# 61 –Sustainability – 2011 original project

The PS2 Rotation: Integrating Training in Invasive Bedside Procedures with training in Patient Safety/QI

By Patricia I. Wathen MD, FACP

Megan Freeman MD

Background

Residency programs have been challenged to develop innovative approaches to teaching patient safety and quality improvement. At UTHSCSA the need to teach these concepts was paired with the goal of improving the safety of invasive procedures performed by internal medicine residents. This initiative, called the PS2 rotation, is in its third year and represents a sustained effort that has had a positive effect on resident education and the quality of patient care.

Description of Project

The PS2 rotation(Patient Safety/Procedure Service) is a required rotation for first year internal medicine residents. Two or three PGY-1 residents, led by a Chief Resident. perform procedures such as paracentesis, thoracentesis, and lumbar puncture for inpatient teams and affiliated hospital emergency department and clinics. Training includes instruction in a simulation lab and use of bedside ultrasound. Residents also participate in root cause analysis and longitudinal QI projects. Since the inception the PS2 residents have measured the impact of the procedure service on the safety and timeliness of invasive bedside procedures performed by the team.

Outcomes

In the first year of the program, residents on the PS2 rotation performed 300 paracentesis, 121 thoracentesis, 76 lumbar puncture and 30 arthrocentesis. Sixty-seven procedures were deferred due to patient safety considerations, most commonly coagulation parameters. Residents participated in eight root cause analysis. All 25 residents completed the IHIOpenSchool basic certification. Scores on the QIKAT improved from 8.4 to 11.5.

Additional outcomes included:

1) reduction in pneumothorax rates after thoracentesis from 12% to 4%

2) reduction in time to paracentesis from 15 hours to 12 hours

3) prevention of admission by performance of procedures in the emergency department, for an estimated cost savings of $120,000.

4) reduction in need for radiologic 'marking' of fluid for paracentesis, from 79% to 47%, for an estimated cost savings of $20,000.

Based on the initial data, coagulation parameters were developed to guide teams requesting invasive procedures (see supporting documents). In the second year residents performed 371 procedures . Rates of pneumothorax after thoracentesis declined to 3%. Sixteen admissions were prevented for an estimated cost savings of $90,000. Final scores on the QIKAT rose to 12.5.

The average rating for the learning value of the rotation a 4.58 on a 5 point Likert scale (average for all rotations is 4.3/5). Chief residents and residents participated in scholarly work related to the rotation with one published article, two podium presentation, and four posters presented by residents at regional and national meetings.

Conclusion

The PS2 rotation has improved resident training in bedside procedures, introduced residents to important concepts and approaches to patient safety. It has resulted in measurable improvements in patient safety, costs, and the efficiency of care. Ongoing projects of the PS2 rotation include studying appropriate test ordering related to procedures and participating in an outpatient quality improvement project.

Supporting documents

Table 1. Procedures performed by the PS2 Team July 2011-June 2012

performed / Unsuccessful
attempt / Complications* / Declined/deferred due to safety concerns / Insufficient fluid by US
Paracentesis / 300 / 2 / 7 / 19 / 65
Thoracentesis / 121 / 2 / 6 / 20 / 41
Lumbar Puncture / 76 / 10 / 2 / 23
Arthrocentesis / 30 / 3 / 0 / 4
CVC / 9 / 3 / 0 / 1
I and D of abscess / 4 / 0 / 0 / 0
TOTAL / 540 / 19 / 15 / 67 / 106

Table 2: Coagulation parameter developed by PS2 team

Procedure Type / Platelet Count / INR / DVT Prophylaxis / Therapeutic Lovenox / Therapeutic Heparin / ASA / Plavix
Paracentesis / 10K[1] / None1 / Can be given[2] / Hold 12 hours prior2 / Hold 6 hours prior2 / Can be given2 / Can be given2
Thoracentesis / 25K[3] / INR <2.023 / Can be given2 / Hold 12 hours prior2 / Hold 6 hours prior2 / Can be given2 / Can be given2
Lumbar Puncture / 40K [4] / INR <1.5[5] / Hold 12 hours prior2 / Hold 24 hours prior2 / Hold 6 hours prior2 / Can be given2 / Hold 7 days2
Arthrocentesis / 25K[6] / INR <2.026 / Can be given2 / Hold 12 hours prior2 / Hold 6 hours prior2 / Can be given2 / Can be given2
Central Line / 20K[7][8] / INR <2.08 / Can be given2 / Hold 12 hours prior2 / Hold 6 hours prior2 / Can be given2 / Can be given2

Runyon, B.A., Management of Adult Patients with Ascites Due to Cirrhosis. Hepatology, 2004. 39(3): p.841-856.

2 Malloy, P.C., Grassi, C.J., Kundu, S, et.al. Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions.Journal of Vascular Interventional Radiology, 2009. 20: p.S240-S249.

3 Patel, M.D., Joshi, S.D., Abnormal Preprocedural International Normalized Ratio and Platelet Counts Are Not Associated With Increased Bleeding Complications After Ultrasound-Guided Thoracentesis. American Journal of Roentgenology, 2011, 197: p.W164-W168.

4 Van Veen, J.J., Nokes, T.J., Makris, M., The Risk of Spinal Haematoma Following NeuraxialAnaesthesia or Lumbar Puncture in Thrombocytopenic Individuals.British Journal of Haematology. 2009, 148: p. 15-25.5

5Layton, K.F., Kallmes, D.F., Horlocker, T.T., Recommendations for Anticoagulated Patients Undergoing Image-Guided Spinal Procedures. American Journal of Neuroradiology, 2006, 27: p.468-470.

6O’Connor, S.D., Taylor, A.J., Williams, E.C., Winter, T.C., Coagulation Concepts Update. American Journal of Roentgenology, 2009, 193: p.1656-1664.

7Zeidler, K., Arn, K., Senn, O., et.al. Optimal Preprocedural Platelet Transfusion Threshold for Central Venous Catheter Insertions in Patients with Thrombocytopenia.Transfusion, 2011, 51: p.2269-2276.

8Haas, B., Chittams, J.L., Trerotola, S.O., Large-bore Tunneled Central Venous Catheter Insertion in Patients with Coagulopathy. Journal of Vascular Intervention Radiology, 2010, 21: p.212-217

Figure 1: Effect of PS2 team on time to paracentesis