Scripps Mercy Hospital Continuous Circle of Care

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Scripps Mercy HospitalContinuous Circle of Care

• APDIM Meeting, April 6, 2006
• David Shaw, M.D., Director of Medical Education
• Stanley Amundson, M.D., Program Director

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The overall concept Continuous Circle of Care

• Opportunity to improve patient care and improve
  resident education at every point in the
  patient-physician encounter
• Starts with initial encounter between resident
  and patient where empathy is established and
  patient develops confidence in the therapeutic
  relationship

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The overall concept Continuous Circle of Care
(continued)

• Circle is complete when patient returns for
  follow-up
• At this point resident learns whether he/she has
  been effective in motivating patient to comply
  with prescribed, evidence-based diagnostic
  procedures and therapeutic interventions

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The overall concept Continuous Circle of Care
(continued)

• In between opportunity to improve patient care
  and resident education in a measurable fashion at
  each intervening point in circle history,
  physical exam, formulation of problem list,
  selection of diagnostic tests, creation of
  differential diagnosis resolved to highest level,
  development of therapeutic plan, education of
  patient about diagnosis and therapies,
  integration of patient safety into processes of
  care, and timely and cost-effective provision of
  services

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Low-Tech Example of the Continuous Circle of Care

• The Cardiac CEX
• Used to measurably improve physical examination
  and ensure accurate diagnosis, improving patient
  care

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Background

• Studies continue to show that 70 of our
  diagnostic medical information comes from a
  well-performed history and physical examination.
  
• Studies also show that current United States
  Residents miss 50 or more of significant cardiac
  physical exam findings.
• The physical exam is cost effective, non-invasive
  and it enhances the doctor patient relationship.
• A structured Cardiac CEX can evaluate and teach
  cardiac physical exam skills while the patient is
  being staffed, which is time efficient.

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I. CARDIAC CEXJVP Analysis Format

• Feel L carotid pulse look for the R IJ vein
  with the patients neck relaxed and head rotated
  30o to the L
• Change angle of bed to localize the top of the
  oscillating column of venous blood to the
  mid-neck area
• Determine if A wave or V wave dominant
• Measure height of JVP in cm of water using the
  angle of Louis 5 cm as reference
• Credit is given for doing the appropriate
  maneuvers even if the wrong answer is obtained

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II. CARDIAC CEX JVP Analysis Accuracy

• Was the JVP wave-form analyzed accurately?
• Was the JVP pressure measured accurately?
• Credit for this part of the CEX is given only if
  accurate results are obtained.

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Making the Cardiac CEX Efficient as a Teaching,
Evaluative and Patient Care Enhancing Tool

• 1. Schedule two one-hour long lectures on the
  cardiac exam early in the academic year.
• 2. Use the evaluation form as one of the handouts
  and teach to it. This helps residents organize
  their cardiac exam, informs them about what they
  will be evaluated on, and it promotes home
  study.
• 3. Have a limited number of specially trained
  core faculty do all of the Cardiac CEXs so that
  evaluation and teaching are standardized.

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Making the Cardiac CEX Efficient as a Teaching,
Evaluative, and Patient Care Enhancing Tool

• 4. It is most time efficient for CEX-trained
  clinic attendings to supervise CEXs on the first
  patient of their AM and/or PM shifts so that CEX
  time is also patient staffing time. It takes
  approximately 30 min. to complete the Cardiac CEX
  and staff in real time the patients other
  problems. Staffing other patients with their
  residents is not impeded if only the first
  patient of each shift is CEXed.

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High Tech Example of the Continuous Circle of Care

• The Medication Translator Project Web tool used
  to enhance patient safety by reconciling
  medications across the continuum of care, and
  providing patients with clear instructions
  translated from English to Spanish, resulting in
  improved patient compliance with medications, and
  providing new prescriptions with a single click
• Being utilized by Residents discharging
  inpatients and in their continuity clinic. Being
  adopted by Attendings in their Offices

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