QI Quarterly. In the Journal. Safety First. Kudos: Resident experience. Stop & Resolve when questions arise. Validate and verify.

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1 QI Quarterly 1 In the Journal Creighton Quality Improvement: Internal Medicine The Delivery of true early mobilization March 2017 in an [Edition 1, Volume 1] intensive care unit. Willigen et al. BMJ Qual Improv Report Background: Early mobilization in the ICU has been shown to improve outcomes for patients. Objective: This QI project considered providing two additional daily sessions of mobility therapy in combination with minimal sedation when possible. Setting: University Hospital Southampton Foundation with a mixed medical and surgical ICU with 1600 patients admitted annually Design/Intervention: Baseline data was collected from January to March Improvement cycle 1 completed in March An education program was introduced for all ICU physical therapy, nursing and medical staff. This program included one-to-one bedside teaching, single discipline and multidiscipline group sessions, and demonstration using YouTube videos. Improvement cycle 2 was completed in March In order to re-engage the team, the existing education program was introduced on a rolling basis due to the high turnover of rotational staff on GICU. Additional educational cards were provided for the Richmond Agitation and Sedation Score (RASS) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) to assess patients for readiness. Daily, weekly and monthly multidisciplinary meetings were established to re-inforce the early mobilization program. Results: Results suggested a reduction in time to first mobilization for intensive care survivors from 16.3 days in 2012, to 4.3 days at the end of improvement cycle 2. This was associated with a decrease in mean intensive care length of stay from 20.8 days in 2012, to 11.2 days at the end of improvement cycle 2. Limitations: Lack of blinding of the study team. Data was collected over 3 months annually, without considering results from the other 9 months. Learning points: - QI model: 4 E s: Engage, Educate, Execute and Evaluate - Create a team, understand the problem, enlist relevant stake holders, and create change - Multidisciplinary involvement is key to success of the project Article Link: Safety First Stop & Resolve when questions arise. Validate and verify. Have a questioning attitude: I will think it through Kudos: To the following QI projects for being IRB approved: Dr. Urja et al: Echo use Dr. Buddam et al: HCC screening Dr. Nayfeh et al: Pna readmissions Dr. Ratnaraj et al: IPASS handoff Dr. Breen et al: Stroke management Dr. Bardeloza et al: Family conferences Dr. Alghoula et al: ICU handoff Dr. Norris et al: Telemetry use Dr. Macaraeg et al: Oxygen transport Dr. Fowler et al: Sepsis order set Dr. Alshebani et al: HIV screening Dr. Gupta et al: COPD readmission Dr. Anugula et al: aldosterone/mi Dr. Onaiwu et al: CLABSI Dr. Millner et al: Daily Labs Dr. Buaisha et al: PPI use, VA Resident experience Hamza Rayes also worked on a similar project at the VA. He noticed that ICU patients were rarely mobilized in the ICU and that had detrimental effects on the length of stay and readmissions. He planned to make a protocol to be followed by nurses to ensure patients were mobilized within 48 hours of admission. He denies experiencing any Dr. Bhatty et al: Daily Weights, VA roadblocks, in fact the nurses and techs were very helpful. He notes that more contribution from other team members are needed.

2 CHI Living Our Mission (LOM) Goal Catheter Associated Urinary Tract Infection Background: Within three days of insertion of the urinary catheter, a biofilm can form to protect the bacterial organisms. Urine samples obtained from these catheters may contain this biofilm, resulting in overidentification of a positive urine culture and a CAUTI. Assessment: Implementing the new CHI Health policy will result in more accurate diagnosis of patients and reduce costs and unnecessary antibiotics. Recommendation: Beginning immediately, the use of urine cultures should 1) Be limited to special circumstances stated in the policy, and should 2) Be obtained from a catheter placed within the past 72 hours. If necessary, the nurse should replace the catheter before taking the specimen. Teasers (Answers are on page 4) 1) What does PDSA stand for? 2) What does ARCC stand for? Andukuri Avenue Dear Colleagues, As physicians, we take an oath to first do no harm! So, safety should be innately built into everything we do. Increasingly, our patients expect us not only to provide safe care, but also to provide effective and highvalue care with better access. Given the current national debate on how to do all the above, we as a health care system and professionals need to further educate ourselves on improving the health care for the population we serve and their needs in a cogent way. Accreditation Council of Graduate Medical Education (ACGME) and Clinical Learning Environment Review (CLER) are requiring residency programs to integrate quality into their curriculum to develop future physicians who would apply these principles in their practice thereby providing high quality and high value care. At Creighton University based on our Jesuit values and the outstanding support and direction from GME and the department of Internal Medicine we started a journey with the following goals: To teach the key principles of patient safety, systems thinking and quality improvement (QI) principles & methodology to all our trainees To develop a culture of safety, quality and teamwork which will help our trainees to carry the skills onto their careers To prepare physicians in training to be stewards of safe, high quality, high value, and patient centered care To develop future leaders in quality and safety and health care innovation Towards this journey, in the last several months, we have started integrating quality and safety into our curriculum. The initial steps were to develop a structure and provide residents with resources for both data and QI experts. In the meanwhile, we started with didactics and encouraging QI projects for all residents. Furthermore, we also started to incorporate selfpaced IHI learning modules and started to incorporate residents into hospital safety, quality and CHI Living Our Mission (LOM) committees. There has been ongoing support for all the QI projects, their implementation and methodology. This new QI quarterly publication is our attempt to further encourage learner involvement in scholarly activity and to provide latest journal articles and ideas for QI research. Hope you will like it! 2 Sincerely, Giri Andukuri, MD

3 M&M to go Date Topic Action Item Status Jan Escalation of care. I have a concern. Use ARCC. If no response after 2 pages, escalate your concern of the chain of command: Supervising resident, fellow, attending in the same division, Program director or Dr. Fox. Jan Amion Attending names and numbers on Amion. In progress Jan Neurosurgery Dr. Patil agrees with attending to attending hand off In progress Feb Renal Consults Dr. Aaronson agrees all after hour consults warrant a chart check, discussion with attending on call and progress note. Feb Neurosurgery Working on ideas of alerting HMS of admission of comanaged patients. Feb Feb Respiratory therapy Alerting HMS teams to arrival of transfers Save the Date Spirometry lab is currently closed. Bedside spirometry can be done by RT with advanced notification. Oxygen assessment requires a functional pulse oximeter that comes in different modalities. Night float pagers will be carried by a member of the HMS teams and hand off to night float team. 4/1/17 Abstract submission for High Value Health Care National Research Symposium 4/26/17 Department of Medicine QI symposium 5/19/17 GME QI symposium Quality Improvement during Ambulatory block In progress In Progress We are piloting some changes for the QI portion during the ambulatory experience. In an effort to standardize, improve, and utilize the dedicated time we have made the following changes. Residents will be encouraged to use this time to get oriented to the Institute for healthcare Improvement (IHI). The IHI modules lay the groundwork for QI & Patient safety, giving them the basic tools to succeed with their projects. They will have the opportunity to attend patient safety and quality meetings, facilitate M & M conferences and most of all, to take an active role in advancing their QI projects. Chief s Corner The Telluride Patient Safety summer camp was an eye-opening experience. We were a collection of residents in a variety of specialties across the county who came together for a common purpose, patient safety. The experience set the foundation for the year to come as we looked to forge ahead and take quality improvement to the next level at Creighton. The Culture of Safety we have at Creighton is fantastic and it comes from the top down, but how do we improve? As partners in healthcare we feed off each other and by collaborating we can achieve more. Quality improvement sets the groundwork for our continued success. By working together in a multidisciplinary fashion the ultimate winner is the patient. Transporting hospitalized patients with oxygen needs has been an area of interest for me. How long does the oxygen tank last? Where do I find out? I had no idea, and I am sure I was not the only one. I decided to survey hospital personnel this very question, and I was surprised to know that less than a quarter surveyed had an idea. After some literature search our team could identify an intervention that we hoped would improve a process that occurs daily in every hospital in the world. We are still in the process of data collection, but preliminary feedback is encouraging. - Jeff Macaraeg

4 4 Magis Clinic Interview with Stephanie Windish, MD, PGY III Internal Medicine 1) Why do you work at Magis Clinic? We work with the underserved population in a hospital setting. I wanted to continue that work in a primary care and preventive role. 2) What do you find rewarding volunteering at Magis Clinic? I love working with medical students just starting their medical career. Helping them shape and learn to care for vulnerable patients. 3) What have you learned in your time at the Magis Clinic? I learned and continue to learn how to work with limited resources and how to be flexible in that environment. 4) If you could change anything about Magis Clinic, what would it be? It would be great to have more openings for clinic. There is a long waiting list for medical students to volunteer at Magis. 5) What advice would you give other residents about Magis Clinic? It s an amazing experience where get to teach medical students and help improve the care of patients we commonly see in a hospital setting. Teasers Answers (from page 2) 1) PDSA stands for Plan, Do, Study, Act. a. It is an effective tool that allows for small tests of change in the work place in real time. Carrying out the test allows us to observe the results and determine what modifications are needed to improve the plan. 2) ARCC stands for Ask a question, Request a change, voice a Concern, invoke Chain of command. This safety behavior allows us to check and coach team members and improving patient safety. Creighton Internal Medicine GME QI/PS Physician Lead & IM QI Champion, Dr. Giri Andukuri Division Director of Risk Management, Laura Peet Erkes Internal Medicine Program Director Dr. Erica Cichowski QI/Patient Safety Chief Resident 2016/17, Dr. Jeff Macaraeg CMO & Assistant Dean for QI/PS, Dr. Devin Fox QI/Patient Safety Chief Resident 2017/18, Dr. Vritti Gupta Questions/Feedback/Contact IMQI@Creighton.edu Website: CreightonIM.com

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