DukeHealth.org: Duke Health Features

Eyes on the Ball: Duke Sports Vision Center for Excellence

Fri, 10 Feb 2012 14:59:30 -0500

Scheyer with Terry Kim, MD, head of the new Duke Sports Vision Center of Excellence, and Duke men’s basketball coach Mike Krzyzewski, who encouraged the center to treat members of the military as well as athletes.

On July 13, 2010, Duke ophthalmologist Terry Kim’s phone rang, and on the other end of the line was former Duke basketball player Jon Scheyer, who in his senior year had helped lead the Blue Devils to the 2010 NCAA basketball championship.

Kim had examined Scheyer’s eyes every year since he joined the team as a freshman. On the phone, Scheyer didn’t sound like himself. He told Kim that while he was working out with an NBA Summer League team, another player had poked him in the eye.

Then he put the team doctor on. The doctor said that Scheyer showed signs of optic nerve damage -- a very serious injury.

Kim couldn’t believe it. Optic nerve damage usually happens with serious trauma, like a car accident. Eye pokes happen all the time in basketball, and they usually aren’t that big of a deal.

Scheyer was about to fly to Chicago to be with his family, so Kim put him in touch with a friend and fellow ophthalmologist Kirk Packo, MD, in Chicago, who the next day confirmed the bad news. Scheyer had a very severe injury, called a partial optic nerve head avulsion, that would likely cause a permanent decrease in vision and visual field.

Kim knew this type of injury could be devastating for Scheyer’s hopes of a pro basketball career. He flew to Chicago the next day to see Scheyer and his family himself.

“When I had my eye injury, the first person I called was my trainer from Duke to get ahold of Dr. Kim,” Scheyer says. “He is the only eye doctor I’ve seen my whole life. Since he flew out to Chicago to see me in the hospital, he has guided me through my recovery process. He has been not only a great doctor to have but a great friend as well.”

After a career– changing eye injury, Scheyer turned to his Duke ophthalmologist for guidance.

In Chicago, Kim examined Scheyer’s eyes and spent the entire day with him and his family, explaining that the injury was serious but that it was too soon to tell the extent of Scheyer’s vision loss.

“Not once did Jon cry. He showed such determination to do everything he could to make this better and to accept the consequences,” Kim says. “To see Jon, barely out of college, face this potentially career- threatening eye injury with such maturity and optimism really impressed me.”

Scheyer’s determination in the face of this injury inspired Kim to take the first steps toward developing the Duke Sports Vision Center for Excellence to offer diagnosis, treatment, and support for athletes of all levels with eye injuries and eye diseases.

Whereas in the year and a half after his injury Scheyer saw 14 different doctors in six different states, Kim envisions the new Duke center as a one-stop location providing diagnosis and treatment of problems of the optic nerve, cornea, lens, retina, and eyelids or orbit. Low-vision rehabilitation services would also be offered at the center, which Kim hopes could be located in the new Eye Center Pavilion that will open in 2014.

Duke basketball coach Mike Krzyzewski and his wife, Mickie, who are supporters of the center, suggested extending the services to members of the military. “Athletes and military members have extraordinary talents and need extraordinary vision to use their talents,” Kim says. “They both have to function at a higher level than the average person.”

Kim sees a need to standardize treatment and follow-up of eye injuries and diseases for this special group of people.

Injury prevention education as well as research would be part of the mix too. Many athletes, including children, don’t wear protective eyewear, and many sports leagues don’t require it. Education could help change that.

Kim also sees the center as a natural place to conduct peer-reviewed research regarding recovery rates from serious sports-related eye injuries, as well as evaluation of new devices, such as “vision training” aids that purport to improve hand-eye coordination.

Formal support groups for athletes and military members with eye injuries will round out the center. After Scheyer was injured, he heard that a player for the Baylor University women’s basketball team had just suffered a similar blow. He contacted her to offer his support. “I just wanted to tell her that there was someone out there who had a similar injury and could answer any questions she might have. When I first had my injury, I didn’t know of many instances of other basketball players getting injured in the eye. When you’re going through a tough time, it’s great to have a couple of people you can lean on,” Scheyer says.

Kim says the new center will help standardize treatment and follow-up for eye injuries—and it will focus heavily on prevention, education, and research.

One finger poke changed Scheyer’s life; he lost much of the sight in his right eye. But it hasn’t kept him from basketball. After completing vision rehabilitation (he says adjusting to his changed depth perception was the biggest challenge), Scheyer landed a spot with the Rio Grande Valley Vipers, the NBA development league team for the San Antonio Spurs. He started in 19 of their 24 final games, averaging more than 13 points in 33 minutes of action per game. The team advanced to the finals of the league’s championship.

“I don’t want this injury to slow me down. Because of this injury, I’ve met so many people who are completely blind, or blind in one eye. Mine isn’t the best situation, but mine isn’t the worst either,” he says.

Scheyer is now beginning a new challenge as shooting guard for Maccabi Tel Aviv, a team in Israel’s Super League, which is a member of the Euroleague.

“When I got injured, I remember being on the ground and feeling pretty scared. I told myself that when I can get back and am allowed to play, I’m gonna give it everything I have,” he says. “Now when I go out and play, I’m playing for that person on the ground.”

Kim and Scheyer hope the new Duke Sports Vision Center for Excellence will help many other athletes have equally triumphant outcomes. “There’s such a great need for a center like this,” Scheyer says. “I’ve been able to see the best eye doctors in the world, between Dr. Kim and my specialists in Chicago and Memphis. But for people who aren’t as lucky as me, there’s a need to have one place where they can go to get the best care and support.”

Compassion Cart

Mon, 16 Jan 2012 11:00:47 -0500

Durham Regional Hospital has developed a new service to help the loved ones of patients who are receiving end-of-life care in the hospital -- the compassion cart.

Upon staff request, a cart containing snacks, beverages, coffee, and a special card is delivered to the patient’s room.

“Food can often provide comfort in painful situations, and the compassion cart is designed to comfort those who are losing their loved ones,” says Andrew Hennis, director of Food & Nutrition.

The idea for the compassion cart came from Carolyn Scott, RN, who learned about the idea at a conference.

The idea became reality through the collaboration of teams from Food & Nutrition, Palliative Care, Ambulatory Care, Nurse Governance, Radiation Oncology, Vascular Access Services, Patient Care Leadership, and Unit 5-3/Neurology Oncology.

Durham Regional Hospital’s Auxiliary provided funding for the compassion cart.

It Takes a Team: Creating the Duke Experience

Fri, 13 Jan 2012 14:27:04 -0500

It was a team-based experience that won’t soon be forgotten.

In June 2011, thousands of physicians, staff, and volunteers who work at Duke University Hospital came together for the 2011 All-Staff Event to recommit to caring for patients and their loved ones.

For the second year in a row, the event was held at the Durham Performing Arts Center. Based on employee feedback, the theme continued to spotlight teamwork, with this year’s event specifically focused on creating the unique experiences that differentiate the care delivered at Duke University Hospital from the care received any other place in the world.

Duke’s executive leaders showed comparative data to highlight organizational performance and then took the team beyond the numbers, inviting patients to tell their "Duke Experience" stories through video, live expressions of gratitude, and even through song.

And the stories were powerful.

Patient and lifelong athlete Eric Gabriel bent his prosthetic knee for the first time in order to propose to his partner Melissa onstage in front of his Duke family. Michael Bolognesi, MD, who performed Gabriel’s amputation, brought the engagement ring and a dozen roses to the stage to support his patient at the beginning of another important life journey.

Two-year-old Madison Smith, one-half of energetic identical twins, thanked the team in pediatrics for the specialty care that saved the toddler. “Thank you for my life,” she said, blowing a kiss to the crowd.

Nicole Graziano, who has struggled with cystic fibrosis since childhood and dreamed of a career in musical theater, performed the song “Love Like Breathing” while surrounded by members of Duke University Hospital’s team, who sang backup; hospital president Kevin Sowers, RN, MSN, accompanied them on piano. This was made possible because of the heroism of Shu Lin, MD, PhD, and his team, who performed Graziano’s double-lung transplant, thereby giving back her life and her song.

“Each patient has a unique history -- a life story that blends with ours,” one staff member wrote following the event. Another added, “Great motivation; [makes] me thankful to be part of this team!”

New Recognition for Total Joint Replacement at Duke Raleigh Hospital

Fri, 13 Jan 2012 14:23:41 -0500

In September 2010, The Joint Commission awarded Disease-Specific Care Certification to Duke Raleigh Hospital's Total Joint Replacement Program, in recognition of the program’s commitment to excellence in providing care for total joint replacement patients.

Duke Raleigh Hospital

Duke Raleigh Hospital is the first in the Triangle to receive this distinction. To earn it, the program underwent an extensive, announced on-site evaluation by The Joint Commission.

The program was evaluated against Joint Commission standards through an assessment of the program’s processes and ability to evaluate and improve care within its own organization and through interviews with patients and staff.

“Duke Raleigh Hospital voluntarily pursued this comprehensive independent evaluation to enhance the safety and quality of care we provide,” says hospital president Doug Vinsel. “We are honored to demonstrate our standard of excellence and the caliber of teamwork and collaboration across the entire hospital that enables us to provide the very best care to our patients.”

Disease-Specific Care Certifications are based on three core areas:

Compliance with national standards
Effective use of established clinical practice guidelines
An organized approach to performance measurement and improvement activities

Disease-specific care programs that successfully demonstrate compliance in all three areas are awarded certification for a two-year period.

In April 2011, Blue Cross and Blue Shield of North Carolina (BCBSNC) also designated Duke Raleigh Hospital as a Blue Distinction Center for Knee and Hip Replacement. Blue Distinction Centers for Knee and Hip Replacement are part of the Blue Cross and Blue Shield Association’s expansion of its Blue Distinction designation.

“Last fall, BCBSNC invited Duke Raleigh to participate in the Blue Distinction program, and we were proud to demonstrate our accomplishments within their rigorous criteria,” says Liz Jackson, PT, MBA, director of the orthopaedic service line at Duke Raleigh.

“Receiving this designation validates the high quality of care and teamwork we provide that ensures every patient has the best outcome and experience possible.”

Duke Raleigh’s Total Joint Replacement Program is a comprehensive and multidisciplinary program that includes preoperative patient education, surgical and medical care, acute rehab, assistance with discharge planning, and postoperative wellness instruction. Duke Raleigh performed more than 700 joint replacement surgeries last year.

Architects of Quality Care and Patient Safety

Fri, 13 Jan 2012 14:11:58 -0500

Hundreds of Duke Medicine faculty and staff members have been involved in an interactive design process for the new 580,000-square-foot Duke Medicine Pavilion, scheduled for completion in 2013.

The team -- comprising nurses, physicians, occupational therapists, infection control staff, and others -- have worked through patient-care scenarios from mock intensive care unit (ICU) patient rooms housed in an old warehouse.

Each mock room is as real as it is fake -- designed to the exact specifications of the state-of-the art rooms that will comprise the Duke Medicine Pavilion, from the ceiling tiles and lighting to the location of the signage on the wall.

By practicing scenarios in these rooms, the team offers real feedback about the space and equipment incorporated in the design.

Becky McKenzie RN, MSN, MBA, administrative director of perioperative services at Duke University Hospital, acts as a facilitator for the process, ensuring everyone has a voice in the design and workflow processes of the new building.

Duke is as committed to staff safety as it is to incorporating the latest in clinical technology. Half of the ICU rooms will have built-in ceiling lifts to ensure that patients are moved as safely as possible and that staff members are protected from lift injuries.

The patient can be positioned 360 degrees within the room, increasing patient access, thanks to a boom system that keeps cords out of the way and beds untethered to the wall.

McKenzie estimates that 100 items have been revised to increase quality of care and increase patient safety -- all thanks to staff feedback.

One key design revision was that of the size, angle, and location of the observation window in the nurse alcove to ensure the greatest visibility of the patient from the corridor. Another was the coordination of patient lift components with other elements in the room.

Having the opportunity to test the location of the equipment may have prevented expensive, construction-delaying errors.

According to McKenzie, input gathered from the Duke experts is extremely valuable because they know their patients’ needs best.

When patients visit the new facility, they can expect that those needs will continue to be Duke’s top priority.

One Shared Goal: Successful Steps to Reduce Central-Line Bloodstream Infections

Fri, 13 Jan 2012 14:10:49 -0500

Duke Raleigh Hospital's administration supported a Six Sigma infection prevention team to address the increase in central line-associated bloodstream infections (CLABSI). The Intensive Care Unit (ICU) staff at Duke Raleigh joined the team after attending the North Carolina Quality Center collaborative meeting.

The infection prevention team, along with the ICU champion, Stephanie Johnson-Dean, RN, worked to put together a plan to adopt the proven techniques and procedures that can reduce harm to patients through central-line bloodstream infections. The ICU staff embraced the evidence-based principles, and their resulting motto was “Every Patient, Every Time.”

The ICU staff’s diligence paid off, as the unit has not had a central-line bloodstream infection in over 15 months.

Staff from throughout the hospital have demonstrated their commitment to patient safety by using the central-line bundle (a list of tasks to prevent BSIs); all areas of the hospital (i.e., OR, PACU, Cardiac Cath Lab, Imaging, PICC Team) are using the proven guidelines when inserting central lines.

As the infection prevention team moves forward, they are focusing more on central-line maintenance issues and incorporating best practices, while continuing to refine the tools and processes that have been developed.

Recently, the team developed a monthly unit report for each area to remind staff how they are doing and to give pointers in areas that need improvement. The team’s new goal is to decrease all bloodstream infections to zero.

Durham Regional Hospital Reduces CLABSI

In December 2010, Durham Regional Hospital’s Critical Care Unit (CCU) unit celebrated 12 months with zero hospital-acquired CLABSI.

This success was due to the leadership of the bloodstream infection (BSI) team and staff nurses in the CCU. Together, these teams developed innovative ways to make sure everyone washes their hands appropriately and to ensure that central-line processes are as safe as possible.

Staff concentrated their efforts on compliance with evidence-based guidelines, including compliance with the Institute for Healthcare Improvement Central Line Bundle which includes:

Hand hygiene
Maximum barrier protection
Chlorhexidine gluconate (CHG) skin antisepsis
Optimal site selection
Daily review of necessity

All CCU staff were educated about the less-obvious patient effects of CLABSI, including the extension of their hospital stay, changes in mortality rates, and costs. Education was consistently reinforced in addition to daily departmental huddle discussions and staff meetings that emphasized CLABSI as preventable hospital-acquired infections.

Staff were also empowered to hold all medical staff, including physicians, accountable for following bundles.

The team updated line carts and checklists, and introduced new supplies, including alcohol swabs with CHG and dressings utilizing a CHG-impregnated sponge. The executive leadership team supported these initiatives during safety rounds to the unit.

To generate enthusiasm, the team hosted bundle education parties; created and displayed animated posters in the staff areas; and wrote and introduced a 15-second song to sing while “scrubbing the hub." (The “hub” refers to the spot where the nurse connects IV tubing for medications; it is the barrier between the environment and the patient’s bloodstream.)

The team also used similar measures to educate and encourage each other to use appropriate hand hygiene. As a result, hand hygiene compliance has improved significantly, contributing to a decrease in CLABSI.

One Month, Lasting Impact: Duke's Employee Weight Loss Program

Fri, 13 Jan 2012 14:10:04 -0500

Howard J. Eisenson, MD

Since fall 2009, the Duke Diet & Fitness Center (DFC) has offered the Duke Employee Weight Loss Program, a novel approach to achieving lasting weight-loss and lifestyle changes.

The program simulates what occurs in the DFC's highly esteemed residential weight-loss program, but it is geared toward working people and their schedules.

"I have been searching the DFC Web site for years and knew that the program was world-renowned, but it seemed out of reach with regards to both the expense and the time required to participate in the program," says Njira Lugogo, MD, a Duke pulmonologist who participated in the program.

"I have seen the effects that obesity can have on the lives of many of my patients but previously felt that I could not help them much with this issue," she says. "I now share my experiences with my patients -- teaching them what I have learned about how to make small changes that lead to a healthy lifestyle."

In its first iteration, the program lasted four weeks and included five classroom sessions per week, exercise classes, and 40 meals (10 per week), which participants could eat at the center or carry out.

The 20 lectures were culled from the top lectures offered in the residential program; all components of the regular residential program were represented in these lectures, including physiological and behavioral health, diet, and exercise.

As a result, program participants were given the tools they needed to sustain their weight loss outside of the program. Participants saw an average weight loss of 10 to 15 pounds during their enrollment.

"This is the most gratifying program that I've been involved with while at Duke," says Howard Eisenson, MD, executive director of the Duke Diet & Fitness Center. "It has been particularly gratifying to see colleagues take control of their own diet and exercise habits and make significant changes for themselves that empower them to be effective advocates of a healthy lifestyle for patients and for family members."

The Duke Employee Weight Loss Program will continue to be offered several times throughout the year, with 20 to 25 people participating in each cohort. These small group sizes help to build a sense of community around the program, helping people stay motivated and inspired, according to Eisenson.

This fall, the program opened up to the community at large, to help local residents with busy schedules as well as Duke employees. Based on participant feedback, the program has also been expanded to eight weeks in length.

"Making time for one's health is often not a focus within medical professionals," says Lugogo. "However, if I am not healthy then I will eventually be unable to care for others when they are sick. I now have the ability to be more focused and to continue to thrive at work -- even with my demanding schedule."

Better, Together: Care Partners Program

Fri, 13 Jan 2012 14:06:44 -0500

An outpatient case management intervention known as Care Partners is a collaboration between Duke University Hospital, Durham Regional Hospital, Duke HomeCare & Hospice, Durham Community Health Network, and various community-based health care agencies.

The goal of the Care Partners program is to enhance the focus and care of patients with chronic diseases.

The program uses a patient-centered model to help empower patients to optimize their health, gain further understanding of their chronic disease, and to have timely access to appropriate services and providers, enhancing their ability to manage their care outside of the acute or emergency department setting.

In this model, patients are joined with a “care partner” who is supported by an oversight team of individuals representing the participating groups.

Care partners are clinically trained professionals with backgrounds that include nursing (diabetes, geriatric, nutrition), social work, and community health education. The oversight team members' broad range of additional training strengthens their ability to make resources available to these patients.

Engaging and Empowering Patients

Patients enrolled in Care Partners are empowered to better understand their health problems, make more effective use of the health care system and improve self-care in order to manage health problems outside of the emergency department and inpatient setting.

An initial analysis of utilization and readmission data at Durham Regional Hospital and Duke University Hospital revealed that, in some instances, patients were seeking their care at both hospitals, and at times on the same day. Frequency of emergency department visits for some patients exceeded 50 visits in 12 months.

Through engaging with the patients, the team learned that patients often experienced difficulty in keeping follow-up appointments and getting their prescriptions filled.

Care Partners seeks to address these issues by voluntarily enrolling residents of Durham County with chronic medical conditions and high risk for medical crisis or recurrent hospitalization. The patients are also either enrolled in NC Medicaid or Carolina Access.

Enrolled patients participate in a three-phase, nine-month intensive program, which includes phone follow-up and home visits. Each phase consists of inclusion criteria as well as expected interventions during each phase.

Key components include assessing current health literacy, building trust and honest communication with patients, and providing consistent education and follow-up.

“We found in most cases, our patients had given up. We had to gain their trust and convince them things could be better,” says Pam Aldridge, director of Revenue Enhancement and Clinical Documentation Improvement at Durham Regional Hospital, who adds that there are many contributing factors, including homelessness, mental health issues, and substance abuse. “We couldn’t treat chronic conditions without first treating behavior.”

The program has additional goals which include:

Seamless and appropriate care for patients along the care continuum
Coordination and optimization of care across all care settings
Patient education and empowerment
Integration of health care “systems” to enhance communication among care providers
Creation of a sustainable operational and financial structure which allows for program growth and success
Support for hospital operational and financial efficiency
Reduction of inappropriate use of acute and emergency resources
Reduction of inappropriate readmissions to the acute setting

Impressive Results

Twelve patients were enrolled in the Care Partners program between July 2009 and April 2011. The impressive results include:

30-day readmission rates reduced by 45 percent
Inpatient admissions reduced by 37 percent
ED admissions reduced by 49 percent
Clinic encounters increased by 80 percent

“Patients who enrolled and graduated from the Care Partners program report significant improvement in the overall quality of their lives and ability to manage their health,” reports Mary O’Brien, director for Patient Resource Management at Duke University Hospital.

"The Care Partners model, which incorporates home visits as an integral part of the program, along with regular support from the oversight committee, has been key in supporting patients, and Care Partners in achieving a successful outcome."

Student Ambassador Program: Improving the Patient Experience

Fri, 13 Jan 2012 13:58:10 -0500

Durham Regional Hospital's new Student Ambassador Program, which started in summer 2010, enlists the help of local university students to serve as patient experience ambassadors in the Emergency Department (ED) and Perioperative Services -- all in an effort to help improve the patient experience.

“Our ambassadors have fulfilled a critical role in improving our customer service and communication with patients,” says Bianca Briola, director of Nursing Business Operations and Patient Experience.

“The Ambassador Program, in conjunction with other initiatives, has allowed the DRH Emergency Department to achieve the highest patient satisfaction scores in its history, and two consecutive quarters exceeding the 75th percentile in its peer group.”

The ambassadors perform a number of functions, such as greeting patients, maintaining the patient waiting areas, talking with and comforting patients while they waiting for care, and keeping loved ones informed of the patient’s status.

“We have found that, sometimes, patients who are waiting to see the doctor or clinician can feel more comfortable asking questions and expressing complaints to our ambassadors,” says Briola. “The compassion and enthusiasm they provide is of great value to our patients.”

According to ambassador Elizabeth Cotton,“We act as liaisons between the patient and the care team in some situations.” Cotton spends time each week in the ED visiting the patient rooms and waiting area to ask if patients and visitors need anything to help them feel more comfortable. She often brings pillows, blankets, and snacks, and helps with bed adjustments or other services.

She says the experience has exposed her to the medical environment, and helped solidify her decision to apply to medical school.

Cardiac Monitoring: Waking Up to Alarm Fatigue

Fri, 13 Jan 2012 11:29:42 -0500

In many nursing units, patients are connected to monitors that signal dozens of different occurrences -- everything from cardiac arrest to a patient simply rolling over.

Alarm fatigue is the term for what happens when alarm sounds occur so frequently that caregivers may begin to tune them out.

Recognizing the concern with alarm fatigue across the county, Duke University Hospital charged the Monitoring Committee to study hospital practices in responding to cardiac monitor alarms.

The study found variability in nursing management of and response to alarms across various care units, due in part to differences in policies for monitoring and procedures for physician ordering of monitoring. This led to a significant performance improvement effort to standardize and streamline protocols not just at the hospital, but systemwide.

The study also identified a need to record data from cardiac monitors to measure caregivers’ response to alarms.

With the current monitoring system, there is no way of storing information gathered by monitors -- and therefore no means of reviewing if and when response was adequate. It is difficult to fully determine whether staff are providing optimal care per the defined protocols and policies.

“If you don’t measure it, you can’t improve it,” says Chris Granger, MD, chair of the study committee. Granger adds that recording and storage of data would allow physicians to review patients’ cases in a way that has not been possible before, even after patients leave the hospital.

The Monitoring Committee is evaluating technology products that can help with data storage and interpretation.

The review of the variability in process and method was compelling enough to escalate this project to a system-wide effort. Nurses, physicians, and technicians from the three DUHS hospitals are collaborating to achieve more reliable application of cardiac monitoring, including standardized measurements.

Greater standardization can lead to a better understanding of the core processes that need improvement, and that improvement will contribute to more effective and timely patient care.

Duke Residents and Fellows Aim to Improve Handoff Processes

Fri, 13 Jan 2012 11:28:11 -0500

In early 2010, house staff with special interests in patient safety and quality improvement coalesced to form the Duke GME Patient Safety and Quality Council (PSQC).

With executive-level support and health system resources, residents and fellows from across Duke University Hospital formed interdepartmental partnerships and began working together to address broad patient safety and quality issues.

The PSQC's early work has focused in three primary areas -- handoffs, education, and supervision -- with the Handoffs Initiative being the most productive to date.

Work on the PSQC's Handoffs Initiative began in August 2010 to prepare Duke's GME community for major changes around transitions in care in GME regulations (known as the ACGME Common Program Requirements).

Members spent months reviewing the relevant literature to identify best practices around handoff structure, education, and evaluation, and developed a comprehensive plan to reform transitions in care among Duke's house staff.

Standardizing Handoffs, Improving Patient Outcomes

Its first efforts were focused on defining a flexible method of standardizing handoffs among varying clinical specialties.

In January 2011, PSQC brought its new standardized guidelines for handoff core content to both ICGME and ECMS for review and met with broad approval.

To help implement the new core-content guidelines, the group developed a new teaching session for institution orientation and worked with individual programs to implement program-level modifications.

Working with GME's IT specialists, the group then created an electronic evaluation template within GME’s existing MedHub system. The tool incorporates the new hospital-wide core content and will serve as a mechanism for both programs to evaluate trainees and the institution to monitor program compliance with the new handoffs guidelines.

PSQC members have presented the work of the Handoffs Initiative at multiple national meetings and written a manuscript that has been accepted for publication in a major national journal, with the hope that the experience at Duke can serve as a model for other institutions to engage house staff in safety and quality initiatives.

Access Revolution: Improving Appointment Wait Times

Fri, 13 Jan 2012 11:06:18 -0500

The clock starts ticking as soon as a new patient requests an appointment within the Duke Department of Medicine.

From that moment on, a metric called "time to arrive" tracks the span between that first phone call and the actual date of the appointment. Department-wide, the time-to-arrive goal limit is 25 days.

Three years ago in Duke's outpatient endocrinology service (Clinic 2F/2G), the combination of high disease incidence and dearth of local care alternatives amounted to overwhelming demand and appointments booked six months out.

"There is a high prevalence of diabetes in this region, and Duke is one of a few providers in the area for tertiary diabetes care," says Lindsay MacDiarmada, associate director for access and performance improvement. "And it's not just diabetes patients in the clinic; the endocrinologists also see patients for lipid management and complex thyroid conditions."

Staff Changes Increase Patient Access

Early in 2009, Duke leadership declared addressing wait times to be a priority, and in February that year, MacDiarmada began an evaluation of the clinic's capacity, access issues, and solutions in response. Implementation followed in 2010, and the new processes have now been in effect for a full year.

Among them, the responsibilities of advanced practice providers -- nurse practitioners and physician assistants -- have been restructured so that everyone works "at the top of their license," according to MacDiarmada.

Returning patients have the new option of scheduling appointments with highly skilled advanced practice providers, thereby decreasing new patients' wait for initial physician evaluations and diagnoses.

Two full-time endocrinologists were added to the clinic staff to open up the backlog of patients, while a dedicated nursing staff took the lead in telehealth/triage.

Patient Education Improves Care

"We have also placed a strong emphasis on patient education. Floor nurses work with patients one-on-one to guide patients through their treatment plan and answer questions the same day as their appointment," says MacDiarmada. “That way, patients can leave feeling more in control of their condition.”

Diabetes patients also see a nutritionist and a certified diabetes educator, as necessary, to stay on top of chronic disease-related issues and avoid painful and costly complications.

While additional tweaks continue to be made, the initiative to open up access has received positive feedback from those involved, and the consensus is borne out in traffic data.

Model of Care

Clinic 2F/2G is now serving as a model for the whole of the Department of Medicine, as each division in the department is undergoing a structured process to increase patient access.

Seven divisions are currently under way and five more are in the kickoff process, with full impact to be felt in 2012 -- for the benefit of Duke patients as well as Duke staff.

Security Check: Improving Specimen Labeling

Fri, 13 Jan 2012 10:43:44 -0500

During a busy day in Duke Clinic 3K (Dermatology) in January 2010, specimen labels for two patients were inadvertently swapped.

Though a DNA-based test was able to confirm which specimen went with which patient, the patient safety event triggered a root cause analysis to identify the factors that contributed to the event and establish steps to avoid similar events in the future.

Kelly Nelson, MD, medical director of Clinic 3K, and the PDC Accreditation and Patient Safety group looked for opportunities to improve specimen labeling within the clinic. She answers questions related to how they've improved labeling.

Describe how you approached the analysis of the labeling process.

Nelson: During the root cause analysis, we mapped out all of the steps that take place every time a provider in our clinic decides to perform a skin biopsy.

We then identified “forced functions” to remind team members about essential safety events; for example, before we put a patient label on the specimen bottle, we ask the patient to tell us their name and date of birth, and we double-check the accuracy of their label.

The Safety Committee for the Department of Dermatology, made up of medical assistants, registered nurses, nurse managers, and resident physicians, refined the essential steps and discussed our recommendations at a Grand Rounds presentation. The department faculty, residents, and nursing staff provided us with critical feedback and suggestions for improvement.

Once we developed a plan that everyone felt was suitable, we trialed and refined the new labeling process in my clinic before launching it to the department as a whole, which happened about eight weeks after the originating specimen labeling event.

What were some of the goals you had in mind with this project?

Nelson: Our first (and largest) goal was to improve the specimen labeling process, but we have since identified other areas for improvement within the department.

We have created an environment where discussing opportunities for continuous improvement is “safe.” The entire faculty and staff have observed our open, respectful, and collaborative discussions about high-quality and safe patient care, which has empowered all members of our care team to speak up with concerns about patient safety.

Could you describe the feedback thus far?

Nelson: The feedback has been profoundly positive. We have seen a significant decline in the number of specimen labeling events, despite adding a new off-site clinic (Duke Dermatology at Patterson Place), hiring four providers, and generating over 6,400 specimens per year.

Dr. Sean Thomas, one of our senior residents, and I presented our specimen labeling initiative and preliminary data at the Duke Medicine Patient Safety and Quality Conference and were very honored to be recognized as an outstanding Patient Safety presentation. It has also been very rewarding to share our straightforward, low-cost initiative with other Duke departments.

Advanced Imaging: Balancing Patient Safety and Image Quality

Fri, 13 Jan 2012 10:38:11 -0500

With no pain and little discomfort for patients, computed tomography (CT) scans provide physicians with a wealth of information, allowing them to more accurately diagnose and treat disease or injury.

Like most medical imaging procedures, CT scans expose patients to small amounts of radiation, which can add up over time. In the absence of national regulations regarding CT radiation doses, Duke researchers are investigating evidence-based ways to protect patients from excess radiation while maintaining the highest level of image quality.

Reducing Radiation Exposure, Preserving Image Quality

It sounds simple, but reducing exposure takes more than adjusting a knob -- there’s a direct relationship between dose and image quality: as radiation decreases, so does quality.

“If the dose is reduced to a level that the image quality is poor, you’re not doing any service to the patient,” says Ehsan Samei, PhD, professor of radiology, whose research focuses on finding the delicate balance between the two.

“Duke is one of the national leaders in the reduction of radiation dose, especially for pediatric patients,” Samei says.

For years Duke has used a color-coded system to ensure that children receive the right amount of radiation for their size and age. Now researchers hope to develop similar guidelines for all patients.

Using computer-simulated patients -- referred to as phantoms -- Samei and his team are determining the lowest dose needed to obtain high-quality images for any CT scan. Manipulating the phantoms provides data on patient variables such as height, weight, age, and gender.

Less than a year into a NIH-funded project (co-directed by Samei and Paul Segars, PhD), the results are already being used at Duke to optimize select CT procedures.

To further reduce radiation, Duke is transitioning to advanced-reconstruction CT machines, which provide more information than traditional scanners. “Because we take advantage of every iota of information that every snapshot is providing, we can reduce the radiation dose by 30 to 50 percent,” Samei says.

Duke currently has two advanced-reconstruction scanners and will add more over time, starting with the Duke Cancer Center and Duke Medicine Pavilion.

To monitor these efforts, Duke is tracking the amount of radiation used for all CT scans across the medical center. This comprehensive quality control tool ensures that protocol is being followed and allows researchers to independently “verify that we are doing what we think we are doing,” says Samei.

Multimodality Concurrent Therapy: Improving Communication and Patient Safety

Fri, 13 Jan 2012 10:28:08 -0500

Multimodality concurrent therapy has changed the way cancer is treated, but can present challenges in the coordination of care.

If communication fails between the interdisciplinary team members, essential components of care can easily fall through the cracks and prevent the patient from receiving optimal care and result in a lack of timely intervention.

“The current handoff process of faxing patient information between nurses and providers resulted in a negative trend of patient care incidents,” says Carrie Byrns, clinical operations director at Duke Raleigh Cancer Center. “After an in-depth review it became evident that a new handoff process was needed.”

An interdisciplinary team including Cancer Center staff from medicine oncology and radiation oncology was established to determine where communication was failing. It became evident that a new process was necessary to improve patient flow and efficiency within the Cancer Center.

After identifying specific issues related to communication, follow-up appointments, and parameters/criteria for treatment interventions, the team recommended that a new role of concurrent therapy nurse be established. Additionally, a concurrent therapy form was created for use in the handoff process.

The concurrent therapy nurse serves as the primary person responsible for coordination of the plan of care for all concurrent therapy patients.

The coordination is further enhanced through interactions at the bimonthly interdisciplinary rounds as well as the morning huddle where information is communicated to all nursing staff and providers.

Data collected to date has demonstrated a decrease in patient care incidents and improved communication and handoff processes for concurrent therapy patients.

“The addition of a concurrent therapy nurse to the care team has improved the handoff process, thus improving patient safety and ensuring proper oversight of the concurrent therapy regimens,” says Byrns.