Quality Initiatives: Physician Leadership in the Emergency Department

On the CUSP: Stopping CAUTI at the Front DoorNJHA – August 15, 2013

Quality Initiatives: Physician Leadership in the Emergency Department

David J. Adinaro MD, MAEd, FACEPPresident, NJ-ACEPChief, Adult Emergency Department, SJRMCEM Residency Research Director, SJRMC

Disclosures

I have nothing to report in terms of financial disclosures.

My opinions are myown.

Biases

I believe That I have the best job in the

world That I work with the best

people in the best profession That we do noble work

Biases

I believe That I have the best job in the

world That I work with the best

people in the best profession That we do noble work That we can do better

» ED Physicians role in preventing CAUTI

» Identify the opportunities to change physician behavior

» Importance of collaboration in ED to change systems and cultures

Objectives

» Where the work is done and errors are made\discovered

» Real time decisions based on available information

» Last line of defense in error prevention

» In healthcare made up of doctors, nurses, techs

The Sharp End

» Distal to the sharp (work end)

» Often remote from real time decisions but contribute to the care given and errors made

» ED Exec, Hospital Administration, State regulations, National Policies

The Blunt End

Reason’s Model of Normal Accidents

Patient developsCAUTI

Lack of institutional policyor goal

Foley need not reevaluated on floor

Family requests

ED physician orders

Admitting physician does not address

» ED Physician Role in Preventing CAUTI

Preventing CAUTI at the Front Door

• In theory placement of a foley catheter needs a physician order.

• Good evidence based indications for placement


–KT (Knowledge Translation) Approach• Lack of knowledge about consequences• Lack of consequence• Prior training• Lack of alternatives

–Systems approach• This is how we do it• Changing the easiest pathway


• Great summary article from a respected elder of emergency medicine

• http://www.epmonthly.com/columns/in-my-opinion/rick-bukata-the-high-cost-of-convenience-caths/


http://www.epmonthly.com/columns/in-my-opinion/rick-bukata-the-high-cost-of-convenience-caths/





• Also reviewed the inappropriate indications for catheter placement:• Incontinence (without additional indication)• Diuresis• Frequent, nonessential measurement of UOP• Nurse’s concern about patient discomfort• Diarrhea (without additional indication)• Patient’s preference



“Small Wins” Approach Academic detailing\Physician Champion Group responsibility

Monthly or quarterly data Trend Foleys and infections

Individual responsibility Audit and feedback Inclusion in yearly reviews


• Small Wins – produce change without confronting the system directly or aggressively.

• Impact is from examples they provide others.»Through doing something tangible.»Through showing change is possible.

Preventing CAUTI at the Front Door• Academic Detailing\Physician Champion• Physician Champion

• Unlikely to be chairman\ED director • Tend to have a full plate.• Champions need to have ability to

focus on the project for at least a year.• A younger (training-wise) doc with

some stature in department.


Group responsibility Tends to be least threatening to individual

physician Monthly or quarterly data Trend Foleys and related infections


Group responsibility Usually a good first step Will usually get attention of “center of

department” Ineffectual for outliers


Individual responsibility Audit and Feedback Yearly reviews Best for outliers


Audit and Feedback methodology: Mentioned frequently in KT

literature Fits in with Plan, Do, Study, Act

cycles Really just behavioral

reinforcement to effect change Most basic and probably most

effective


Audit and Feedback methodology: Based on clearly defined guidelines Must be on-going and as real-time as possible Should include a mechanism to address systemic

(non individual) issues.


Audit and Feedback methodology: Real-time feedback (days\

weeks not months) Feedback from consistent

source (physician champion) Feedback is on success and

failure Include alternatives

ED Collaborations

PICTURE

• Department is made up of physicians and nurses• No one group fixes any problem without the other• Likelihood of success lower without close integration• Unlikely in future medicine will be successful without

collaborative leadership and care• Proximity is not enough!

ED Collaborations

• SJRMC• Paterson, NJ• 150,000 visits• 50 physicians, 120+ nurses• 2008 – ED Exec Team • 2009 - EDQA Committee

ED Collaborations

• ED EXEC• ED Physician and ED Nurse

leadership • Formally meets weekly• Informally constantly• Joint decision making• Unified Implementation• Message travels separate

pathways

ED Collaboration

• EDQA• Off shoot of ED Exec• Open meetings• Open, “anonymized” referral process• Screens used• Separate from Audit and Feedback related to

quality initiative (STEMI, pneumonia, stroke)

ED Collaboration

• EDQA• Relies on an established worksheet• Examines individual care provided and systems

involved• Key in identifying system\cultural strengths and

weakness• Forms the basis of many decisions made by ED

EXEC

ED Collaboration

• EDQA• To date reviewed over 1,000

cases• Majority have no findings\

concerns• Feedback provided to

treating staff• CME\contact hours available• Highlights excellent care also

ED Collaboration

» ED Physician Role in Preventing CAUTI




Thank You!• [email protected]

• @PatersonER

• PatersonER.com (blog)• Slides available

• NJEmergencyDocs.com (acep blog)

Quality Initiatives: Physician Leadership in the Emergency Department

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