Older PBLI Projects
The following is a summary of the Practice Based Learning Projects and improvement (PBLI) conducted by the residents during the period July 2009 – June 2010.
PROJECT 1
Anticoagulation management in an Internal Medicine outpatient clinic.
Mahvish Muzaffar MD PGY 2
Leonard White, MD PGY 3
The purpose of the study is to evaluate Coumadin management in internal medicine resident clinic. The following end points were looked at 1) complications 2) efficacy of monitoring, 3) implementation of guidelines and 4) patient education.
PATIENTS
Forty five patients were identified as being on Coumadin monitoring list of internal medicine outpatient clinic. The average age of patients was 60.1 years, male: 19/45 (42.2%), females: 26/45 (57.8%), two patents had longest documented intake of Coumadin for 8 years
The most common indications were: DVT and PE combination in 20/45(45%) patients. A fib/A-flutter in 9/45 (20%), DVT only in 7/45 patients (15.5%) PE only in 9/45 (20%), 9/45 patients also had some form of hypercoagulable state.
Progress notes, hospitalization records discharge summaries were evaluated for Coumadin related complication and hospitalization.
Results: 10/45 patients had hospitalization related to Coumadin complication (3/10 GI bleed, 2/10 subtherapeutic INR and new thrombus, 5/10 supratherapeutic INR)
HOW CAN WE IMPROVE / Recommendations
Follow evidence based guideline
Use Coumadin flow sheet
Improve documentation of patient flow sheets
Review indication, plan and goals periodically
Patient education, education and education
Evaluate for complication
PROJECT 2
Residents involvement in the curriculum development
Dr. Kiranmayee Lanka, PGY 3
Dr. Amjad shidyak, PGY 3
Sources
Pub Med, MKSAP 15, Up to date, ACCP, AHA, NEJM
Objectives
Provide direction and motivation for future learning, including knowledge, skills and professionalism.
Protect the public by upholding high professional standards and screening out trainees and physicians who are incompetent.
Meet public expectations of self- regulation
Choose among applicants for advanced training.
From above the need for fundamental redesign of medical training is clear and in some instances the road is also clear, but it is not an easy task. The challenge is not only defining the appropriate content but also incorporating it into the curriculum in a manner that emphasizes its importance relative to traditional biomedical content and then finding and preparing faculty to teach this revised curriculum.
PROJECT 3
Frequent Readmissions to UTMC
Usman Ahmad, MD PGY 3
Hemlata Bhaskar, MD PGY 2
A study from Medicare data for beneficiaries discharged in 2003-2004 revealed:
One of Five patients were readmitted.
Estimated cost: 17.4 billion
Potentially Preventable Readmissions are defined as return hospitalizations that may result from deficiencies in the process of care and treatment or lack of post discharge follow-up 76% of re-hospitalizations were preventable. 14 - 46 % were assessed as "potentially avoidable" in retrospective clinician reviews
Research and quality improvement initiatives have demonstrated reduction of30-day readmission rate Clear indication that there is room for improvement
Retrospective Study Design
Review the number of patients readmitted 2 or more times within 30 days of discharge between the defined window. The 30 Day readmission window for discharges beginning August 1, 2009 and ending November 1, 2009. All Internal Medicine Services were included in the study.
Data retrieved from billing information at UTM C for the defined period of time.
Objectives
Fadi Safi, PGY 2
Objective
Rate of self extubation in our MICU and compare it with the national average.
Method
Retrospectively over 6 months period between August-January 2009/2010 charts reviewed of MICU admission for patients with Self-Extubation / Accidental Extubation
Define the size of the problem at UTMC
Identify the most common diagnosis at UTMC for readmission
Identify the patient demographic (age, gender, form of insurance)
Analyze the cost burden of the problem at UTMC
Propose recommendations adapted to the UTMC health system to address the problem
174 Medicine service patients were readmitted within the study period
Total cost $16,724,991 , Totaling 2,496 days. The longest readmission was 24 days
Average length of stay on readmission was 2 days.
Strategies to Reduce Re-hospitalizations
Medication reconciliation, Personal health record, Physician appointment scheduled within 7 days of discharge (visit within 2 weeks), Patient emergency plan, Transition coaching.
PROJECT 4
ANALYSIS OF QUALITY OF RESIDENT DICTATIONS
Analysis of discharge summary dictations and compare to standard.
Objectives
List common mistakes done by majority of residents.
Suggestions to improve the quality of dictations by recognizing the common mistakes.
We analyzed randomly 100 dictations done by 9 interns.
The second year residents and third year residents were not included in the study.
The softmedia software was used to analyze the dictations with the help of IT department.
The first principal diagnosis was used as the primary diagnosis and the other principal diagnoses were not included.
Results
Primary diagnosis: 100 percent
Secondary diagnosis: 100 percent
Procedures: 46 Percent
Hospital Course: 100 percent
Discharge Medications: 100 percent
Condition at Discharge: 90 percent
Discharge Disposition: 90 percent
Discharge Instructions: 90 percent
Out of 10 patients with CHF only one dictation mentioned the ejection fraction in the list of principal diagnosis and in other six dictations it was mentioned in the hospital course.
Two out of 10 patients had diastolic heart failure and it was only listed as CHF without mentioning its diastolic nature. One out of eight systolic heart failure patients did not have ACE inhibitor in the discharge medication list where the patients EF was 10 percent.
None of the pneumonia listed in the diagnosis was categorized as community acquired or hospital acquired. It was observed that the residents dictation improved with time. It was more organized, and did not miss things in the subsequent dictations.
PROJECT 5
IMAGING STUDIES FOR VENOUS THROMBOEMBOLIC DISEASE –
Is there any other safer method?
Dr Jacob PGY 3
Dr Rkaine PGY 2
REASERCH QUESTION… When used by our residents, Well's criteria is a very good tool for risk stratification for PE.
Retrospective study
55 records with D-dimer positive test results were reviewed
All these patients had either CTA, V/Q or Doppler positive results
Risk stratification thru wells criteria was done by the investigators, by chart review.
RESIDENT DIAGNOSIS
It was observed that thou indicated in 10% of patients who had high probability for PE, anticoagulation therapy was not started.
It was also observed that increasing D- dimer value correlates very well with new incidence of thromboembolism.
Residents are hesitant to use CTPA in renal disease patients.
Screening, Management and Adult Vaccinations –
How are we doing?
Asma Taj PGY 2
Jagannath Saikumar PGY 3
Objectives
Management of Hypertension
Screening for Cancer
Vaccination of adult population
"How much are we doing and how well are we doing?"
Study Methodology
Chart review of patients in GIM clinic
The patient seen by the same resident for at least 3 consecutive visits in 1 year
2-3 patients per resident
HTN
The measures taken according to the BP recordings noted by going through the dictations and the progress notes in the chart:
- Screening for complications in poorly controlled HTN
- Increasing or decreasing the dose of anti-hypertensive meds
- Adding 2nd or 3rd medication to the hypertensive regimen
- Are all patients with DM on ACE- inhibitors or ARBs; if not, why (documentation in chart/dictation)?
Cancer Screening
- Screening done or started on time at appropriate age
- Follow-up and discussion of results
- Documentation if not done
Females: Mammogram, Pap smear, Sigmoidoscopy/Colonoscopy
Males: PSA, Sigmoidoscopy/Colonoscopy
Immunization
- Tetanus
- Influenza
- Pneumonia
- Appropriate age and population offered and given
- Complications from vaccinations noted?
- Documentation if refused/not given
No of patients per year of training
Compliance with JN C 7 guidelines for HTN + Diabetes
Drugs for different stages
Documentation of stages during initial diagnosis
Cancer screening and adult vaccination - Appropriate age of screening
Regular follow-up with patient
Vaccination guidelines for target population
PROJECT 6
Unplanned Extubation in the Intensive Care Unit.
Abd Alkarim abu Malouh PGY 3
Fadi Safi, PGY 2
Objective
Rate of self extubation in our MICU and compare it with the national average.
Method
Retrospectively over 6 months period between August-January 200912010 charts reviewed of MICU admission for patients with Self Extubation/Accidental Extubation
Express the rate as number of extubations per 100 intubation days
Focus on risk factors mainly Admitting Diagnosis, Agitation/Sedation, Number of patients and staff, Nursing overtime within unit, Breathing trial, Timing and Event and Restraints
- Agitation is one of the well-documented risk factors and several study reported that self extubation occurred more in patients who were less sedated
- Conflicting results in the literature regarding the use of restraints to prevent unplanned extubation
- Tominaga et al found more self extubation when the use of restrains was limited to meet (JCAHO) Standards
- Patient Characteristics with self extubation.
PROJECT 7
Standardizing Vasopressor doses in Shock
Rifat Hassan PGY 3
Rehana Qadir PGY 3
The aim of this study was to determine how frequently the safe dosing (mcg/kg/min) of the Vasoactive medications are being utilized in various hospitals. This was a prospective study in which information collected was from various institutions about the methods of administration of vasoactive medications.
A search was performed and the top ranking hospitals of the US were identified.
Next the ICU staff and/or the pharmacists of these hospitals were contacted either by a telephone or by an email. The information about the protocols of their ICUs (if any), medications administration methods and dose titration was collected from each hospital which agreed to provide the required information. Some of the hospitals had the ICU protocols available on their websites.
A search about these protocols and any available literature was also performed with the help of our pharmacist and a librarian.
Results
Out of 35 hospitals contacted only 19 hospitals responded either by email (N=10), or via telephone call (N=5). Eleven hospitals were using the dose calculated as mcg/kg/ min for epinephrine, norepinephrine and phenylepinephrine. Seven hospitals reported use of the dose calculated from mcg/ min for epinephrine, norepinephrine and phenylepinephrine.
One center reported dosing varied from patient to patient. Eighteen hospital were using vasopressin in Units/min and dopamine as mcg/kg/ min. Most of the hospitals do not follow the standard protocols for the administration of vasopressors.
PROJECTS 8
QTc interval changes during Therapeutic Hypothermia
Aijaz Sofi PGY 2
Khaled Abuhantash PGY 3
We attempted to investigate the effects of therapeutic hypothermia (TH) on QT-interval and to investigate if this QT-prolongation is clinically relevant with regards to the incidence of cardiac arrhythmias directly resulting from TH.
Methods:
We reviewed all the patient charts who were admitted in Intensive Care Unit (ICU) following a cardiac arrest between 03/12/2009 until 04/08/2010. We further divided this patient population into 2 groups- those who received TH and those who did not. We compared the QT-prolongation on admission in the two groups. Then we measured the effects of hypothermia on QT-interval in the TH-group. We further compared the incidence of arrhythmias in the patient group who underwent therapeutic hypothermia with those who did not. Some of the variables taken into consideration were- medications which can prolong QT-interval and previous h/o- prolonged QT-interval. Pearson's co-relation was used for the QT-interval and core-temperature.
Results:
A total of 37 patients (18 females and 19 males) were admitted to ICU between 03/12/2009 until 04/08/2010 following a cardiac arrest. Of these, 26 patients received TH and 12 patients did not receive TH.1n the TH group, 21 (70.2%) patients died during the TH. Seven patients (29.2%) survived. Mean QTc interval in TH group before the initiation of TH was 402.92 msec and in non-TH group was 443 msec. Mean QTc interval during hypothermia was 538.37 msec. Paired t-test for QT interval between patients who survived and those who died was not significant (p-0.09). Pearson's correlation for QTc interval with the core temperature was available for one patient and there was negative co-relation between the two variables (fig-I).
Discussion:
TH has been found to be beneficial in preventing neurological damage in patients who survive cardiac arrest. However, hypothermia is associated with numerous arrhythmogenic and electrophysiological effects on heart. These include: l. Atrial fibrillation with slow ventricular rate; 2. Bradycardias, including junctional rhythm and asystole; 3. Prolongation of PR, QRS and QTc intervals; 4. Osborn (J)-waves; 5. Premature ventricular complexes (PVC), VT and ventricular fibrillation (VF); 6. Serum hypokalemia and hypomagnesaemia.
Mean QTc interval in both TH group and non-TH group was similar prior to induction of hypothermia. QTc-interval during TH was prolonged in TH group by 33.8 %. This is important as there has been reported cases of Torsades de pointes3 and idioventricular rhythm 5 during prolongation of QTc secondary to TH. Even though, TH is recommended both by International Liaison Committee on Resuscitation (ILCOR) 2 and European Resuscitation Committee (ERC), there are no guidelines on ECG monitoring during hypothermia. In addition, treatment of VT or VF secondary to hypothermia might not be straightforward. The commonly used anti-arrhythmic drug, amiodarone can produce QTc-prolongation and can cause torsades de pointes 6, therefore its use can potentiate QT prolongation during hypothermia. More data is required to determine the safety of various anti-arrhythmic for VT /VF during TH.
The drawbacks with our study were:
- There were no frequent EKG recordings;
- Time of re-warming was not always charted;
- Some pts had support withdrawn per family.