scholarly journals Creation of a dedicated line team for critically ill patients with COVID-19: A multidisciplinary approach to maximize resource utilization during the COVID-19 pandemic

2021 ◽  
pp. 112972982199175
Author(s):  
Pooja Nawathe ◽  
Robert Wong ◽  
Gabriel Pollock ◽  
Jack Green ◽  
Michael Kissen ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Resource Utilization ◽  
Vascular Access ◽  
Medical Center ◽  
Academic Medical Center ◽  
Target Population ◽  
Primary Data ◽  
Arterial Line ◽  
Central Venous ◽  
Development Organization

Background: Pandemics create challenges for medical centers, which call for innovative adaptations to care for patients during the unusually high census, to distribute stress and work hours among providers, to reduce the likelihood of transmission to health care workers, and to maximize resource utilization. Methods: We describe a multidisciplinary vascular access team’s development to improve frontline providers’ workflow by placing central venous and arterial catheters. Herein we describe the development, organization, and processes resulting in the rapid formation and deployment of this team, reporting on notable clinical issues encountered, which might serve as a basis for future quality improvement and investigation. We describe a retrospective, single-center descriptive study in a large, quaternary academic medical center in a major city. The COVID-19 vascular access team included physicians with specialized experience in placing invasive catheters and whose usual clinical schedule had been lessened through deferment of elective cases. The target population included patients with confirmed or suspected COVID-19 in the medical ICU (MICU) needing invasive catheter placement. The line team placed all invasive catheters on patients in the MICU with suspected or confirmed COVID-19. Results and conclusions: Primary data collected were the number and type of catheters placed, time of team member exposure to potentially infected patients, and any complications over the first three weeks. Secondary outcomes pertained to workflow enhancement and quality improvement. 145 invasive catheters were placed on 67 patients. Of these 67 patients, 90% received arterial catheters, 64% central venous catheters, and 25% hemodialysis catheters. None of the central venous catheterizations or hemodialysis catheters were associated with early complications. Arterial line malfunction due to thrombosis was the most frequent complication. Division of labor through specialized expert procedural teams is feasible during a pandemic and offloads frontline providers while potentially conferring safety benefits.

scholarly journals A Quality Improvement Project to Reduce Unnecessary Use of Multilumen PICCs

2020 ◽  
Vol 41 (S1) ◽  
pp. s101-s102
Author(s):  
Jennifer Kleinman-Sween ◽  
Angela Lowrie ◽  
Jane Kirmse ◽  
Priya Sampathkumar
Keyword(s):  
Quality Improvement ◽  
Decision Support ◽  
Vascular Access ◽  
Medical Center ◽  
Academic Medical Center ◽  
Clinical Decision ◽  
Quality Improvement Effort ◽  
Improvement Project ◽  
Single Lumen ◽  
Lumen Catheter

Background: Peripherally inserted central catheters (PICCs) are an increasingly common vascular access device. At our institution, >4,000 devices are placed per year by a trained team of vascular access nurses. Although PICCs are generally safe and effective, they do carry the risk of infection and thrombosis, and this risk increases exponentially with increasing number of lumens. As part of a multidisciplinary quality improvement effort to address rising CLABSI rates, we designed interventions to improve PICC utilization. Methods: The project team used 6-σ methodology, specifically following the DMAIC (define, measure, analyze, implement, control) framework to guide analysis and interventions. Process mapping, semistructured interviews with key stakeholders, electronic surveys, and audits were performed to identify gaps and inform interventions. The interventions consisted of 3 components: changes to the electronic ordering system, education (presentations to ordering providers and an online toolkit), and clinical decision support in the form of a team of vascular-access subject-matter experts who provided guidance on line selection. Results: In total, 4,655 PICCs and 434 midlines were inserted in the 12 months before the intervention, and 7,457 PICCs and 929 midlines were placed in the 24 months after the intervention. Following the implementation of the intervention, proportions of triple-lumen catheter utilization decreased from 31.9% to 22.3% (P < .0001). Concurrently, the proportion of single-lumen catheters has increased from 28.5% to 41.9% (P < .0001). Overall PICC utilization decreased in the postintervention period from an average of 387.9 PICCs placed per month to 310.7. The proportion of midline catheters increased from 8.5% of total lines inserted to 11.4% in the postintervention period (P < .001). Conclusions: Our intervention reduced overall PICC use and triple-lumen PICC use and increased relative utilization of single-lumen PICCs and midline catheters. Optimization of electronic orders, in conjunction with targeted education and decision support, can have a sustained impact on provider ordering behaviors and can shift the culture of utilization, even in a large academic medical center with frequent turnover of trainees.Funding: NoneDisclosures: Consulting fee- Merck (Priya Sampathkumar)

scholarly journals Impact of Critical Care Consultation Requests for Avoidable Central Venous Catheters on Medical-Surgical Units

2020 ◽  
Vol 41 (S1) ◽  
pp. s258-s258
Author(s):  
Madhuri Tirumandas ◽  
Theresa Madaline ◽  
Gregory David Weston ◽  
Ruchika Jain ◽  
Jamie Figueredo
Keyword(s):  
Critical Care ◽  
High Risk ◽  
Medical Center ◽  
Academic Medical Center ◽  
Retrospective Chart Review ◽  
Bloodstream Infections ◽  
Central Line ◽  
Central Venous Catheters ◽  
High Risk Population ◽  
Central Venous

Background: Although central-line–associated bloodstream infections (CLABSI) in US hospitals have improved in the last decade, ~30,100 CLABSIs occur annually.1,2 Central venous catheters (CVC) carry a high risk of infections and should be limited to appropriate clinical indications.6,7 Montefiore Medical Center, a large, urban, academic medical center in the Bronx, serves a high-risk population with multiple comobidities.8–11 Despite this, the critical care medicine (CCM) team is often consulted to place a CVC when a peripheral intravenous line (PIV) cannot be obtained by nurses or primary providers. We evaluated the volume of CCM consultation requests for avoidable CVCs and related CLABSIs. Methods: Retrospective chart review was performed for patients with CCM consultation requests for CVC placement between July and October 2019. The indication for CVC, type of catheter inserted or recommended, and NHSN data were used to identify CLABSIs. CVCs were considered avoidable if a PIV was used for the stated indication and duration of therapy, with no anatomical contraindications to PIV in nonemergencies, according to the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).6Results: Of 229 total CCM consults, 4 (18%) requests were for CVC placement; 21 consultations (9%) were requested for avoidable CVCs. Of 40 CVC requests, 18 (45%) resulted in CVC placement by the CCM team, 4 (10%) were deferred for nonurgent PICC by interventional radiology, and 18 (45%) were deferred in favor of PIV or no IV. Indications for CVC insertion included emergent chemotherapy (n = 8, 44%) and dialysis (n = 3, 16%), vasopressors (n = 3, 16%), antibiotics (n = 2, 11%) and blood transfusion (n = 2, 11%). Of 18 CVCs, 9 (50%) were potentially avoidable: 2 short-term antibiotics and rest for nonemergent indications; 2 blood transfusions, 1 dialysis, 2 chemotherapy and 2 vasopressors. Between July and October 2019, 6 CLABSIs occurred in CVCs placed by the CCM team; in 3 of 6 CLABSI events (50%), the CVC was avoidable. Conclusions: More than half of consultation requests to the CCM team for CVCs are avoidable, and they disproportionately contribute to CLABSI events. Alternatives for intravenous access could potentially avoid 9% of CCM consultations and 50% of CLABSIs in CCM-inserted CVCs on medical-surgical wards.Funding: NoneDisclosures: None

scholarly journals An innovative resident-driven mortality case review curriculum to teach and drive system-based practice improvements in the United States

2018 ◽  
Vol 15 ◽  
pp. 31
Author(s):  
Nila S. Radhakrishnan ◽  
Margaret C. Lo ◽  
Rohit Bishnoi ◽  
Subhankar Samal ◽  
Robert Leverence ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Systems Of Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
The United States ◽  
Case Review ◽  
Failure To Rescue ◽  
Internal Medicine Residents ◽  
Mortality Case

Purpose: Traditionally, the morbidity and mortality conference (M&MC) is a forum where possible medical errors are discussed. Although M&MCs can facilitate identification of opportunities for systemwide improvements, few studies have described their use for this purpose, particularly in residency training programs. This paper describes the use of M&MC case review as a quality improvement activity that teaches system-based practice and can engage residents in improving systems of care. Methods: Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2014 to September 2017. The residents used case review worksheets to categorize and track causes of mortality, and then debriefed with a faculty member. Selected cases were then presented at a larger interdepartmental meeting and action items were implemented. Descriptive statistics and thematic analysis were used to analyze the results. Results: The residents identified a possible diagnostic mismatch at some point from admission to death in 54.5% of cases (n= 189) and a possible need for improved management in 48.0% of cases. Three possible management failure themes were identified, including failure to plan, failure to communicate, and failure to rescue, which accounted for 21.9%, 10.7 %, and 10.1% of cases, respectively. Following these reviews, quality improvement initiatives proposed by residents led to system-based changes. Conclusion: A resident-driven mortality review curriculum can lead to improvements in systems of care. This novel type of curriculum can be used to teach system-based practice. The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.

Behavioral Health Resource Utilization of Emergency Department Patients Presenting from Mass Gathering Events

2019 ◽  
Vol 34 (s1) ◽  
pp. s105-s106
Author(s):  
Charles Hebert ◽  
Gary Peksa ◽  
Joshua DeMott
Keyword(s):  
Mental Health ◽  
Emergency Department ◽  
Behavioral Health ◽  
Resource Utilization ◽  
Medical Center ◽  
Academic Medical Center ◽  
Mood Stabilizers ◽  
Health Staff ◽  
Mass Gathering ◽  
Physical Restraints

Introduction:Behavioral health needs of attendees at mass gathering events who require emergency department (ED) evaluation are poorly understood. Appropriate resource allocation of mental health staff and other behavioral interventions necessary to support this patient population are also unclear.Aim:To describe behavioral characteristics and psychiatric resource utilization of patients presenting to a tertiary academic medical center emergency department from mass gathering events.Methods:Single-center retrospective study evaluating attendees at mass gathering events who presented to a Chicago ED. Electronic medical records for patients presenting between October 13, 2013, and December 31, 2015, were reviewed and descriptive analyses performed.Results:209 distinct records were reviewed. Most patients presented from large outdoor concerts (n = 186, 89%). Forty-two (20.1%) reported a mental health complaint at presentation, including concerns related to pre-existing psychiatric disturbances or onset of new symptoms. Twenty-seven of the total cohort (12.9%) endorsed a prior psychiatric history. Thirty-five (16.7%) reported use of prescribed psychotropic medications, including antidepressants, stimulants, mood stabilizers, and others. Diagnostic testing among the total sample included serum ethanol measurement (31.1%), urinary toxicology (25.4%), acetaminophen (6.2%), aspirin (5.3%), and creatine kinase measurements (11%). Computed brain tomography was ordered for 20 patients (9.6%). Twelve patients (5.7%) received an anxiolytic (lorazepam) and 113 (54.1%) received intravenous fluids. An antipsychotic (olanzapine) was administered to one patient (0.5%). There were no reports of suicidal ideation, but physical restraints for agitation were employed in 13 patients (6.2%). Police consultation occurred in 10 cases (4.8%). No formal psychiatric consultations were requested by ED providers.Discussion:Patients presenting to the emergency department from mass gathering events frequently endorse behavioral complaints requiring directed use of diagnostic and other emergency department resources for their ailments. The need for physical restraints and limited use of anxiolytics and antipsychotics in our sample suggest that psychiatric consultation is underutilized.

Factors associated with physician attitude and management of financial toxicity.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18300-e18300
Author(s):  
Katrina Fischer ◽  
Anne Margaret Walling ◽  
John A. Glaspy
Keyword(s):  
Quality Improvement ◽  
Medical Center ◽  
Point Of Care ◽  
Insurance Coverage ◽  
Academic Medical Center ◽  
Financial Stress ◽  
Care Practice ◽  
Financial Toxicity ◽  
Perceived Knowledge ◽  
Financial Issues

e18300 Background: Little is known about the attitudes and knowledge of oncologists who discuss financial toxicity with patients compared with those who do not. We assessed perceptions of the oncologists’ role in discussing out of pocket (OOP) costs and financial stress (FS) to inform quality improvement strategies in the management of financial toxicity. Methods: We surveyed 45 practicing medical oncologists at a large academic medical center in 2019 using Likert scale responses. Questions covered three domains; self-perceived knowledge of financial issues related to care, practice of cost discussions with patients, and perceived ability to navigate toward solutions related to FS. Results: Fifty-three percent of oncologists felt comfortable discussing OOP costs, but only 42.5% discussed FS with patients. Over half (55%) lacked confidence they could help patients experiencing FS from treatment. These providers were less likely to ask about FS than those who were confident (r0.416, p0.004). Perceived knowledge among many was low: 48% felt they had little to no knowledge of OOP treatment costs, 33-37% had little to no understanding of how private or public insurance covers treatment respectively, and 60% reported low knowledge of point of care (POC) resources. Those who ask patients about FS reported higher perceived knowledge of insurance (public r0.47, p < 0.001, private r0.452, p 0.002) and POC resources (r0.392, p 0.007), but not more knowledge of OOP cost. Three factors were associated with increased confidence in the ability to help patients; higher knowledge of POC resources (r 0.379, p 0.01); having changed a treatment because of cost within the past year (r 0.395, p 0.047), and years in practice (r 0.329, p 0.047). Conclusions: Many oncologists lack confidence that they can help patients with financial issues, particularly early on in their career. Providers who lack confidence that they can help their patients appear less likely to ask patients about financial stress. Those who do ask about financial stress report higher self-perceived knowledge of insurance coverage and POC resources. This suggests that quality improvement efforts aimed at improving education and resources for providers to help navigate financial toxicity are needed.

A multicentered academic medical center experience of a simulated root cause analysis (RCA) for hematology/oncology fellows.

2020 ◽  
Vol 38 (29_suppl) ◽  
pp. 188-188
Author(s):  
Danielle Wallace ◽  
Denise Cochran ◽  
Jennifer Michelle Duff ◽  
Julia Lee Close ◽  
Martina Cathryn Murphy ◽  
...  
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
Medical Center ◽  
Academic Medical Center ◽  
Near Miss ◽  
Safety Skills ◽  
Clinical Patient ◽  
Root Cause ◽  
Event Flow ◽  
Flow Map

188 Background: Quality improvement and patient safety education is an Accreditation Council for Graduate Medical Education (ACGME) common program requirement for hematology/oncology fellowships. Specifically, the ACGME requires trainee participation in interprofessional clinical patient safety activities, such as root cause analyses. These can be challenging to incorporate into busy schedules and are intimidating to some trainees, but simulated RCAs are a novel way to assure trainees gain important patient safety skills. We report on a multicentered experience utilizing a simulated RCA educational module in an attempt to provide fellows with the tools needed to participate in a live RCA and to increase awareness of the need to analyze patient safety events. Methods: The two-hour module included a didactic session explaining the basics of an RCA including common terminology, effective chart review, and personal interviews. The fellows assessed a patient safety event of a missed coagulopathy and created an event flow map and fishbone analysis. They then formed root cause/contributing factor statements and proposed a solution. Seventeen fellows from two institutions completed pre- and post-session surveys regarding the experience. Results: There was a 47% increase in both the percentage of fellows who felt comfortable participating in live RCAs in the future, and in the number of fellows who felt comfortable with using the tools typically utilized in an RCA. 70.59% of respondents felt that as a result of the mock RCA, they were more likely to report a near miss or adverse event. Conclusions: Mock RCAs are a feasible method of incorporating ACGME-required patient safety activities into hematology/oncology fellow education and are effective in increasing their comfort and understanding of important quality improvement skills

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