ED Knows MONA

Team Members: Tonya Thompson, MD

Kim Nelson Becky Liggins, MD

Taylor Bagwell, MD Kris Saunders, RPh

Kristen Campbell, RN Beth Storm, MD

Mentor: CJ Richards

Background

Residents have little experience and low comfort in treating adults

ACH ED in 2014:• 262 patients over the age of 21 were

seen • 68 of those had cardiac related

complaints.

Noon Mock Code

• Adult Chest Pain Case - February to June 2015• Comfort/Worry assessment before and after each course• Knowledge-based quiz before and after each course• Checklist evaluation by faculty based on ACLS protocols• Key elements including MONA pulled for closer examination

M – MorphineO – OxygenN – NitratesA – Aspirin

Project Aim

Increase the ACH Residents’ confidence in ACLS protocols for adult patients with chest pain in the ED by 25% by June 10, 2015.

Measurements

Outcome Measures:• ACH Residents’ confidence in ACLS

protocols for adult patients with chest pain

Process Measures:• Pre and post comfort/worry assessment • Facilitator checklist• MONA sub-checklist

ED Knows MONA

Project Aim Key Drivers/ Processes

Design Changes

SMART Aim : Increase the ACH Residents’ confidence in ACLS protocols for adult patients with chest pain in the ED by 25% by June 10, 2015.

Resident and Faculty Buy-in

Consistent teaching amongst Fellows compared to MDs with ACLS experience.

Consistent attendance of Nursing and Pharmacy

Identification of key elements in the ACLS protocol that are critical in proper patient care

Meeting with Faculty and Residents to emphasize importance of initiative. Sending repeated emails to faculty requesting participation and personal verbal invitations in staff meetings. Review teaching points and objectives with Fellows or have Tonya/Becky teach course.Met with Kris Saunders and Kristen Campbell to insure we have participation. We send faculty to recruit nurses. Kris is scheduling pharmacists. Review checklist details including key MONA elements and modify to support important teaching elements.

Measure: • Confidence level based on pre and post confidence assessments

Pre/Post Confidence & Knowledge1. Today’s Date

2. I am a Med/Peds resident (circle one):

Other: ___________________________________________________________

3. Did you read the teaching guide? No Yes

1= Not Confident at All 2= Somewhat Confident 3= Confident4= Very Confident

1Not

Confident At All

2Somewh

at Confide

nt

3Confide

nt

4Very

Confident

4. I am confident I can perform an assessment on an adult with chest pain

5. I am confident I can administer medications at the correct dosages to an adult patient with chest pain

6. I am confident I can perform proper CPR on an adult

7. I am confident I can recognize a STEMI in an adult patient

8. I am confident I can correctly defibrillate an adult patient

9. I am confident I can treat an adult chest pain patient without causing harm

10.

I am confident I can give timely and proper information to the adult receiving facility for an adult patient with a STEMI

11.

How far do you depress the chest in Adult CPR (insert answer in the box to the right)?

12.

What is the initial energy voltage set for an adult patient with unstable Ventricular Tachycardia (insert answer in the box to the right)?

13.

What is the target O2 saturation for an adult chest pain patient after a return of spontaneous circulation?

14.

Name a medication specific contraindication to giving nitrates in adult chest pain patients.

15.

What drug is indicated for shock resistant VT in adults

41% Average increase in knowledge from pre to post

34% Average increase in confidence from pre to post Assessment

Confidence Scale by Date

3-Feb-15 3-Mar-15 17-Mar-15 26-Mar-15 21-Apr-15 30-Apr-15 5-May-15 19-May-15 28-May-15 2-Jun-150.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

2.18

2.61

1.75 2.25 2.05

1.711.86

1.90

2.502.46

2.57

3.25

2.68

2.963.05

2.29

2.61

2.64

3.50

3.00

Average Pre and Post Comfort/Worry Assessment

Pre Assessment Post Assessment Median

Feb 3:2 Pharmacy2 Nurses5 Res/ 0 were Med/PedsNo cognitive aids

March 3:0 Pharmacy0 Nurses5 Res/2 were Med/PedsNo cognitive aids

March 17:0 Pharmacy3 Nurses5 Res/ 1 was Med/PedsUsed cognitive aids

March 26:0 Pharmacy2 Nurses4 Res/ 0 were Med/PedsUsed drug sheet

April 21:3 Pharmacy0 Nurses3 Res/ 2 were Med/PedsUsed cognitive aids(first run since death of co-resident with cardiac complications)

April 30:1 Pharmacy2 Nurses4 Res/ 0 were Med/PedsUsed cognitive aids

May 5:3 Pharmacy0 Nurses4 Res/0 were Med/PedsUsed cognitive aids

May 19:1 Pharmacy0 Nurses6 Res/1 was Med/PedsUsed cognitive aids

May 28:1 Pharmacy5 Nurses2 Res/0 were Med/PedsUsed cognitive aids

June 2:2 Pharmacy0 Nurses4 Res/1 was Med/PedsUsed cognitive aids

Average Pre and Post Confidence Scale

1 - Not Confident at all2 - Somewhat Confident3 – Confident 4 - Very Confident.

I am confident I can perform an assessment on an adult with chest pain

I am confident I can administer medications at the correct dosages to an adult patient with chest pain

I am confident I can perform proper CPR on an adult

I am confident I can recognize a STEMI in an adult patient

I am confident I can correctly defibrillate an adult patient

I am confident I can treat an adult chest pain patient without causing harm

I am confident I can give complete and proper information to the adult receiving facility for an adult patient with a STEMI

0 0.5 1 1.5 2 2.5 3 3.5

Average Pre and Post Confidence level

Post Pre

Pre vs Post Knowledge

0%

20%

40%

60%

80%

100%

120%

49%41% 43%

64%

47%

74%

91% 92% 96% 94%

Knowledge based questions

Averages Pre Correct Averages Post Correct % Increase

There was an average 41% increase in the post test

Complete Checklist

2 = Done Well1 = Attempted0 = Not DoneThese scores are averaged from the completed checklists

3-Feb

3-Mar

17-Mar

26-Mar

21-Apr

30-Apr

5-May

19-May

28-May

2-Jun

1.21

1.411.47

1.34

1.67

1.551.48 1.48

1.64

1.48

Complete Checklist Average Score

2 = Done Well☺1 Ο = Attempted0 Ø = Not DoneThese scores are averaged from the completed checklists

Performance Key Checklist ScoresPlace on supplemental O2 (4 L+)Brief targeted Hx, ask about last

use of CialisOrder stat EKG (within 5 min of

arrival)Give ASA 160-325 mg (within 5

min of arrival)If no Cialis use- give SL NTG

(400mcg) x3 5 min apartGive Morphine 2-4mg IVNotify Adult Facility/Prepare for

transport (within 3 min of obtaining EKG)

Recognize Unstable VT

Provide good quality CPR immediately -30:2 (within 1 minute of arrest)

Shock at maximum voltage circle one (120- 200J or 360J) (within 3 minutes of arrest)

3-Feb 3-Mar 17-Mar 26-Mar 21-Apr 30-Apr 5-May 19-May 28-May 2-Jun0

0.5

1

1.5

2

2.5

1.61.7

1.9

1.71.6

1.8 1.8 1.8

2 2

Key Checklist Items Averaged

AveragesMedian

2 = Done Well1 = Attempted0 = Not DoneThese scores are averaged from the completed checklists

Interventions• First run confusion: confidence scale changes• Encouraging use of cognitive aids• Time frames on key items– CPR within 1 minute– Notify adult facility within 3 minutes

• Course cancellations– Weather– Colleague death

• Confidence dip

Barriers and Lessons Learned

• Hawthorne effect May 19• Cognitive aids March 17 • One or two facilitators• Subjective checklist• Meditech notes

Next Steps• Follow-up course October &

January• Adult stroke case• 3-year rotation• Analyze patient data

And The Beat Goes On…