, the CHAMP faculty development program (FDP) merges the educational needs of faculty teachers, residents, and medical students around the goal of improving the care of hospitalized older adults.
2. CHAMP—How to Use the Materials:
The CHAMP FDP has the potential for widespread portability to all teaching faculty who care for the aging hospitalized patient. These materials can be used in their entirety to recreate a similar FDP at your institution for General Internists, Hospitalists, Geriatricians, Family Practitioners and fellows who attend and teach adult medicine in the inpatient setting. Or, they can be used in modular pieces as well, e.g., specific geriatric topic areas lecture /bedside teaching materials/tools. The Teaching on Today’s Wards can also be used in its entirety or in modular pieces, e.g., a workshop on teaching Practice Based Learning and Improvement (PBLI) or Systems Based Practice (SBP) competencies or just using the census audit tool to teach.
3. CHAMP Faculty Development Program: Methods and Materials
CHAMP (Curriculum for the Hospitalized Aging Medical Patient) is a multi-tiered educational project with a faculty development program at its core. Hospitalists, general internists and family practitioners who teach residents and students are the targeted audience.
The CHAMP FDP is a 12-week course consisting of 12 four-hour sessions. Two hours of each session cover inpatient geriatric content and two hours address improving clinical teaching. Geriatric content is organized around four themes, as outlined below. General clinical teaching skills are addressed using the Stanford “Improving Clinical Teaching Skills” course, and challenges specific to the inpatient wards are covered using a newly developed mini-course entitled: “Teaching on Today’s Wards.” The aims of content areas in “Teaching on Today’s Wards” are also outlined below.
Bedside teaching skills are practiced in a four-hour Observed Standardized Teaching Experience (OSTE) Session. Similar to an observed structured clinical evaluation (OSCE), the OSTE is a performance-based assessment method for teaching skills which uses “standardized” students in a simulated teaching environment. The OSTE allows the deliberate practice of teaching new curricular materials and skills and have been shown to improve teaching skills for both faculty and resident teachers. In the CHAMP curriculum, OSTE’s allowed the participants to practice teaching new geriatric content. Teaching topics include: hospital discharge, appropriate indications for foley catheter use, delirium, teaching the mini-cog. and the gait-timed get up and go assessment at bedside.
CHAMP materials include bedside teaching triggers which identify opportunities to teach geriatrics at bedside or during the course of ward rounds with the house staff and medical student team. Each “teaching trigger” consists of a clinical question and summary 5-10 minute teaching points. See Figure #1—sample teaching trigger and materials.
4. CHAMP FDP Curriculum:
Aging Medicine Themes and Topics
Identify the Frail /Vulnerable Elder
• Identify and assess the frail hospitalized older patient
• Dementia in the Hospitalized Aging Medical patient: Recognizing dementia, Assessing Medical
Decision Making Capacity, implications for the treatment of non-dementia illness, pain assessment,
improving the transition of care post-hospitalization
Avoid Hazards of Hospitalization
• Delirium: Diagnosis, Treatment, Risk stratification and Prevention
• Falls: Assessment and Prevention
• Foley Catheter Use: Appropriate indications
• Deconditioning: Scope of the Problem and Prevention
• Adverse Drug Reactions/Medication Error: Principles of Drug Review
• Pressure Ulcers: Assessment, Treatment and Prevention
Palliate and Address End-of-Life Issues
• Pain Control
• Symptom Management in Advanced Disease: Nausea
• Difficult Conversations and Advanced Directives
• Hospice/Palliative Care and Changing Goals of Care
Improve Transitions of Care
• The IdealHospital Discharge
• Destinations of Post-Hospital Care
Teaching on Today’s Wards: Aims and Content Areas
Aims:
- Assist the teaching faculty to improve their own individual process of teaching in the specific site of the inpatient wards.
- Advance techniques and materials for teaching across all the ACGME competencies with an emphasis on teaching aspects of systems based practice (SBP) and practice based learning and improvement (PBLI) in “real” time during the course of ward rounds.
- “Teaching on Today’s Wards” uses geriatric content as the basis for all discussions.
CHAMP (Curriculum for the Hospitalized Aging Medical Patient)
University of Chicago
Supported by a Donald W. Reynolds Foundation grant
Sessions One and Two: Improving the Teaching Process
- Use of process mapping to analyze and improve a faculty learner’s teaching process
- Incorporating professionalism/communication into the bedside teaching agenda
- Setting teaching goals
- Two interactive card games that explores goal setting for the team of residents and medical students and how to expand a teaching agenda to include more teaching across the ACGME competencies using geriatric content.
Card Game #1: “I hope I get a good team.” explores the effects of the inpatient team dynamics on
the teaching process. The aim of this card game is to reflect on your teaching process with regard
to how you goal setting for the team and members of the team based on level of learner and
individual strengths and weaknesses.
Card game #2—“Missed teaching opportunities”— explores what you teach on a given call cycle,
How to develop a teaching agenda to include more of the aging related topics and
teach this geriatric content across the ACGME competencies.
Session Three: Systems Based Practice
- Introduction to systems
- Introduction to triggers for teaching about systems problems
- Introduction to quality improvement using the Plan-Do-Study-Act (PDSA) model
Session Four: Practice-Based Learning and Improvement
- Introduction to practice-based learning and improvement
- Use of the case audit and census audit tools. See Figure # 2 – sample census audit
Session Five: Life-Long Learning
- When, what and how to formulate teaching questions
5. CHAMP FDP Evaluation
Evaluation of the CHAMP FDP includes traditional methods of evaluation of both the faculty teachers and faculty learners. The faculty learner takes a knowledge test 1 2 3 * (given pre and post-course), an attitudes survey 4 about aging (given pre-course only), and a self-assessment survey measuring self-confidence, importance and frequency practicing and teaching geriatric skills on the wards. The same measures are assessed relating to the advanced teaching skills in Teaching on Today’s Wards. The faculty learner also signs a “commitment to change” contract at the end of the CHAMP course selecting topics of interest to teach on future inpatient teaching attending months from the geriatric topics section and an aspect of the ACGME competencies or specific tools developed, e.g., census audit tool. Developing a Quality Improvement (QI) project is another option on the faculty learner’s commitment to change contract. These contracts are reviewed during the CHAMP course and reminders via e-mail are sent prior to the faculty learner’s month on the inpatient service. Contact with the faculty learners is frequent before, during and after each time the faculty learner attends on the wards. After the faculty leaner’s month on the inpatient service they receive a follow-up survey contract asking them to rate their success in attaining their teaching goals.
At the end of the year, all faculty in general internal medicine are surveyed about the frequency of teaching geriatric clinical skills on the wards, and the frequency with which the team performed the skills. The residents and medical students are likewise surveyed about the frequency of being taught geriatric clinical skills on the wards and the geriatric teaching of their inpatient team attending physician (s). In addition, the residents are surveyed annually, on their self-confidence practicing geriatric clinical skills on the wards, the importance of geriatric clinical skills and the frequency with which they practice geriatric skills. The residents will be completing the geriatric knowledge test at of the start of the academic year 2006.
Medical students—second and third years—also complete the geriatrics knowledge test pre and post their inpatient month, in addition to completing the attitudes survey.
*Note the Geriatrics knowledge test is a 23-item exam from the sources referenced. Questions were selected based on their relevance to the specific goals and modules covered in the inpatient geriatrics portion of CHAMP. Four additional questions were developed to address content areas not covered in these sources.
Bibliography
- Reuben DB, Lee M, Davis JW, et al. Development and evaluation of a geriatrics knowledge test for primary care residents. J Gen Intern Med 1997;12 (7): 450-452.
- Storey P, Knight CF. UNIPAC Three: Assessment and treatment of pain in the terminally ill. Second edition. AmericanAcademy of Hospice and Palliative Care. 2003.
- Lee M, Wilkerson L, Reuben DB, et al. Development and validation of a geriatric knowledge test for medical students. J Am Geriatr Soc 2004; 52(6):983-8.
- Reuben DB, Lee M, Davis JW Jr, Eslami MS, et al. Development and validation of a geriatrics attitudes scale for primary care residents. J Am Geriatr Soc 1998; 46(11):1425-30.
CHAMP (Curriculum for the Hospitalized Aging Medical Patient)
University of Chicago
Supported by a Donald W. Reynolds Foundation grant
Figure #1 Sample CHAMP Bedside Teaching Materials:
Teaching trigger on assessing pain
ASSESSING PAIN
By Stacie Levine MD
Teaching Trigger:
During daily rounds, when obtaining history, ask the patient if he/she is feeling pain. If a patient responds affirmatively, OR, for patients with advanced cognitive impairments, exhibits a change in behavior, there may be pathology contributing to pain.
Clinical Question:
How do you assess pain in older adults, regardless of cognitive status?
Teaching Points:1) Every older adult should be screened for pain when hospitalized (“the Fifth Vital Sign”)
2) Even patients with moderate, and some with advanced dementia, may be able to reliably report pain
3) Assume persons with dementia feel pain the same as cognitively intact persons
4) Find the patient’s Preferred Pain Terminology
- hurting, aching, stabbing, discomfort, soreness
5) Use a Pain Scale that works for the individual
- Numeric Rating Scale
- Verbal Descriptor Scale
- Faces Pain Scale
- Pain thermometer
6) In patients with advanced dementia:
(a)Formal assessment tools may not be useful
(b)Identify Unique Pain Signature
- How does the patient usually act?
- What changes are seen when they are in pain?
- Communication across caregiver settings is key!
(c)Look for Nonverbal Pain Indicators
- Changes in interpersonal interactions
- Changes in mental status
- Changes in usual activity
(d)Perform timely, thorough physical exam
(e)Insure basic comfort needs are being met
(f)Rule out other causative pathologies
(g)Consider empiric analgesic trial
CHAMP (Curriculum for the Hospitalized Aging Medical Patient)
University of Chicago
Supported by a Donald W. Reynolds Foundation grant
Figure #2 Sample Census Audit
CENSUS AUDIT: FOLEY CATHETER USE*
By Chad Whelan, MD
Foley Catheter:YesNo
If Yes then:Where was it placed? ______
When was it placed? ______
Appropriate indication when placed? Yes No
Appropriate indication now?YesNo
If No, then DC
If Yes, Plan for DC Yes No
Patient Safety Issues/Systems Issues?
Summary
Proportion of Patients with Foley Catheter ______
Proportion of Patients with Catheters with indication when placed ____
Proportion of Patients with Catheters with indication now ______
Patient Safety Issues/Systems Issues Themes
______
______
Plan for Change: ______
______
Plan to Re-Measure: ______
CHAMP (Curriculum for the Hospitalized Aging Medical Patient)
University of Chicago
Supported by a Donald W. Reynolds Foundation grant