Description: In 2008, the established program of shared medical visits (SMV) to increase self management skills in diabetes care was expanded. Both faculty and residents completed a training module and then participated in a SMV for diabetes, osteoarthritis or one developed by the individual resident.

Methods: Residents completed attitude surveys prior to training module and after participating in SMV which evaluated 3 domains; physician attitudes, perceived barriers, and the perceived impact on chronic diseases..

Results:

Conclusions: Gaining experience with SMVs improves residents’ perception of this effective intervention.

References:

Nasca, T. Open letter to the GME Community http://www.acgme.org/acWebsite/home/NascaLetterCommunity10_27_09.pdf

IOM report on duty hours Dec 2, 2008

Greenwich

Conclusion: There is correlation between CVC simulation training in Internal Medicine residents and reduction in CVC related complications.

Additional Interventions/Future directions: More measures, direct observation, direct chart audits and possible “procedure focus” for selected residents starting in 2009-2010.

Background: In 2003, the Accreditation Council for Graduate Medical Education implemented common duty hour standards. The standards were created to optimize resident learning, resident well-being, and patient safety. Since then, the ACGME has aggressively enforced the standards and monitored compliance through site visits, review of program data, confidential resident surveys, and interviews with residents. In December of 2008, the Institute of Medicine released their report from the Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. Based on its review, the committee recommended adjustments to the 2003 rules given considerable scientific evidence that 30 hours of continuous time awake, can result in fatigue. However, all stakeholders agree that it is also necessary to look beyond hours of work alone and to put into place practices, including time for sufficient sleep, enhanced supervision, and appropriate workload.

Program Characteristics:

2 hospitals- Banner Good Samaritan Medical Center + Phoenix VA

670 vs VA•Situation: Housestaff are exhausted and not able to optimally learn when they work >24 hours at a time.•Background:

–Prior night float attempts were unsuccessful –Success with staggered call for Good Sam Ward seniors–Can’t add more ward months –VA interns have a large volume of cross cover calls that interrupt admissions

•Assessment: We need to find a way to maximize continuity and patient ownership with optimal scheduling.

•5 ward teams instead of 6 “call” q 5•1 Ward team senior: only stays overnight if Friday or Sat call, no clinic •2 Ward team interns: alternate between early and late call and do their admissions only•Nightfloat: The old 6th team

–Resident NF: 1 per month does Sunday-Thursday every week–Intern cross-cover NF: 2 divide all the nights of the month and provide all of the cross cover

RRC-Internal Medicine Educational Innovations Project:

Work Intensity and reduced shift duration: Unexpected ‘Competing Goods”: Closing in on Moving Targets

Banner Good Samaritan Medical Center/Phoenix VA Medical Center Internal Medicine Residency Program, Phoenix, ArizonaCheryl W. O’Malley MD, KeriLyn Gwisdalla MD, Chris Kurtz, MD and Ruth Franks, MD

The objective of this project are to allow our program to integrate the culture of quality improvement and patient safety (both major components of patient-centered care) into the curriculum of our program. Through innovative design we plan to make this culture an integral part of residency education and future practice for our graduates. Through education and evaluation of residents and measurement of their clinical outcomes, the strengths of GME can be exported to the entire hospital.

Overall Project Outcomes: Graduates participate in quality initiatives and patient safety projects as part of their daily practice. This improves patient care now and in the future.

Description:

In the United States, 5 million central venous lines are placed per year and 15% develop mechanical, infectious or thrombotic complications.

Resident training in placement of central venous catheters has been enhanced through the use of one day courses in the simulation center at the start of ICU months. They complete pre-course preparation, engage in hands-on proctored practice with didactics covering complications, errors and prevention. This is followed by a video recorded performance of the procedure which is evaluated by faculty and written test.

Program requirement addressed: I.A.2.j.2009 The sponsoring institution and participating sites must provide residents with access to training using simulation;

Methods: We compared complications by Internal Medicine residents during the years prior to simulation training with those in the year following training. We also compared the number of complications over time at the teaching facility to those rates of attending physicians at a “sister” facility with no simulation training.

Results:

Central Line Complications: BGSMC Residents Complications in 2008 compared to 2006

  2006 2007 2008 BGSMC residents Control institution

DVT distal leg 27 21 10 63% reduction 150% increase

Iatrogenic Pneumothorax 24 3 2 92% reduction No Change

Air Embol Comp Med Care 5 3 0 100% reduction No change

Retroperitoneal hemorrhage 5 4 0 100% reduction 100% reduction

Mechanical complications 4 0 2 50% reduction 50% increase

Infection and inflammatory reaction due to vascular device, implant

76 72 13 83% reduction 26% reduction

Total 141 103 14 90% reduction 2.4% increase

Pre-participation Post-participation

Physician Attitudes

Resource allocation 70% agreed 90% agreed

Would improve patients’ health 80% agreed 100% agreed

Perceived Barriers

Patient interest 30% agreed 100% agreed

Efficient use of physician time 20% agreed 60% agreed

Perceived Impact on Chronic Diseases

50% would voluntarily do another SMV

100 % felt they could make a positive impact in patients with chronic diseases before

and after participating

Mon 1 Tue 2 Wed 3 Thu 4 Fri 5 Sat 6 Sun 7WR OR RR BR GR WR NF-RNF a NF a NF a NF b NF b NF b NF b

WR call WR post WR 1 WR 2 WR 3 WR call WR postWI A call L WI A post* WI A 1 WI A 2 off 1 WI A call E WI A postWI B call E WI B post WI B 1 off 1 WI B 3# WI B call L WI B post*

OR 3 OR call OR post OR 1 OR 2 off 1 OR callOI A 3 OI A call L OI A post* OI A 1 off 1 OI A 3 OI A call Eoff 1 OI B call E OI B post OI B 1 OI B 2 OI B 3# OI B call L

RR 2 RR 3 RR call RR post RR 1 off 1 RR 3RI A 2 RI A 3 RI A call L RI A post* RI A 1 RI A 2 off 1RI B 2 off 1 RI B call E RI B post RI B 1 RI B 2 RI B 3

BR 1 BR 2 BR 3 BR call BR post off 1 BR 2BI A 1 BI A 2 off 1 BI A call L BI A post* BI A 1 BI A 2BI B 1 BI B 2 BI B 3 BI B call E BI B post BI B 1 off 1

GR post GR 1 GR 3 GR 3 GR call GR post off 1GI A post GI A 1 GI A 2 off 1 GI A call E GI A post GI A 1GI B post GI B 1 off 1 GI B 3# GI B call L GI B post* GI B 1

Monday Tues Wed Thursday Friday Saturday Sunday1 2 3 4 5 6 7

BR 1 BR 2 BR 3 BR call BR post off 1 BR 2BI A 1 BI A 2 off 1 BI A call L BI A post* BI A 1 BI A 2BI B 1 BI B 2 BI B 3 BI B call E BI B post BI B 1 off 1

8 9 10 11 12 13 14BR 3 BR call BR post BR 1 BR 2 off 2 BR calloff 2 BI A call E BI A post BI A 1 BI A 2 BI A 3# BI A call LBI B 3# BI B call L BI B post* BI B 1 off 2 BI B 3 BI B call E

15 16 17 18 19 20 21BR post BR 1 BR 2 BR 3 BR c BR post off 3BI A post* BI A 1 BI A 2 off 3 BI A call E BI A post BI A 1BI B post BI B 1 off 3 BI B 3# BI B call L BI B post BI B 1

22 23 24 25 26 27 28BR 2 BR 3 BR call BR post BR 1 off 4 BR 3BI A 2 BI A 3# BI A call L BI A post* BI A 1 BI A-2 off 4BI B 2 off 4 BI B call E BI B post BI B 1 BI B 2 BI B 3#

1 2 3 4 5 6 7BR call BR post BR 1 BR 2BI A call E BI A post BI A 1 BI A 2BI B call L BI B post* BI B 1 BI B 2

NF team is on from 7pm-8amE: early call. Admissions from 12-7pmL: late call. Admissions from 7pm-7ampost: full day (i.e. 7am-5pm)post*: leave by 10-11 am#: 24 consecutive hours off