Interprofessional Education

Today's installment of the Inter-Professional Education series was delivered by Kristi Larned, pharmacist, on situational awareness in the clinic between our IPE members. Our clinic consists of attending physicians, med students, nursing students, pharmacists, and other related healthcare professionals such as administrative assistants and patient recruiters.

Situational awareness: 

• Understanding of, or knowledge about, a situation or process that is shared among team members through communication.
• Being attentive to the environment.
• Technique used in decision-making in settings that need quick action.
• A skill that can be improved over time.

Situational monitoring:

• Pay attention to the status of the patient
• Cross-monitor team members
• Survey environment
• Preventing errors that may be caused
• Fosters mutual respect and communication for team members
• Ensures everyone on the team has an idea of what it should look like
• Enables team members to predict and anticipate better
• Creates commonality between members
• Progress toward goal

Barriers:

• Distraction
• Workload
• Fatigue
• Misinterpretation
• Failure to share information (forgot, distracted)

Shared mental model: 

• Perception
• Understanding of or knowledge about a situation or process that is shared among team members through communication.
• Increased accountability

Situation Monitoring Prescribed to:

• Rounds, which are quick
• When more attention is given to patients with more acute conditions.
• People are talking over the team so it's easy to miss information

Strategies to overcome this:

• Checklists
• Engage the patient when discussing regimen
• Helping others with a heavy workload
• Cosigner making sure you're doing everything complete
• Huddles, debriefs, more communication
• Cross-monitoring

Clinical encounter:

• 47 year old female
• History of coronary artery disease, diabetes, mild hypertension
• Status post CABG (Coronary Artery Bypass Grafting) and NSTEMI (Non-ST segment elevation myocardial infarction).
• Chief complaint: shortness of breath and intermittent substernal discomfort.

Our plan to address patient:

• Getting a set of vitals to figure out tests to run
• Approaching the pt directly to identify the cause of SOB
• Survey the scene for any helpful people around
• Notifying the appropriate personnel
• Start triaging

Image of the Week 11/18/2014

What physical examination finding is displayed on this nail? Why does this condition develop?

Image of the Week 11/11/2014

What is notable about this patient’s hands? What diseases contribute to this condition?

Infectious Disease Case

Our talk this evening was on an infectious disease (ID) case by Sarah Housman, Primary Care Resident at BIDMC.

Case:
A 21M patient who is otherwise healthy complains of a sore throat, fevers, and chest pain. He had a fever 3 days prior. A nurse told him he had strep throat and started him on penicillin. The patient says it feels like someone is sitting on his chest.

In clinic:

• Has strep throat, no remarkable physical exam
• WBC 12
• 70% Neutrophils
• Trop 0.32
• CRP 91
• EKG: ST elevation everywhere
• Day 2 Labs showed Trop 1.09
• Echocardigram shows focal myocarditis and myoregional systolic dysfunction.

Differential Diagnosis:

• Myocarditis (inflammation of muscle tissue, enzyme count increases)
• Pericarditis (inflammation of lining of heart, ST and PR elevation on EKG)
• Myopericardits (heart tissue inflammtion and damage --> CRP elevation)

Diagnosis:
The patient has myopericarditis. Diagnose for both pericarditis and myocarditis conditions by EKG changes, auscultation, pleuric chest pain, cardiac enzymes elevated, depressed injection fraction certain areas are hypokinetic, and look at the MRI.

Treatment:

• NSAIDs (for 2 weeks)
• Cholchicine to prevent recurrence by inhibiting microtubule formation (for 3 months).
• The most common side effect is diarrhea.
• Patients who are at risk of peptic ulcer disease, kidney disease don’t tolerate NSAIDs.

What about the Strep Throat?

• Group A strep can cause myocarditis.
• This patient could have rheumatic fever.
• Use JONES Criteria to help diagnose.

JONES Criteria:

• J- joint pain and migratory polyarthritis
• O- (represents a heart) carditis
• N- painless nodules on achilles tendon
• E- erythema
• S- Sydenham's chorea

For diagnosis: one major criterion (chorea, carditis, migratory arthritis) PLUS two minor criteria (fever, arthralgias, elevated ESR and CRP, prolonged PR). Our patient has 1 major and 2 minor criteria.

Why not Rheumatic Fever?

• 2-4 weeks after developing strep throat, rheumatic fever develops.
• This patient's timing is 2 days, making rheumatic fever an unlikely case.

Conclusion:

• Because he met the criteria, the patient should go to the ID clinic and be treated for rheumatic fever. 
• Patient is on long term penicillin (5 yrs while he’s in college since he’s at the risk of getting strep again). 
• Also treated for myopericarditis with NSAIDs for 2 weeks and Colchicine for 3 months.

Image of the Week 11/04/2014

What injury of the ear is shown in this image? What causes this condition?

Interprofessional Education Using TeamSTEPPS

Today’s talk and interactive session were delivered by Amy Weinstein on IPE Teams in Primary Care.

TeamSTEPPS 

• The program our clinic uses for inter-professional education.
• Provides an opportunity to learn about them to enhance patient care. 
• Created by the AHRQ that provides skills in 4 areas for us to work in teams. 
• Performance
• knowledge
• skills
• attitudes
•  This nationally studied program works. 
• We can see a 50% reduction in weight adverse outcome score which describes the adverse event score per delivery. 
• We also see significant improvement in teamwork outcomes, communication, supportive behavior, reductions in turnover rate, increases in employee satisfaction, and better continuity of care.

IPE teams consist of attending physicians, med students, nurses, pharmacists, social workers, case managers, admins, medical assistants, front desk. The physician and nurse workflows sometimes do not line up. Some of them, such as the phone scheduling staff, are never seen when working with patients yet they are all part of patient care. How do we interact with all of these team members? TeamSTEPPS is designed to break down the barriers and come together as a team.

Barriers to teamwork:

• people: workload, distraction, conflict 
• systems: hiearchy, lack of coordination, miscommunication, lack of role clarity.

Case— Background: 
The patient is a 49 y/o F with Type 2 diabetes and depression comes in for follow up care. She takes Lantus and Humalog. The patient also takes insulin morning and evening, but rarely at lunch. She's been getting increasingly depressed.

MD: Biggest concern is depression
PharmD: Wants to review medication regimen and discuss action plan for hypoglycemia

Case— Clinical encounter: It’s a busy IPE night and the team rushes off to see the patient before huddling. The attending goes in with her own agenda about depression and the PharmD doesn’t get to talk to the patient about hypoglycemia and changes to the medication regimen. The MD thought the visit went well but not the PharmD.


Strategies for addressing breakdowns: 

1.  Leadership: 
• Process of motivating people to work together
• Anyone can be a leader
• They are role models who shape teamwork through open sharing of info
• Give constructive and timely feedback
• Faciliates briefs, huddles, debriefs, and conflict resolution. 
• Organize ppl to achieve common goal.
• Involves planning, processing, and improvement.
2. Planning: 
• form the team and huddle
• designate team roles and responsibilities
• establish climate and goals
• engage in short and long term planning
3. Problem solving: 
• touch base
• discuss critical issues and emerging events
• anticipate outcomes and likely contingencies
• assign resources
• express concerns.
4. Debrief:
• brief and information information exchange and feedback session
• occurs after event or shift
• designed to improve teamwork skills
• designed to improve outcomes
• recognize what good teamwork is

Case— Solutions: deal with pt chief complaint, pt centered; have a plan in advance, finding time to debrief after; knowing what the pt thinks about the plan, making sure pt understands regimen and offer perspective on big picture. have pts repeat directions back to ensure understanding, checking in mid visit. debriefing afterward. otherwise it wont be a good set up for teamwork. keep in mind that we’re all here for the pt.

Take home points: 

• Everyone can be a leader
• Hold huddling sessions
• Hold debriefs to bring the team together

Image of the Week 10/28/2014

A patient presents with the lesion on his back. What factors should the provider keep in mind in evaluating this lesion for melanoma?