Editor’s Note: Colleen McCormick, a fourth-year medical student from Wright State University in Ohio, is using the IHI Open School Quality Improvement Practicum to conduct her first quality improvement project.
Every Wednesday during February and March, Colleen will write a blog post about her progress as a student trying to make a change in the health care system. You can catch up on her previous posts here.
By Colleen McCormick, fourth-year medical student, Wright State University
we started PDSA cycle #2 — use of a screening tool to evaluate patients for
palliative care consults. We developed the tool with input from physicians and
nurses on both the ICU and palliative care sides. And as I mentioned last week,
we also used feedback from many of the nurses and physicians to continue making improvements.
support of our clinical nurse manager, we distributed the tools in the medical
ICU setting; we educated the nurses educated in person and via e-mail on how to
the use the tool. For all patients in the ICU, the tool was to be placed at the
front of the paper chart, so that each time the chart was opened, the nurse or
physician would be reminded to review the tool. The tool was designed to assess
all patients on the day of admission to the ICU (day 0), on day 3, and on day 6,
should the patient still be in the ICU.
the beginning of the week, we had 13 patients in the medical ICU. Eleven of the
patients had a palliative care screening tool at the front of their chart. That
means the tool was applied to 85% of the patients in the first week of the
intervention. While we are aiming for 100% of our patients to be screened, this
wasn’t a bad place to start!
looked at the number of patients who should have triggered a consult from the
screening tool. In other words, I wanted to know which patients had a score
above our threshold and could have benefited from palliative care. (You may recall
that we are aiming to increase consults from 3% of patients to 9% of patients
in the next six weeks.)
1 of the PDSA cycle, we had one patient that scored above the threshold.
Unfortunately, this patient did not receive a palliative care consult. The
other 12 patients did not meet criteria for a palliative care consult based on
the nursing assessments of the patients. So in summary, our consult rate was 0%
in week 1.
additional step, I looked through the charts of the patients who had been
screened, to compare my own assessments to the assessments of the nurses. The
goal was to make sure that the nurses were educated correctly on how to
complete the screening tool. As I was looking through these tools, I noticed
that some of the screening tools weren’t filled out completely or correctly.
Also, I discovered that my assessments were more likely than the nurses’ to
trigger palliative care consults. I determined that 5 out of 13, or 38% of the
patients, could have benefitted from palliative care.
Why did our
assessments differ by so much? I will have to meet with the nursing team
members to discuss the differences and consider additional educational sessions
with the ICU staff.
we will be having a team meeting to discuss where we are and where we are going.
We will be going back to the basics, looking at our fishbone diagram, and
brainstorming future PDSA cycles, as our results in week 1 were not as
promising as we had anticipated.
Do you have
any ideas on other changes we can test?