Providing Quality Education in a Timed Limited Work Environment

1
Providing Quality Educationin a Timed- Limited
Work Environment

• By
• L. Ray Matthews, MD., FACS
• Director of Trauma/ Surgical Critical Care
• Morehouse School of Medicine
• Department of Surgery
• Atlanta, Georgia

2
Objectives

• By the end of the lecture, participants should be
  able to
• Understand the historical aspect of residency
  training in the U.S.
• Understand current residents work-hour
  restrictions along with proposed changes and how
  it impacts medical education.
• Understand different teaching methods of
  providing quality medical education.
• Discuss ways to decrease medical errors.

3
Historical Aspects of Medical Education
William Stewart Halsted
4
William Halstead

• Father of Safe Surgery (Halsteads Principle)
• Hemostasis
• Atraumatic dissection
• Antisepsis
• Debridement of devitalized tissue
• Obliteration of layers
• Approximation of layers
• Performed first radical mastectomy for breast
  cancer.
• Introduced surgical gloves.

5
William Halsted, MD

• In 1897, introduced concept of surgical
  residence.
• Graded responsibility
• Lengthy training period
• Pyramidal system
• Restrictive lifestyle

6
Restrictive Lifestyle

• Little or no pay
• Discouraged from marriage
• Duty was 24 hours, 7 days a week, 365 days a year
• Advent of Medicare/Medicaid abolished most of
  above restrictions

7
Libby Zion and the 405 Regulations (Bell)

• On 3/5/84 at 630am , Libby Zion died
• Cause of death Bilateral Bronchopneumonia
• Daughter of Sidney Zion, a noted NYC newspaper
  columnist and former federal prosecutor
• Grand Jury Recommendations
• Residents should be limited in
• their consecutive working hours

8
(No Transcript)
9
Resident Work Hours

• Despite changes in residents work hours, no
  study to date has demonstrated a quantitative
  improvement in patient outcomes or safety
• Research on subject consisted of small, single
  site studies, lacking in statistical power
• Systematic (Upstream and Downstream) Approach
• All errors are not resident- related
• Risk of death increases.
• 7 per patient when nursing patient ratio gt 14
• Pharmacy errors 5 per 1,000 prescription
• Housekeeping errors
• Equipment failure
• CT Scans
• Patient monitors
• Lab equipment

10
Morehouse Department of Surgery Conference

• Mondays
• 7 am Morning Report (Trauma Call)
• 3 pm Trauma Outcome Registry Conference (3rd
  week)
• Trauma/ SICU deaths reviewed
• Wednesdays
• 7 am Grand Rounds (2nd and 3rd Week)
• 815 am Perioperative Conference
• 915 am Basic Science/ Absite Review
• 2 hour exam 4th Wednesday
• Thursdays
• 7 am Journal Club (1st and 3rd week)
• Electronic Articles
• Fridays
• 7 am Morbidity and Mortality Conference
• Ladies and Gentlemens Club
• Evidence- Based Medicine Articles

11
Morehouse Evidence- Based MedicineProtocols
(February 2007)

• ARDS Net Protocol vs. Inverse Ratio Ventilation
  (IRV)
• Mortality rate 25
• Patients sedated paralyzed (IRV)
• P/F ratio lt 300 must be explained
• Tight glycemic control (glucose lt 150)
• Ventilator Bundle/ Sedation Holiday
• Fewer ventilator days
• VAP
• Temporary Abdominal Closure vs. Wound Vacs
• Incidence of Abdominal Compartment Syndrome
• SICU deaths

12
Morehouse Evidence- Based MedicineProtocols
(February 2007)

• Early Goal Directed Therapy
• MAP gt 70
• SBP gt 110
• SVO2gt 70
• Lactate lt 2
• Base deficit 0 2
• HGB gt 10 CAD
• Early and Aggressive Nutrition
• Albumin lt 2.5
• Prealbumin lt17
• morbidity and mortality
• Trauma / SICU patients seen by surgical attending
  within
• 24 hours
• Sepsis Bundle

13
Education! Education! Education!

• Monthly ABSITE/ Surgical exam
• Medical diagnosis
• Treatment
• Complications
• Medication
• 100,000 deaths/ year from adverse drug
  reactions
• dosages
• side effects
• mechanism of action (paralytics)
• drug interactions
• Weekly electronic Journal Club articles
• Socratic teaching rounds
• TORC, Morbidity and Mortality conference

14
Education! Education! Education!

• Multidisplinary Approach/ Teaching Rounds
• Nurse Managers
• Nurses 80 patient care
• Pharmacists
• Respiratory Therapist
• Nutritionist
• Social Workers
• Physical/ Occupational Therapist
• Hospital Administrators
• Housekeeping

15
Failure Mode Effect Analysis
16
Failure Mode Effect Analysis
17

• Evidence- Based Medicine and Close Staff
  Supervision Reduce Mortality Rate 46.3 at a
  Level I Trauma Center

18
2000-2008 Morehouse Trauma Stats

19
2000-2008 Mortality

20
Death Rate

21
Population Characteristics

22

• Patient Success Stories

23
Solider Airlifted To Grady After Falling 500ft
24
Patient And Parents Grateful To Grady For Care
After Gunshot
25
Patient Thanks Grady For Saving His Life
26
Patient Pronounced Dead Gets A second Chance
27

• Questions?