Transcript QI Project Team ESTRO-JEN

QI Project
Team ESTRO-JEN
CLINIC A
&
MEDICATION CHEAT SHEET
CHEN, COWAN, LEVIN, MOSTAFAVI,
YANG, ZIAEE AND QUACH
Survey Says:
How can
Clinic A be
improved?
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More beds, more computers, more attendings, healthier patients. No big deal
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more prescription printers, more printers. effectively each room should have a
printer, a prescription printer, a resident, 6 assigned patients and every 3 rooms
should have an attending
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better medication organization (when trying to find out what the patient was
actually last prescribed), and easier ways of ordering things than yellow forms, etc.
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The forms are never in the right places. They are always empty. The patients are
not showing up ready to be seen at 8am, oftentimes we are waiting for them to
clear financial, be vitaled by the nurses, and then 9am rolls around by the time the
housestaff start seeing them. We need more staffing. We need more rooms.
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More rooms--one room per housestaff.
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Continuity continuity!!!!!! It's an acgme requirement. It improves efficiency bc we
already know our patients and how to read our previous notes and it improves
provider satisfaction. It's so rewarding to take care of a panel of patients and
simply providing continuity will fix a lot of the problems in clinic a
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not feeling pressured to work through lunch!
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Less emphasis on how many patients each person saw and more about how much
we learned. If we are supposed to see more pts please let us know what to cut out.
Should I not use an interpreter (which takes more time)? Not ask a ROS (which
inevitably opens a can of worms)? Do a more pointed exam? If we move to a
system where we have to account for number of pts seen then I think that should
be addressed as well.
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Don't overbook the clinic!
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If at all possible, it would be nice to have clearer expectations about how in depth
to go. Efficiency always comes at the cost of thoroughness.
Continuity of Care in Clinic A…
Survey Says:
…makes no difference to
me.
…doesn't exist. Fix it.
…is fine as is. Don't mess
with a good thing.
0
50
100
Clinic A…needs help
CONTINUITY  RICK’S ON TOP OF THIS
WORK SPACE/EQUIPMENT  QI PROJECT
FOR NEXT YEAR
PATIENT LOAD  ONLY GOING TO GET
WORSE. BRACE YOURSELF.
EFFICIENCY  WE’RE HERE TO HELP
Clinic A – Patients are kept waiting
Because the chart rack looks like this…
Because the patient you’re seeing looks like this…
Here’s a
close-up
of that
list:
Your response by patient #4:
…in the end
Our little
contribution…
A questionnaire
to be given to
patients at
check-in that
will address
some of the
more common
problems we
see
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Please list 3 things you would like to discuss at today's appointment:
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Do you have any allergies to medications?
IF you have diabetes, please answer these questions:
Fasting blood glucose values:
Blood glucose values 2 hours after meals
When do you take insulin?
What kind of insulin do you take
How many times a week do you skip your medicines
In the last month, has your sugar been <90 or >250
When was the last time you went to the eye doctor
Do you check your feet routinely?
If you have high blood pressure, please answer these questions:
Home blood pressures (if you have a cuff at home)
How much salt do you have in your diet
Eating Habits:
What do your typical meals consist of
Circle thos items which you have regularly:
soda, juice, bread, tortillas, fast food
Do you exercise? Yes No
IF yes:
How many times a week do you exercise
How long
What type of activity
Please list the medications, with name, dose, and how often you take this.
Please circle the medications you want:
 Residents were asked:
BRIEF TRIAL
PERIOD
Questionnaire
(available in Spanish
and English) was tested
in Clinic A for ten days
recently.
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Did you find the questionnaire helpful for
your Clinic A interview?
6
5
4
3
2
Feedback was then
requested from 21
residents on Amb
rotation during those
ten days….
Unfortunately only 8
people responded.
1
0
YES
NO
 How effective/helpful was the form in stream-
lining your Clinic A interview?
7
6
5
4
3
2
1
0
EXTREMELY
EFFECTIVE
MODERATELY
EFFECTIVE
MINIMALLY
EFFECTIVE
NOT AT ALL
EFFECTIVE
 Please rate the usefulness of sections:
7
6
5
4
3
2
1
0
not useful
possibly useful
useful
 Do you think Clinic A should use
the form next year?
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
YES, LEAVE IT AS IS
YES, BUT MODIFY IT
NO
FEEDBACK
SUGGESTIONS
/CONCERNS
 Form needs to be shorter and less
complicated
 Issues with patient completing
only limited parts of the form
and/or not submitting the form at
all
 Issues with handing out the form
– not all patients received the
form at time of check-in
 Some patients did not receive the
spanish version
BOTTOM
LINE…..
CLINIC A is a constant work in
progress.
Thank you Rick and all of our attendings who
helped with continuity in Clinic A.
Medication Cheat Sheet
FOR THOSE MOMENTS ON WARDS AND
H O S P I T A L I S T W H E N T H E 1 ST, 2 ND, A N D 3 RD
MEDICATIONS YOU TRIED HAVEN’T WORKED
YET….
Survey Says:
Would you like to have a
pocket cheat sheet (kind of like
the antibiotics orange card) for
various meds/dosing for
common patient problems?
Why yes,
please.
I already know
everything.
What topics might you like to see on
aforementioned "cheat sheet?"
Stuffy Nose
Decreased UOP
Eye Complaints
Agitation
Dyspepsia
Insomnia
"10/10" Whole Body Dolor
Shortness of Breath
Chest Pain
Headache
Nausea/Vomiting
Diarrhea
Constipation
0
Other: Lyte repletement
20
40
60
80
As an example…
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--Constipation-Colace (stool softener) 100mg PO bid
Dulcolax (stimulant) 10mg daily, can be
given PO or PR
Fleet enema (lubricant) 197mL PR daily
**caution renal impairment**
Metamucil (fiber) 1 packet (3.4gm) PO dailytid
Milk of Magnesia (saline laxative) 30-60mL
PO daily **avoid in renal failure**
Miralax (osmotic)17gm PO daily
Senna (stimulant) 8.6mg tabs, start with 2
tabs PO qhs, max of 8 tabs PO daily
Tap water enema, one PR daily prn
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--Nausea/Vomitting-Ativan 1mg SL q6hr x2 doses
Chlorpromazine 10-25mg PO q4-6hrs
Compazine 10mg PO q3-4hrs
Dexamethasone 8mg PO or 12mg IV daily
Dramamine (for vertigo/motion sickness) 1-2
tabs PO q4-6hrs, max 8 tabs/24hrs
Erythromycin (for gastroparesis) 250mg PO
tid qac **caution prolonged QTc**
Meclizine (for vertigo/motion sickness)25100mg PO daily divided bid-tid
Phenergan 12.5-25mg PO/IM/IV q4-6hrs
Reglan 10mg PO/IM/IV qac and qhs
**renally adjust**
Zofran 4-8mg PO/IV q4-12hrs **caution
hepatic impairment and prolonged QTc**
We are so glad you’re here, new interns!!!!