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May 14, 2019

Continuously improving patient care

Marybeth Sexton, Shailly Shah, Kim Cooley

"For Our Patients, For Our People" was the theme of the 2019 Emory Quality Conference held earlier this month. Gary Kaplan, chairman and CEO of Virginia Mason Health System, delivered the keynote speech. Virginia Mason was one of first health systems to adopt the Lean operating system, and Kaplan shared lessons learned. Attendees then adjourned to view the finalists in the quality innovation poster contest. Selecting this year's finalists, and then winners, was even harder than in years past. Submissions jumped to 180 from an average of 125, and the quality of the submissions continues to improve. "It was very hard to choose the winner with so many excellent posters," says Nate Spell, director of the EHC Quality Academy and associate dean for education and professional development at the medical school, who oversees the poster competition. "We finally identified our top two, but we just couldn't pick between them, so we had a tie for Best Overall Poster."

Infectious disease specialist Marybeth Sexton, director of antimicrobial stewardship for Emory University Hospital (EUH), presented work from a multidisciplinary team that claimed one of the top awards for an initiative to increase the use of cephalosporins for perioperative prophylaxis in penicillin-allergic patients. These antibiotics are the gold standard for preventing surgical site infections, but surgical and anesthesia teams were often reluctant to use them in patients who were allergic to penicillin.

Sexton's team included another infectious disease physician, two attending anesthesiologists, an anesthesia resident, a surgeon, and an allergist. Their research showed that perioperative use of cefazolin or cefuroxime was safe in the vast majority of patients with a penicillin allergy label, excepting a small subset with a history of a reaction involving skin blistering or organ damage.

To get this message out, the team conducted two educational presentations--one at an anesthesiology morning conference at EUH and the other at anesthesia grand rounds. The response was surprisingly strong. Use of cephalosporins in penicillin-allergic patients jumped from less than 10% before the intervention to almost 90% after.

"The literature shows that educational interventions aren't necessarily effective," says Sexton. "I think this one was so successful because the message was so simple and because it was presented by a multi-disciplinary team with members from medicine, surgery, and anesthesiology."

Shailly Shah, director of inpatient pharmacy at Emory University Hospital Midtown (EUHM), led the other team that tied for Best Overall Poster. This team, which included pharmacists, pharmacy leaders, clinic administrators, a point of service representative, registration and admissions staff, and the unit director for the inpatient infusion floor, tackled the problem of lengthy wait times for inpatient chemotherapy for patients who had planned admissions from the EUHM Hematology Oncology clinic.

"We were getting a lot of complaints from patients, so pharmacy was working on improving its practices. The unit was also working on improving its practices. But none of us were working together," says Shah.

Unit director Dushon Copper and Shah assembled the team to go through every process and department involved in admitting a patient for inpatient chemotherapy, and they found it was quite cumbersome. Patients had to go to the clinic to check in, get labs drawn, and see the physician. Then they went to admissions to check in, where they would often wait two to three hours before being sent to the unit for infusion.

Clinic staff were not aware they could schedule appointments by specific times for these patients, not just on a specific day. The team asked the clinic staff to use this scheduling feature so patients are now staggered throughout the day, streamlining the flow. And now patients go directly from the clinic to the infusion unit, where admissions staff come to them. Finally, the team standardized and streamlined the process from placing the order for the chemotherapy drugs to their delivery in the unit.

The changes shaved off an average of two hours from the whole process. "We were each trying to fix things within our separate departments, but we learned we could only make an impact when we worked together," says Shah.

Kim Cooley, clinical nurse specialist at EUHM, led the team that won the Outstanding Safety Results award. In response to an uptick in central line bloodstream infections (CLABSIs) in newborns, the team investigated the problem and initiated two interventions. They found that the hub, or the access point that connects to the central line, was not being cleaned long enough prior to introducing the medicine. So they reeducated staff on proper "scrub the hub" techniques. They also developed a CLABSI checklist that included asking two questions about each infant in the nursery--"Does the central line need to be in today?" and "If this baby did not have a central line, would we start one today?"

As a result of both interventions, the median number of central line days in the nursery dropped from 205 in 2015 to 125 currently, and the nursery went 568 days with no CLABSIs.

See a list of other winners in this year's competition. --Martha McKenzie

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