Successful Resident Engagement in Quality Improvement: The Detroit Medical Center Story.

Background In 2014, the Detroit Medical Center launched a new program to engage residents and fellows in a strategy to deliver optimal care within 1 year, focusing on quality at an earlier stage of their careers and preparing them for working posttraining. Methods Residents from clinically relevant residency and fellowships programs were selected to be Resident Quality Directors. The project involved development of an interactive electronic health record (EHR) checklist to visually depict real time gaps in 40 process measures, while focusing on 14 areas related to stroke and venous thromboembolism (VTE) prophylaxis. We also implemented an incentive approach, using a pay-for-performance (P4P) model. Results The project included 800 residents led by 14 resident quality directors. We were able to achieve 100% resident participation. Prior compliance with VTE quality measures 6 months was 88.5%, with performance increasing to 94.2% (P < .006) at 6 months and 100% at 12 months (P < .005) after the intervention. The VTE prophylaxis score improved from the 89.7% to 92.9% range at inception to 100% by 12 months. A similar steady improvement of stroke process measures was observed, with a 100% compliance within 12 months. The institution made 4 incentive payments to trainees (ranging from $300 to $4,000 per year). The remaining 26 process measures remained at goal with above 95% compliance. Conclusions This quality improvement initiative was associated with system-wide quality performance on VTE prevention and stroke care process measures, which was facilitated by a interactive EHR-based checklist and linkage to P4P incentive payments.

2007 survey of medical toxicology practice.

To date, there appear to be no studies investigating the practice settings of all Medical Toxicology (MT) diplomates. The MT Assessment of Practice Performance Taskforce queried all MT diplomates about their current practice settings relative to the number of patients seen, the most common diagnoses, and the percent of time spent in their roles as medical toxicologists (MTs) and in their primary specialty. One hundred twenty-seven surveys were completed (44% response rate). Seventy-nine percent of respondents were affiliated with poison centers. Eighty-eight percent of participants were clinically active and reported seeing or consulting on behalf of at least ten patients over a 2-year period. Acetaminophen toxicity was the most common diagnosis encountered by respondents. Other common diagnoses included antidepressant toxicity, antipsychotic toxicity, mental status alteration, metal/environmental toxicity, envenomation, and pesticide toxicity. While respondents were likely to spend more time in direct patient care in their primary specialty, compared to consulting on behalf of patients, they were more likely to consult on behalf of patients in their role as MTs. Respondents spent more time in research, education, and population health in their role as an MT than in their primary specialty. Administrative activities were more commonly reported in association with the respondents' primary specialty than in their role as MTs. Most MTs encounter certain diagnoses with significant frequency and see a substantial number of patients within these categories. The majority spends more time on direct patient care in their primary specialty but is actively engaged in MT education, research, population health, and administration. A longitudinal assessment of MT practice patterns could inform MT curricular development and practice performance evaluation.

2007 survey of medical toxicology practice improvement activities.

To date, there appear to be no studies that assess Medical Toxicologists' (MTs) practice improvement (PI) activities in their Medical Toxicology practice settings. The MT Assessment of Practice Performance (APP) Taskforce queried all MT diplomates about (1) activities currently available in their practice settings that potentially would meet the requirements of APP, (2) potential APP activities that best fit with current MT practice, and (3) the relationship between MT practice patterns and APP requirements. One hundred twenty-seven surveys were completed. Participation in MT practice improvement activities is not universal, with approximately a third of the survey participants reporting that they are not involved in any practice improvement activity. Few respondents reported that they collected performance improvement-related data. Most who did so participated in CME, case, or chart reviews. Peer reviews, self-improvement plans based on chart reviews, and population research were considered the most valid measures of MT practice improvement. Communication skills were considered important topics for patient surveys. Suggested outcomes for peer assessment included accuracy of information provided, understanding medical staff concerns, timeliness of feedback, and helpfulness. Most respondents rated all of the APP options as being somewhat very intrusive. Access to those with sufficient knowledge of the diplomate's practice improvement program to verify APP could pose a challenge to a successful completion of APP requirements. Optimal settings for the APP program administration are hospitals and poison centers. While barriers to MT APP activities exist, studying current MT diplomates' opinions and practices could inform the future development and administration of such programs.

Demand for poison control center services "surged" during the 2003 blackout.

BACKGROUND: Beginning 8/14/03, for 24 hours, the largest geographic power failure in U.S. history occurred. Our Poison Control Center (PCC) catchment area was one of the most severely affected, with most of the population left without electricity, fuel, water pressure, or municipal potable water. The paucity of reports on the impact of disasters on PCC operations led us to summarize our experience. METHOD: Data sources included 1) Toxicall human exposures during 8/03 (with comparison to 2002 and to national trends) and 2) an after-action report completed by Specialists-in-Poison Information (SPI's) on duty during the disaster. RESULTS: The average call volume for 8/03 increased by 7.8%. Significant increases in human exposure and information calls occurred in four categories: gasoline, carbon monoxide, food poisoning, and water contamination. After-action report findings included: vulnerability of PCC operations to interruptions in power supply; lack of redundant communication methods; staffing challenges; and exclusion of PCC staff from hospital disaster plans despite co-location. CONCLUSION: During the blackout of 2003, there was a measurably increased demand for poison center services. PCC disaster plans should address increased staffing needs during the time of disaster, communication system redundancy, back-up power supply, and SPI needs (food, water, transportation, environmental safety, and rest/rotation).

Medical management of vulnerable populations and co-morbid conditions of victims of bioterrorism.

Planning for the medical response to bioterrorism has primarily focused around the needs of the population as a whole. There has been little discussion pertaining to certain vulnerable groups such as children, pregnant women, or immunocompromised patients, yet they will likely comprise a significant subset of the exposed population. In addition, they will be at increased risk for morbidity and mortality following an attack. The emergency response to bioterrorism will be more complex as it relates to these vulnerable populations. Careful consideration of their special needs, some of which are presented in this article, may refine our efforts.

Amphetamine toxicity.

Amphetamine abuse is widespread and associated with significant health risk. The most commonly encountered amphetamines are methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy), and the ephedra alkaloids. Although each of these harbors unique toxicity, they similarly impact the cardiovascular and neurological systems in overdose. Other serious complications associated with amphetamine abuse include severe hyperpyrexia and hyponatremia. Secondary conditions such as rhabdomyolysis, disseminated intravascular coagulation (DIC), gastrointestinal (GI) bleeding, hepatic necrosis, and renal failure are common, especially in those with hyperthermia. Chronic abuse poses risk of vasculitis, neuropsychiatric abnormalities, and cardiomyopathy. In addition, there is a growing body of evidence that even recreational abuse of methamphetamine and MDMA may produce long-lasting damage to dopaminergic and serotonergic neurons. Management principles include adequate sedation, aggressive cooling, and the use of titratable agents in the management of cardiovascular abnormalities.