SYSTEMS BASED PRACTICE EXAMPLES
Case #1:
In Conference Room Getting a Run-Down on Patients:
52 year-old male with chronic renal insufficiency secondary to poorly controlled hypertension is admitted to initiate dialysis and to get placed with a dialysis center.
Bedside Presentation: Patient is admitted from ER for initiation of dialysis. Although he has known he will need dialysis soon (he already has access), he did not always show up for his renal clinic appointments. His blood pressure has been poorly controlled and he does not always take his medications. His social history is notable for his current IVDA. His nephrologist was surprisedat how quickly he progressed over the past 6 months to the point where he requires dialysis, although not emergently. The patient was essentially admitted electively to facilitate initiation of dialysis.
Post-Bedside Discussion: You agree that there were no urgent indications for dialysis and wonder why the patient was admitted. Your team tells you that his nephrologist had a difficult time getting the patient a chair as an outpatient as he is poorly compliant and an injection drug user. The nephrologist actually told the patient to go to the ER to get admitted to start dialysis, as it might be easier to get a dialysis spot that way. At this point your team is obviously frustrated by the events that got this patient admitted through the ER to an acute hospital bed for something that medically could have been done as an outpatient.
Triggers for Teaching Matrix
Triggers for Teaching
Location
/ Topic / Transition / FailuresConference Room / Dialysis
Hypertension / Initiation of Dialysis / NA
Bedside / Dialysis
Hypertension
IVDA / Initiation of Dialysis / Compliance Issues
Post-bedside / NA / Home to Admission / Difficult Placement
Direct Admit Work-Around
Use of ER Work-Around
Topic Trigger: Dialysis Utilization
Given the major societal implications of the care of dialysis patients, you have identified that dialysis would make an excellent topic trigger to discuss larger health care system issues related to dialysis care.
Areas of Competency Addressed: 1. Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care. 2.
Residents must practice cost-effective health care and resource allocation that does not compromise quality of care
Strategies: While incorporating some important clinical teaching pearls, consider giving a brief 2-4 minute talk on how dialysis is paid for, the societal costs of dialysis (in terms of health care costs as well as lost work costs), and how even delaying dialysis by months can make real societal impact.
We have had3-4 patients this month with ESRD or transitioning to ESRD
Do you know why ESRD is covered by Medicare? In 1972 ESRD was the poster child for medical technology and costs were expected to be no more than $1,000,000/year. It is now over $22 Billion/year. We’ve talked a little about cost effectiveness and about quality of life before. What are the 6 things we could think about that might improve the patient’s quality of life and reduce costs to society?
If you could work on these 6 things, you could keep the patient off dialysis for a few months which would improve the patient’s quality of life and save society the costs associated with dialysis and increased hospitalization
Transition Trigger: Initiation of Long-Term Dialysis
You have recognized that 4 of your patients this month have transitioned from being patients with chronic renal insufficiency to End Stage Renal Disease requiring long-term dialysis this month. Recognizing that this is a major transition can highlight this as a potentially rich area to discuss Systems Based Practice.
Area of Competency Addressed: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.
Strategies: Discuss with your team that beginning dialysis is a major transition for patients. Using questions or a brief statement, emphasize the major implications from the patient’s perspective about quality of life, medical complications, etc. Then ask the team one or both of the following questions:
- What resources do you have available to assist this patient who is in the hospital to effectively and safely transition to a chronic dialysis patient upon discharge?
2a.What resources do you think would be required to provide an optimal transition?
2b.What one additional resource do you think would be most important to improving the transition process?
Failure Trigger: The Unnecessary Admission
When you recognize that the nephrologist has admitted the patient because of difficulty placing him in a dialysis chair, you have identified a marker of a broken system. While you could use the broken system itself as a discussion point, it might be more successful to use this case to discuss the work-around as the discussion about the system itself may require significant content knowledge about initiation of outpatient dialysis in the health care system in which you work.
Area of Competency Addressed:Understand how their patient care and other professional practices affect other health care professionals, the health care organization,
other health care professionals, and the health care organization.
Strategies: Begin the conversation by recognizing that the nephrologist was likely acting with the patient’s best interests in mind and that your team will be happy to take care of this patient. Consider one of several different directions you could take the discussion to talk about the downstream effects of this admission on the medical system in which you work.
- Discuss the use of the emergency room as the entry point for an elective admission. What are the possible clinical and throughput implications for this action?
- What are the financial implications for the patient and your medical center for an unnecessary admission? Depending on your payor system, the patient’s insurance may not cover the admission, leaving the patient responsible. Be prepared to talk (at least in general) about how your medical center might handle these charges (write off expense as charity care, attempt collection from the patient, etc.). Also, discuss how this decision from the medical center affects the overall system. For example, your hospital may have a limited ability to provide charity care and writing one patient’s bills off may result in another patient’s bills going to collection because of the earlier decision.
- What effect does using an inpatient bed for a non-acute patient (likely for several days while awaiting placement) have on the hospital’s ability to care for the greatest number of patients?
Case #2:
Consider this scenario:
Yesterday, an elderly gentleman was admitted with apathetic delirium. He has done better when taken off some of his medications. The team is presenting him today thinking he will be ready to go. He is not quite back to his baseline, but when they saw him that morning, he was significantly better than on admission. There were no calls from cross cover and his vitals were ok. His labs were not drawn and the senior resident feels the team should complete the dementia work-up before the patient is discharged. She tells the intern to make sure the TSH is done this morning. The intern replies that it will be fine, he will just order it stat and it will be back in a few hours. It’s frustrating but he often has to do this because his orders get lost all the time. Although the patient is some better, you are not quite sure about his readiness for discharge
Triggers for Teaching Matrix
Using the Triggers for Teaching Matrix may vary more among teachers when discussing follow-up patients then for new admissions. These differences are in large part because of the individualized approaches to rounding on these patients. We have completed the matrix below using a common process of teaching in our hospital. In this model process, there is no conference
room teaching. The patient is presented at the bedside and additional discussion takes place outside of the patient’s room.
Triggers for Teaching
Location
/ Topic / Transition / FailuresConference Room / NA / NA / NA
Bedside / Polypharmacy / Discharging the Frail Elderly / NA
Post-bedside / Polypharmacy / Discharging the Frail Elderly / The Missing Lab
1)Work-around
2)Fixing the System
Topic Trigger: Polypharmacy
Since the primary intervention your team has done to improve this patient’s clinical situation was simplifying his medical regimen, you can identify polypharmacy as a possible trigger to talk about system based practice.
Area of Competency Addressed:Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.
Strategies: Given that you practice in a system that is not an integrated health organization, use this opportunity to discuss potential advantages that integrated organizations may have compared to the more traditional system in which you work. Discuss the factors driving integrated organizations’ decisions about medication restricting/checking.
Consider the following questions:
If this patient were taken care of in an organization like the VA or Kaiser Permanente that has significant oversight of prescribing practices, how could you imagine that might have affected his clinical course leading up to this admission?
Be prepared to prompt with questions about formal medication checking and the use of reminder systems.
Ask the team to discuss how patient safety might make business sense. Be prepared to prompt with questions about: 1. Reducing costs of adverse events 2. Ability to Market Quality
Transition Trigger: Discharging the Frail Elderly
You have identified a common high-risk transition situation: an elderly patient with significant change in functional status being prepared to return home. This is an excellent opportunity to determine your team’s understanding of resources available to them to make this transition as safe as possible.
Area of Competency Addressed:Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance
Strategies: Remind your team that aStrategies: Recognize that assessingreadiness for discharge in frail elderly often requires a multi-disciplinary approach. Ask your team to tell you what resources they can draw on that already exist within your medical center that can help make this difficult decision including assessing safety, support at home, change from baseline functional status, and likelihood that the patient will succeed at home?
What it looks like: 3-5 minute interactive session with open-ended questions. Be prepared to use prompts so you need to know the answers.
Nursing: Nursing Documentation (intake sheet), MD/RN communication
PT: Assesses physical skills in ADLs
OT: Assesses ability to perform independent self-care
SW: Assesses resources available and vulnerable elder issues as well as support structure.
Nutrition: Assess need for nutritional supplementation
Physiatry: Assesses readiness for participating in various rehab centers
Failure Trigger: The Missing Lab
Approach #1: The Work Around.
You identify what is likely a common work around with the intern ordering the TSH as a STAT lab (which clearly does not meet the criteria for STAT). You can take the opportunity to turn that into a teaching point about systems based practice.
Area of Competency Addressed: Understand how their patient care and other professional practices affect other health care professionals, the health care organization,
other health care professionals, and the health care organization.
Strategies: Remember to acknowledge that they are working within a broken system and that they are trying to care for their patient as best they are able. However, it is important to understand how their work-arounds, while seemingly in the best interest of the patient, may have significant downstream effects.
Ask intern open ended question about what effects ordering that lab STAT may have within the hospital system.
Be prepared to prompt with:
- How about on your fellow interns?
- What if they needed a lab STAT for a crashing patient and your TSH request gets to the lab 1 minute prior to the real STAT lab?
- Can you imagine a way that your ordering that lab STAT actually contributes to the very problem you are trying to work around?
- What if the lab has a limited number of people and the STAT lab processing takes more person time than scheduled labs?
Approach #2: Changing the System
You recognize that the system is broken and is likely a very complicated issue. While not being able to solve the problem during a busy attending month, you can take the opportunity to talk about how your team could start solving the problem if they had the time and resources.
Area of Competency Addressed:Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.
Strategies: Recognize that it is frustrating to work within a broken system, particularly when as a trainee you may feel you have little ability to change the system. However, emphasize that it will become increasingly important for them to learn the skills to be able to affect change as they advance in their career.
Tell the team that you know you cannot solve the problem in reality. But have them imagine that this team actually had the time and resources to devote to solving the problem. Ask the following:
- Would we be able to fix the problem ourselves, if we had an unlimited budget?
(This will emphasize the need for involving a multi-disciplinary approach.)
- Who would be the other players we would need involved to address this issue?
(Nursing, Ward Clerks, Phlebotomy, Lab Processing, Lab, Lab Reporting)
Leave a few minutes to discuss where they feel the point of greatest impact might be.
Practice Case:
For the following case, complete the topic triggers and related information below. Remember, that there may be multiple triggers among a single type (eg. Topic). In order to complete the Teaching Trigger Matrix, think about your own process of rounding on patients you already know. Imagine how and where you might hear about the specific information given your rounding procedures. This will likely be highly variable reflecting each individual’s rounding/teaching methods.
74 year old female who is otherwise healthy was admitted to your service with community acquired pneumonia. She has developed atrial fibrillation with a rapid ventricular response. After initial attempts at rate control, it becomes clear that she will need to be moved to a telemetry bed. However, the only floor tele bed that is open is being saved for any CT surgery patient that might be transferred from another hospital as per your hospital’s policy. Therefore, you need to transfer this patient to the intensive care unit. This transfer requires a transfer to anther medicine team, while your house officers know that they will be getting the patient back the next day once she is stable for an unmonitored bed or a floor telemetry bed opens up. All of this transferring requires additional work for multiple medicine housestaff.
Triggers for Teaching Matrix
Triggers for Teaching
Location
/ Topic / Transition / FailuresConference Room
Bedside
Post-bedside
Topic Trigger: ______
Area of Competency Addressed: ______
Strategies: ______
Transition Trigger: ______
Area of Competency Addressed: ______
Strategies: ______
Failure Trigger: ______
Area of Competency Addressed: ______
Strategies: ______
Teaching Trigger Matrix
Page 1 of 8