Anesthesiology, Perioperative and Pain Medicine

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Q&A with Stanford Anesthesia's Residency Director

November 2014

What Quality and Safety curriculum is there in the Stanford Anesthesia Residency?

QI activities are increasingly intertwined within the anesthesia residency as anesthesiologists are expected to be problem solvers in all hospital areas. For residents there are many available opportunities for example:

1) CA2 class QI program. The CA2 resident class is divided into 4 groups of 6-7 with each group tackling a QI project for 12-18 months. Dr. Ruth Fanning is the Faculty Director and leads one of the 4 groups. Dr. Sam Wald (OR Medical Director), Dr. Bryan Bohman (Chief Medical Officer for University HealthCare Alliance) and Dr. Tom Caruso (Pediatric anesthesia) lead the 3 other groups.

2) During residency an individual resident can propose to complete a QI project during their conference week time. Or, they can choose to complete IHI Open School Program QI/Patient Safety available at http://www.ihi.org/OFFERINGS/IHIOPENSCHOOL/Pages/default.aspx

3) 4 week Quality and Safety Rotation Elective is available.


FAQs

What percentage of stanford anesthesia residents participate in patient safety programs?

100 % of residents participate in simulation and immersive programs that are built around the principles of Crisis Resource Management. Over 70 % of medical errors causing patient harm result from poor non–technical or crisis resource management skills. Training in these skills has been shown to improve patient safety and outcomes.

100% of residents are versed in the use of cognitive aids and have through active participation and feedback, enhanced the implementation of these aids.

Within each core rotation, 100 % of residents participate in patient safety programs, evidence based clinical care pathways, and patient outcome improvement measures.
Examples include:
Universal protocol: All procedural sites, including operating rooms, radiology suites, endoscopy suites etc. All residents participate in “The universal protocol”, leading the anesthesia time–out, and actively participating in the general time-out protocol.

SCIP Measures: For example, all residents participate in complying with and documenting Core Measures. Antibiotic administration within a 1 hour window prior to incision typically lies at 98-100% compliance rate.

Sepsis bundles to reduce morbidity and mortality from sepsis: 100% of residents participate in the SEPSIS bundle for reducing CLABSI, adopting hand-washing and sterile barrier techniques for invasive line placement and management.

Safe Blood administration: 100 % of residents participate in safe blood administration practices which includes a two step verification process for cross matching blood and a two person checking system prior to blood administration.

Critical incident reporting, investigation and performance improvement: 100 % of residents are actively involved in critical incident reporting and exploration, during regular morbidity and mortality meetings led by Dr. Fanning.


What are examples of recent projects led by residents?

1. Standardizing and improving the ergonomics of the anesthesia medication and supply cart.
2. Radiation safety education and lead apron availability in the Stanford main OR suite

Both of these projects are being written up by the senior residents for publication.


Are stanford anesthesia housestaff taught basic QI methods?

All residents apply Root Cause Analysis, Failure Mode Effect Analysis to cases presented during Morbidity and Mortality meetings.

Residents have also been educated on, and have the ability to report adverse events through the institutional SAFE reporting system, or the departmental critical incident reporting system on the departmental website, ETHER, and the ASA based AQI reporting system. Approximately 30 % of residents will be involved in a SAFE report at some stage in their residency, through their involvement in a critical or patient safety incident. Residents involved will receive feedback on the incident, with suggestions for performance improvement opportunities.


How does the resident engage in perioperative care optimization for patients?

Residents play an active role in optimizing patients in the preoperative anesthesia clinic, and in managing postoperative problems in the PACU. Two residents actively manage patients in the preanesthesia clinic and 1 in the PACU, under attending supervision.

This perioperative care continues post-op where all residents complete the acute pain rotation, managing patients’ pain and comfort until hospital discharge. Perioperative pain management has been markedly improved through such Anesthesiology/Pain specialist-led acute pain programs.

100% of residents in the ICU rotation participate in the SEPSIS reduction initiative and Rapid Response Teams. Both initiatives have been shown to improve patient outcomes.


What QI committees do residents serve on?

1. the anesthesia dept Quality, Efficiency and Patient Satisfaction committee
2. the hospital Quality, Patient Safety and Effectiveness group
3. Resident Patient Safety Council
4. Care improvement committee
5. Medication SAFE report review committee

to name a few.


What percentage of residents participate in inter-professional clinical quality improvement programs to improve health outcomes?

All stanford anesthesia residents go through the required obstetric anesthesia rotation at Stanford during which they participate in “In-situ” inter-professional team-based simulations, both in obstetric and neonatal care teams and participate in interdisciplinary team rounds and huddles. Residents are actively involved in the multi-disciplinary high-risk patient care team, shown to improve the care of high-risk obstetric patients.

All residents also rotate through the pediatric anesthesia rotation at Packard Children's Hospital & participate in the interdisciplinary postoperative handover program known as IPASS, shown to improve handover communication and continuity in patient care. This year, multi- disciplinary in-situ simulation based team-training will be expanded.

100% or residents rotate through the acute pain rotation and are involved in multi-disciplinary care pathways shown to improve patient outcomes. One such program is the hip fracture care pathway, where residents place and manage peripheral nerve catheters in hip fracture patients.

100 % of residents rotate trough the ICU where they are involved in multidisciplinary rounds, Schwartz patient care rounds, and inter-disciplinary teams such as rapid response and outreach teams. All residents also participate in simulation based inter-disciplinary team training exercises, both in situ, and in the simulation suite.

Currently approximately 5 % of residents have participated in a multidisciplinary simulation based team training pilot program. Over the next year, all residents will participate in a hospital-wide interdisciplinary team-training program, “Transform”, fostering interdisciplinary team training with the aim of improving patient outcomes.

All residents play an active leadership role in inter-disciplinary teams during their PACU rotation, VA chief rotation, and/or Ambulatory surgery center perioperative management rotation. The residents gain valuable experience in leading inter-disciplinary teams to improve patient care, flow and efficiency.


What is the Chief resident QI project?
Every year the Chief Residents across the institution tackle a project. The GME Chief committee is working on sharps/exposure prevention as the project for the year.


Are there any post residency fellowship opportunities in QI and Safety?

Yes, the dept offers a QI postgraduate fellowship for residents after residency. Dr. Loren Riskin finished the program in 2014 and Dr. Christine Jette is the 2015 fellow.

Thanks to Dr. Fanning for compiling this list.

Thank you to our wonderful three Chief Residents: here are their short bios

Chrystina Jeter MD
Chrystina was born and raised in Bakersfield, CA and is the youngest of five children. After finishing high school, she left Bakersfield to attend the University of North Carolina, Chapel Hill. She graduated with a major in Biology and a minor in Chemistry. After college, Chrystina spent 3 years working in HIV research at UCLA and healthcare IT at Kaiser Permanente. She attended medical school at UCLA and then moved north to Stanford for residency. She recently matched into the Pain Medicine fellowship at Stanford and is thrilled for the opportunity to spend another year in the bay area.
In her free time, she enjoys relaxing with her husband, Rich, and dog, Kona. She also enjoys traveling, reading, and watching movies.

Jason Johns MD
Jason was born and raised in the Mesa, Arizona area. He attended Arizona State University graduating with a degree in Biology while working in consumer banking at Chase Bank. After graduating he and his wife Annie moved to Chicago, Illinois so he could attend Loyola Medical School while Annie worked as a dental hygienist. Enjoying his time in the snow he subsequently stayed in the Chicago area doing a prelim medicine internship at Christ Hospital in Oak Lawn, Illinois. During his time in Chicago his first son was born, Bennett (5). After enough cold weather he chose to return to the west coast to do his anesthesia residency at Stanford. While here, his second child Cate (2) was born. Jason has an avid interest in regional anesthesia and will stay at Stanford to complete a regional anesthesia fellowship. When not at the hospital Jason can typically be found being a father and husband/enjoying family time. Jason does always enjoy sneaking in some time to golf, hike, fish, or experience new restaurants.

Christopher Press MD
Chris was born in southern California but lived in many places around the U.S. because of his father’s job. He did his undergraduate work at Emory University where he majored in Biology and Economics while competing at a National level as an NCAA swimmer. Upon graduation Chris took a couple years off to work at LABioMed as a research fellow. He then headed to New Orleans, LA for medical school at Tulane where he continued to stay active in all water sports. Chris was ecstatic to return to the West Coast for residency. He plans to stay at Stanford for a year of fellowship training in cardiac anesthesia and hopes to pursue a career in Northern California.

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