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Health systems science (HSS) curricula equip future physicians to improve patient, population, and health systems outcomes (i.e., to become "systems citizens"), but the degree to which medical students internalize this conception of the physician role remains unclear. This study aimed to explore how students envision their future professional identity in relation to the system and identify experiences relevant to this aspect of identity formation.Between December 2018 and September 2019, authors interviewed 48 students at 4 U.S. medical schools with HSS curricula. Semistructured interviews were audiorecorded, transcribed, and analyzed iteratively using inductive thematic analysis. Interview questions explored how students understood the health system, systems-related activities they envisioned as future physicians, and experiences and considerations shaping their perspectives.Most students anticipated enacting one or more systems-related roles as a future physician, categorized as "bottom-up" efforts enacted at a patient or community level (humanist, connector, steward) or "top-down" efforts enacted at a system or policy level (system improver, system scholar, policy advocate). Corresponding activities included attending to social determinants of health or serving medically underserved populations, connecting patients with team members to address systems-related barriers, stewarding health care resources, conducting quality improvement projects, researching/teaching systems topics, and advocating for policy change. Students attributed systems-related aspirations to experiences beyond HSS curricula (e.g., low-income background; work or volunteer experience; undergraduate studies; exposure to systems challenges affecting patients; supportive classmates, faculty, and institutional culture). Students also described future-oriented considerations promoting or undermining identification with systems-related roles (responsibility, affinity, ability, efficacy, priority, reality, consequences).This study illuminates systems-related roles medical students at 4 schools with HSS curricula envisioned as part of their future physician identity and highlights past/present experiences and future-oriented considerations shaping identification with such roles. These findings inform practical strategies to support professional identity formation inclusive of systems engagement.

BackgroundThe second Multicenter Medication Reconciliation Quality Improvement Study demonstrated a marked reduction in medication discrepancies per patient. The aim of the current analysis was to determine the association of patient exposure to each system-level intervention and receipt of each patient-level intervention on these results.MethodsThis study was conducted at 17 North American Hospitals, the study period was 18 months per site, and sites typically adopted interventions after 2–5 months of preintervention data collection. We conducted an on-treatment analysis (ie, an evaluation of outcomes based on patient exposure) of system-level interventions, both at the category level and at the individual component level, based on monthly surveys of implementation site leads at each site (response rate 65%). We then conducted a similar analysis of patient-level interventions, as determined by study pharmacist review of documented activities in the medical record. We analysed the association of each intervention on the adjusted number of medication discrepancies per patient in admission and discharge orders, based on a random sample of up to 22 patients per month per site, using mixed-effects Poisson regression with hospital site as a random effect. We then used a generalised linear mixed-effects model (GLMM) decision tree to determine which patient-level interventions explained the most variance in discrepancy rates.ResultsAmong 4947 patients, patient exposure to seven of the eight system-level component categories was associated with modest but significant reductions in discrepancy rates (adjusted rate ratios (ARR) 0.75–0.97), as were 15 of the 17 individual system-level intervention components, including hiring, reallocating and training personnel to take a best possible medication history (BPMH) and training personnel to perform discharge medication reconciliation and patient counselling. Receipt of five of seven patient-level interventions was independently associated with large reductions in discrepancy rates, including receipt of a BPMH in the emergency department (ED) by a trained clinician (ARR 0.40, 95% CI 0.37 to 0.43), admission medication reconciliation by a trained clinician (ARR 0.57, 95% CI 0.50 to 0.64) and discharge medication reconciliation by a trained clinician (ARR 0.64, 95% CI 0.57 to 0.73). In GLMM decision tree analyses, patients who received both a BPMH in the ED and discharge medication reconciliation by a trained clinician experienced the lowest discrepancy rates (0.08 per medication per patient).Conclusion and relevancePatient-level interventions most associated with reductions in discrepancies were receipt of a BPMH of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were associated with modest reduction in discrepancies for the average patient but are likely important to support patient-level interventions and may reach more patients. These findings can be used to help hospitals and health systems prioritise interventions to improve medication safety during care transitions.

In response to the COVID-19 pandemic, many medical schools suspended clinical clerkships and implemented newly adapted curricula to facilitate continued educational progress. While the implementation of these new curricula has been described, an understanding of the impact on student learning outcomes is lacking. In 2020, the authors followed Kern's 6-step approach to curricular development to create and evaluate a novel COVID-19 curriculum for medical students at the University of California San Francisco School of Medicine and evaluate its learning outcomes. The primary goal of the curriculum was to provide third- and fourth-year medical students an opportunity for workplace learning in the absence of clinical clerkships, specifically for students to develop clerkship-level milestones in the competency domains of practice-based learning and improvement, professionalism, and systems-based practice. The curriculum was designed to match students with faculty-mentored projects occurring primarily in virtual formats. A total of 126 students enrolled in the curriculum and completed a survey about their learning outcomes (100% response rate). Of 35 possible clerkship-level milestones, there were 12 milestones for which over half of students reported development, in competency domains including practice-based learning and improvement, professionalism, and interpersonal and communication skills. Thematic analysis of students' qualitative survey responses demonstrated 2 central motivations for participating in the curriculum: identity as physicians-in-training, and patient engagement. Six central learning areas were developed during the curriculum: interprofessional teamwork, community resources, technology in medicine, skill-building, quality improvement, and specialty-specific learning. This analysis demonstrates that students can develop competencies and achieve rich workplace learning through project-based experiential learning, even in virtual clinical workplaces. Furthermore, knowledge of community resources, technology in medicine, and quality improvement were developed through the curriculum more readily than in traditional clerkships, and could be considered as integral learning objectives in future curricular design.

In acute care settings hearing loss (HL) is associated with impaired patient-provider communication, increased length of stay, and increased mortality. COVID-19 has exacerbated this problem with the widespread use of masks and eye shields which muffle speech and prevent lip reading. Our 800-bed tertiary care medical center lacked a standardized approach to identify patients with HL and address communication barriers. Three first year medical students spearheaded the initiative as part of a health systems improvement curriculum with support from a faculty coach and a faculty researcher. From September 2020 to October 2021, the students met with stakeholders, leadership and champions and unit staff, identified the current state and completed a gap analysis through interviews, surveys, and direct observation. The pilot in May 2021 included two week-long PDSA cycles on one hospital unit to: 1) screen patients aged 65 and older using the validated 10-item HHIE-S questionnaire, 2) implement an education and awareness campaign with bedside signage, posters, and conferences and 3) provide a personal amplifier (purchased in bulk by the medical center) with verbal and written instructions. A total of 29 patients screened positive and were given personal amplifiers. Post-pilot interviews reported increased provider awareness and knowledge around best communication practices. Patients and staff reported limited amplifier use due to poor sound quality, small dials, poorly fitting ear buds and a short battery life. Based on these results the team recommended discontinuing the personal amplifiers and identifying other communication tools including higher quality personal amplifiers and speech to text applications.

PURPOSE: To estimate the effectiveness of a multimodal educational intervention to increase use of shared decision-making (SDM) behaviors by inpatient pediatric and internal medicine hospitalists and trainees at teaching hospitals at Stanford University and the University of California, San Francisco. METHOD: The 8-week Patient Engagement Project Study intervention, delivered at 4 services between November 2014 and January 2015, included workshops, campaign messaging, report cards, and coaching. For 12-week pre- and postintervention periods, clinician peers used the 9-point Rochester Participatory Decision-Making Scale (RPAD) to evaluate rounding teams’ SDM behaviors with patients during ward rounds. Eligible teams included a hospitalist and at least 1 trainee (resident, intern, medical student), in addition to nonphysicians. Random-effects models were used to estimate intervention effects based on RPAD scores that sum points on 9 SDM behaviors per patient encounter. RESULTS: In total, 527 patient encounters were scored during 175 rounds led by 49 hospitalists. Patient and team characteristics were similar across pre- and postintervention periods. Improvement was observed on all 9 SDM behaviors. Adjusted for the hierarchical study design and covariates, the mean RPAD score improvement was 1.68 points (95% CI, 1.33 to 2.03; P < .001; Cohen d = 0.82), with intervention effects ranging from 0.7 to 2.5 points per service. Improvements were associated with longer patient encounters and a higher percentage of trainees per team. CONCLUSIONS: The intervention increased behaviors supporting SDM during ward rounds on 4 independent services. The findings recommend use of clinician-focused interventions to promote SDM adoption in the inpatient setting.

BackgroundThe first Multicenter Medication Reconciliation Quality Improvement (QI) Study (MARQUIS1) demonstrated that mentored implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The objective of this study was to determine the effects of a refined toolkit on a larger group of hospitals.MethodsWe conducted a pragmatic quality improvement study (MARQUIS2) at 18 North American hospitals or hospital systems from 2016 to 2018. Incorporating lessons learnt from MARQUIS1, we implemented a refined toolkit, offering 17 system-level and 6 patient-level interventions. One of eight physician mentors coached each site via monthly calls and performed one to two site visits. The primary outcome was number of unintentional medication discrepancies in admission or discharge orders per patient. Time series analysis used multivariable Poisson regression.ResultsA total of 4947 patients were sampled, including 1229 patients preimplementation and 3718 patients postimplementation. Both the number of system-level interventions adopted per site and the proportion of patients receiving patient-level interventions increased over time. During the intervention, patients experienced a steady decline in their medication discrepancy rate from 2.85 discrepancies per patient to 0.98 discrepancies per patient. An interrupted time series analysis of the 17 sites with sufficient data for analysis showed the intervention was associated with a 5% relative decrease in discrepancies per month over baseline temporal trends (adjusted incidence rate ratio: 0.95, 95% CI 0.93 to 0.97, pConclusionA multicentre medication reconciliation QI initiative using mentored implementation of a refined best practices toolkit, including patient-level and system-level interventions, was associated with a substantial decrease in unintentional medication discrepancies over time. Future efforts should focus on sustainability and spread.

BackgroundThe first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1.MethodsMARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site’s local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient.DiscussionA mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform.We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.

BACKGROUND: Shared decision-making (SDM) improves patient engagement and may improve outpatient health outcomes. Little is known about inpatient SDM. OBJECTIVE: To assess overall quality, provider behaviors, and contextual predictors of SDM during inpatient rounds on medicine and pediatrics hospitalist services. DESIGN: A 12-week, cross-sectional, single-blinded observational study of team SDM behaviors during rounds, followed by semistructured patient interviews. SETTING: Two large quaternary care academic medical centers. PARTICIPANTS: Thirty-five inpatient teams (18 medicine, 17 pediatrics) and 254 unique patient encounters (117 medicine, 137 pediatrics). INTERVENTION: Observational study. MEASUREMENTS: We used a 9-item Rochester Participatory Decision-Making Scale (RPAD) measured team-level SDM behaviors. Same-day interviews using a modified RPAD assessed patient perceptions of SDM. RESULTS: Characteristics associated with increased SDM in the multivariate analysis included the following: service, patient gender, timing of rounds during patient’s hospital stay, and amount of time rounding per patient (P < .05). The most frequently observed behaviors across all services included explaining the clinical issue and matching medical language to the patient’s level of understanding. The least frequently observed behaviors included checking understanding of the patient’s point of view, examining barriers to follow-through, and asking if the patient has any questions. Patients and guardians had substantially higher ratings for SDM quality compared to peer observers (7.2 vs 4.4 out of 9). CONCLUSIONS: Important opportunities exist to improve inpatient SDM. Team size, number of learners, patient census, and type of decision being made did not affect SDM, suggesting that even large, busy services can perform SDM if properly trained.

Patient engagement through shared decision-making (SDM) is increasingly seen as a key component for patient safety, patient satisfaction, and quality of care. Current SDM models do not adequately account for medical and environmental contexts, which may influence medical decisions in the hospital. We identified leading SDM models and reviews to inductively construct a novel SDM model appropriate for the inpatient setting. A team of medicine and pediatric hospitalists reviewed the literature to integrate core SDM concepts and processes and iteratively constructed a synthesized draft model. We then solicited broad SDM expert feedback on the draft model for validation and further refinement. The SDM 3 Circle Model identifies 3 core categories of variables that dynamically interact within an "environmental frame." The resulting Venn diagram includes overlapping circles for (1) patient/family, (2) provider/team, and (3) medical context. The environmental frame includes all external, contextual factors that may influence any of the 3 circles. Existing multistep SDM process models were then rearticulated and contextualized to illustrate how a shared decision might be made. The SDM 3 Circle Model accounts for important environmental and contextual characteristics that vary across settings. The visual emphasis generated by each "circle" and by the environmental frame direct attention to often overlooked interactive forces and has the potential to more precisely define, promote, and improve SDM. This model provides a framework to develop interventions to improve quality and patient safety through SDM and patient engagement for hospitalists.

Background Adverse drug events (ADEs) are a major cause of morbidity in hospitalised and ambulatory patients. Computerised provider order entry (CPOE) combined with clinical decision support systems (CDSS) are being widely implemented with the goal of preventing ADEs, but the effectiveness of these systems remains unclear. Methods We searched the specialised database Agency for Healthcare Research and Quality (AHRQ) Patient Safety Net to identify reviews of the effect of CPOE combined with CDSS on ADE rates in inpatient and outpatient settings. We included systematic and narrative reviews published since 2008 and controlled clinical trials published since 2012. Results We included five systematic reviews, one narrative review and two controlled trials. The existing literature consists mostly of studies of homegrown systems conducted in the inpatient setting. CPOE+CDSS was consistently reported to reduce prescribing errors, but does not appear to prevent clinical ADEs in either the inpatient or outpatient setting. Implementation of CPOE+CDSS profoundly changes staff workflow, and often leads to unintended consequences and new safety issues (such as alert fatigue) which limit the system's safety effects. Conclusions CPOE+CDSS does not appear to reliably prevent clinical ADEs. Despite more widespread implementation over the past decade, it remains a work in progress.

Background: Overutilization of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU) is common. Acid-suppressive therapies routinely used for SUP are best reserved for patients with greatest risk of clinically important bleeding as they have been associated with nosocomial pneumonia, Clostridium difficile infection and increased hospital cost. Objective: The primary objective was to reduce inappropriate utilization of SUP in 2 adult medical and surgical ICU settings at the University of California, San Francisco Medical Center. Secondary objectives included reduction of inappropriate continuation of SUP at ICU and hospital discharge. Methods: To attain the study objective, an interprofessional team developed a bundled quality improvement initiative, including an institution SUP guideline, pharmacist-led intervention, and an education and awareness campaign. To assess the impact of these interventions, we conducted a retrospective cohort study comparing data on prescribing practices at baseline before and after the intervention. Since computerized prescriber order entry (CPOE) was implemented during this time frame, preintervention data collection consisted of 2 periods, one before and one after CPOE implementation. Results: The incidence of the inappropriate use of SUP was not significantly different between the pre-CPOE and post-CPOE groups (20 and 19 per 100 patient-days, respectively; P = .88), but the incidence of inappropriate use of SUP was significantly lower in the postintervention group versus the post-CPOE group (9 and 19 per 100 patient-days, respectively; P = .03). At ICU discharge, 4% of patients in the post-intervention group were discharged inappropriately on SUP compared with 8% in the post-CPOE group ( P = .54). At hospital discharge, none of the patients in the postintervention group were discharged inappropriately on SUP compared with 7% in the post-CPOE group ( P = .22). Conclusions: Implementation of an interprofessional bundled quality improvement initiative is effective in decreasing inappropriate use of SUP in adult medical and surgical ICUs at a university-affiliated, tertiary care academic medical center.

Stress ulcer prophylaxis (SUP) with acid suppressive therapy is often inappropriately prescribed in the intensive care setting. Acid suppressive therapy, including proton pump inhibitors and histamine-2 receptor antagonists, has been associated with adverse effects, including increased risk of nosocomial infections. Reduction in the rate of inappropriate use of SUP may mitigate the risk of medication adverse effects and unnecessary health care costs. Our interdisciplinary team executed a bundled quality improvement initiative to reduce inappropriate use of SUP in the ICU, which included ( a) developing evidence-based clinical practice guidelines for use of SUP, ( b) implementing these clinical guidelines with an education intervention targeting ICU health care providers, and ( c) determining provider attitudes regarding SUP use before and after implementation of the bundled initiative. Within 1 month following implementation, inappropriate SUP (per patient hospital day) decreased from 19% to 6.6% ( P = .002). Our multidisciplinary bundled quality improvement initiative reduced inappropriate use of SUP. The program was successfully integrated into the pharmacists’ workflow, thus yielding a sustainable impact on SUP use.

Introduction Interprofessional (IP) collaboration is key in caring for older adults and a critical part of health professions education. Falls are a source of significant morbidity and mortality in older adults. GeriWard, an innovative curriculum, emphasizes IP collaboration during a clinical encounter with a hospitalized older adult. GeriWard Falls expands on the existing GeriWard curriculum, allowing medical, pharmacy, physical therapy, and nursing students to conduct a comprehensive falls risk evaluation at the bedside. Methods The 2-hour exercise consists of participation in a team-based falls risk assessment at the bedside of a hospitalized older adult, development of a falls care plan and communication with the patient and primary inpatient physicians, and completion of clinical questions focused on systems-based interventions to reduce fall risk. Results A total of 39 students participated in two sessions. Ninety-seven percent of students were likely to change their clinical activities as a result of the session. Faculty facilitators cited the students' ability to effectively collaborate, identify risk factors for falls, and propose systems-based interventions to reduce falls risk. Seventy-eight percent of primary inpatient physicians planned to implement at least one of the IP team recommendations; 89% agreed that the IP team recommendations were helpful. Discussion The activity was engaging for students and helped them achieve competency with fall risk assessment. Communication of the students' assessment to the primary medical team not only was useful to the primary team but also helped students understand how systems can affect patient care.

The curriculum consists of an interactive 120-minute workshop used to train faculty on how to best incorporate social and behavioral science (SBS) constructs at the bedside to improve clinical care and teaching. During this workshop, participants collectively identify, rank, and apply SBS clinical pearls to two role-played scenarios derived from clinical inpatient ward round encounters. This publication includes all materials needed to implement the workshop including: a facilitator's guide, workshop slides, a script for each role play scenario, workshop evaluation form, and a handout for participants. This workshop was delivered to internal medicine and pediatric hospitalist groups at the University of California, San Francisco (UCSF) in June of 2012 and Stanford University School of Medicine in September of 2012. This workshop was later presented at the Association of American Medical Colleges Annual Conference in San Francisco, California in November of 2012. While the latter two groups were not evaluated, workshop participants at UCSF were surveyed. Participants (N = 8) rated the overall quality of the workshop an average of 4.43 (SD = 0.79) on a 5-point Likert scale (1 = Poor 5 = Excellent). The quality of teaching, usefulness of written materials, and likelihood that changes will be made in the participants' teaching/professional practices as a result of this CME workshop had mean ratings of 4.38 (SD = 1.06), 4.13 (SD = 0.99), and 4.25 (SD = 1.04), respectively. In retrospect, administering more evaluations would have provided additional insight into the strengths and weaknesses of this curriculum. Regardless, our results indicate that the overall quality of the workshop remains high. The “quality of written materials” received the lowest marks but have since been improved upon. Teaching quality varies by instructor and, based on our experience, generally improves with each additional workshop. Ultimately, the evaluation results indicate that there is great potential for this curriculum to impact change in everyday clinical practices.

Hospitals are challenged with reevaluating their hospital’s transitional care practices, to reduce 30-day readmission rates, prevent adverse events, and ensure a safe transition of patients from hospital to home. Despite the increasing attention to transitional care, there are few published studies that have shown significant reductions in readmission rates, particularly for patients with stroke and other neurologic diagnoses. Successful hospital-initiated transitional care programs include a “bridging” strategy with both predischarge and postdischarge interventions and dedicated transitions provider involved at multiple points in time. Although multicomponent strategies including patient engagement, use of a dedicated transition provider, and facilitation of communication with outpatient providers require time and resources, there is evidence that neurohospitalists can implement a transitional care program with the aim of improving patient safety across the continuum of care.

Purpose To quantify the prevalence of social and behavioral sciences (SBS) topics during patient care and to rate team response to these topics once introduced. Method This cross-sectional study used five independent raters to observe 80 inpatient ward teams on internal medicine and pediatric services during attending rounds at two academic hospitals over a five-month period. Patient-level primary outcomes— prevalence of SBS topic discussions and rate of positive responses to discussions—were captured using an observational tool and summarized at the team level using hierarchical models. Teams were scored on patient- and learner-centered behaviors. Results Observations were made of 80 attendings, 83 residents, 75 interns, 78 medical students, and 113 allied health providers. Teams saw a median of 8.0 patients per round (collectively, 622 patients), and 97.1% had at least one SBS topic arise (mean = 5.3 topics per patient). Common topics were pain (62%), nutrition (53%), social support (52%), and resources (39%). After adjusting for team characteristics, the number of discussion topics raised varied significantly among the four services and was associated with greater patient-centeredness. When topics were raised, 38% of teams’ responses were positive. Services varied with respect to learner- and patientcenteredness, with most services above average for learner-centered, and below average for patient-centered behaviors. Conclusions Of 30 SBS topics tracked, some were addressed commonly and others rarely. Multivariable analyses suggest that medium-sized teams can address SBS concerns by increasing time per patient and consistently adopting patientcentered behaviors.

The 39 kDa receptor-associated protein (RAP) is a receptor antagonist that interacts with several members of the low density lipoprotein (LDL) receptor gene family. Upon binding to these receptors, RAP inhibits all ligand interactions with the receptors. Our recent studies have demonstrated that RAP is an endoplasmic reticulum (ER) resident protein and an intracellular chaperone for the LDL receptor-related protein (LRP). The HNEL sequence at the carboxyl terminus of RAP represents a novel ER retention signal that shares homology with the well-characterized KDEL signal. In the present study, using immunoelectron microscopy we demonstrate that cells stably transfected with human growth hormone (GH) tagged with either KDEL (GH + KDEL) or HNEL (GH + HNEL) signals exhibit ER and cis-Golgi localization typical of ER-retained proteins. Overexpression of not only GH + HNEL but also GH + KDEL cDNA in transfected cells results in saturation of ER retention receptors and secretion of endogenous RAP indicating that the two signals interact with the same ER retention receptor(s). The role of RAP in the maturation of LRP is further supported by the observation that functional LRP is reduced about 60% as a result of decreased intracellular RAP. Pulse-chase labeling and immunolocalization studies of ERD2.1 and ERD2.2 proteins in transfected cells demonstrate a long half-life and Golgi localization for both receptors. Finally, overexpression of either ERD2.1 or ERD2.2 proteins significantly increases the capacity of cells to retain both KDEL and HNEL-containing proteins. Taken together, our results thus demonstrate that ERD2 proteins are capable of retaining the novel ER retention signal associated with RAP.

Introduction This resource is an interprofessional team-based curriculum for health professions students on systems-based practice and care of the hospitalized older adult. The overarching goal of the curriculum is to provide skills, knowledge, and a team-based experience that ensures graduating students are able to approach the care of older adults in the hospital from a systems-based perspective. Methods This resource contains a 2.5-hour learning exercise where students are exposed to an interprofessional model that is central to patient care. Students actively engage in the learning process by presenting the patient case back to their peers and faculty supervisors. Results This resource was piloted from June through November 2010 in six separate 2-hour workshops. All participating students showed improvement in attitudes toward interprofessional education pre- and postcurriculum. Students rated knowledge and self-efficacy on the competencies higher after participating in the curriculum. After the program, 88% of participants felt confident identifying indications for bladder catheters and risk factors for pressure ulcers, compared to only 60% before the curriculum. Using a 5-point Likert scale, over 90% of students agreed that they learned skills they would apply to future patient care. Discussion These direct experiences can increase students' self-assessed ability to care for hospitalized older adults within a team dynamic, and address how systems issues can directly affect patient care.

The 39-kDa receptor-associated protein (RAP) is a receptor antagonist that inhibits ligand interactions with the receptors that belong to the low density lipoprotein receptor gene family. Our previous studies have demonstrated that RAP interacts with the low density lipoprotein receptor-related protein (LRP) within the endoplasmic reticulum and prevents premature interaction of ligands with the receptor. To analyze whether RAP is also involved in the folding of LRP during receptor biosynthesis, we generated anchor-free, soluble minireceptors that represent each of the four putative ligand-binding domains of LRP (SLRP1, -2, -3, and -4, corresponding to the clusters with 2, 8, 10, and 11 cysteine-rich complement-type repeats, respectively). When these SLRPs were overexpressed by cell transfection, only SLRP1 was secreted. Little or no secretion was observed for SLRP2, -3, and -4. However, when RAP cDNA was cotransfected with SLRP2, -3, and -4 cDNAs, each of these SLRPs was secreted. The cellular retention of SLRPs in the absence of RAP coexpression appeared to be a result of the formation of SDS-resistant, oligomeric aggregates observed under nonreducing conditions. Such oligomers of the SLRPs likely resulted from formation of intermolecular disulfide bonds since they were reduced to monomers when analyzed under reducing conditions. The oligomers were formed not only among molecules of a given SLRP, but also between different SLRPs. The role of RAP in the process of LRP folding was shown by the reduction in aggregated SLRP oligomers upon RAP coexpression. A similar role of RAP in preventing the aggregation of newly synthesized receptor was also observed using membrane-containing minireceptor of LRP. Coimmunoprecipitation and ligand binding studies demonstrated that RAP binds avidly to SLRP2, -3, and -4, but not to SLRP1. These results suggest that these interactions may be important for proper folding of LRP by ensuring the formation of proper intradomain, but not intermolecular or interdomain, disulfide bonds. Thus, our results strongly suggest that, in addition to the prevention of premature binding of ligands to LRP, RAP also plays an important role in receptor folding.

P w t v t u t p d i c Adverse events after hospital discharge are common and often preventable, representing a vulnerable time for patients. Hospitals are challenged to provide patients with a communication safety net postdischarge compared with ambulatory practices. Dedicated transitional care programs have tried to address this gap, focusing on specific diagnoses or selected high-risk populations, such as older adults. However, adoption of communication strategies targeting all discharged patients is still lacking despite its potential to prevent adverse events and reduce readmissions.

The 39-kDa receptor-associated protein (RAP) is a specialized chaperone for members of the low density lipoprotein receptor gene family, which also binds heparin. Previous studies have identified a triplicate repeat sequence within RAP that appears to exhibit differential functions. Here we generated a series of truncated and site-directed RAP mutants in order to define the sites within RAP that are important for interacting with heparin and low density lipoprotein receptor-related protein (LRP). We found that high affinity binding of RAP to heparin is mediated by the carboxyl-terminal repeat of RAP, whereas both the carboxyl-terminal repeat and a combination of amino and central repeats exhibit high affinity binding to LRP. Several motifs were found to mediate the binding of RAP to heparin, and each contained a cluster of basic amino acids; among them, an intact R(282)VSR(285)SR(287)EK(289) motif is required for high affinity binding of RAP to heparin, whereas two other motifs, R(203)LR(205)R(206) and R(314)ISR(317)AR(319), also contribute to this interaction. We also found that intact motifs of both R(203)LR(205)R(206) and R(282)VSR(285)SR(287)EK(289) are required for high affinity binding of RAP to LRP, with the third motif, R(314)ISR(317)AR(319), contributing little to RAP-LRP interaction. We conclude that electrostatic interactions likely contribute significantly in the binding of RAP to both heparin and LRP and that high affinity interaction with both heparin and LRP appears to require mostly overlapping sequence motifs within RAP.

Hospitals now have the responsibility to implement strategies to prevent adverse outcomes after discharge. This systematic review addressed the effectiveness of hospital-initiated care transition strategies aimed at preventing clinical adverse events (AEs), emergency department (ED) visits, and readmissions after discharge in general medical patients. MEDLINE, CINAHL, EMBASE, and Cochrane Database of Clinical Trials (January 1990 to September 2012) were searched, and 47 controlled studies of fair methodological quality were identified. Forty-six studies reported readmission rates, 26 reported ED visit rates, and 9 reported AE rates. A "bridging" strategy (incorporating both predischarge and postdischarge interventions) with a dedicated transition provider reduced readmission or ED visit rates in 10 studies, but the overall strength of evidence for this strategy was low. Because of scant evidence, no conclusions could be reached on methods to prevent postdischarge AEs. Most studies did not report intervention context, implementation, or cost. The strategies hospitals should implement to improve patient safety at hospital discharge remain unclear.