Thursday, June 05, 2008

The "secrets" behind central line improvements

A self-explanatory note from one of our doctors and great teachers, which I am happy to share, in that it gives you a sense of lots of good things.

Hello Mr. Levy,
I missed your blog from Thursday, but Dave Fobert from the Shapiro Institute and the Simulation Center recently pointed it out to me. I'm thrilled to hear that we've been able to reduce our central line infection rate, and more thrilled to hear that we've been able to maintain (and even further reduce) the infection rate over the last year! I've had the privilege of working with a number of colleagues who have helped make the reduction in central line infections possible, and have been impressed with the thoughtful dedication and effort of all of them. I would like to take a moment to point out two projects that I hope have helped contribute to the reduction in central line infections, and, more importantly, highlight the many individuals who helped make these projects possible.

The first is the Department of Medicine procedure service. While many residency programs have begun to develop similar programs, ours was the first of the kind. The AHRQ recently asked Dr. Grace Huang and I to write a perspective piece detailing a variety of issues related to the creation of this service. At the bottom of this e-mail I've included a link to the article, but wanted to share with you a comment from the article and acknowledge some of those involved in the creation of this service.

"As with any new program or intervention that affects an entire department, the success of this program depends on the collaboration and cooperation of many. The willingness to dedicate the resources and faculty support to an untested endeavor was a direct reflection of the institutional spirit and dedication to providing the best possible care for our patients and education for our students and residents."

"Acknowledgment: The authors owe special thanks to those who showed an uncommon foresight and dedication to make the Medical Procedure Service at Beth Israel Deaconess Medical Center successful, including Drs. Moellering, Weinberger, Zeidel, Strewler, Weiss, Reynolds, Feller-Kopman, Gordon, Ernst, Aronson, Clardy, and Weingart."

The second project is our use of simulation to more effectively teach central line insertion. For last year and a half we have brought interns to the simulation center on the first day of their ICU rotation to provide them a comprehensive education of central line insertion in a safe environment. In addition, we have created a validated assessment tool to help determine competency at these procedures (believe it or not, such a tool hasn't existed until now) and are investigating how much our simulation education improved the resident's skill and whether it has resulted in improved patient outcomes. In the meantime we only have the anecdotal reports from our housestaff. Below is an e-mail from Dr. Arash Mostaghimi (a HMS graduate and now one of our outstanding interns) who recently put in a central line while rotating at the Dana Farber Cancer Institute:

From: Mostaghimi,Arash (BIDMC - Medicine)
Sent: Saturday, May 24, 2008 4:34 PM
To: Smith,Christopher (HMFP - Health Care Associates)
Subject: central lines

Hi Chris,
I wanted to let you know that I put a semi-emergent IJ in yesterday on one of my patients at the DF in less than 10 minutes, which was fairly impressive to my BWH colleagues. They were especially surprised to hear that I've only put in 5 central lines before. I think the key was the training that I had with the simulator earlier in the year--even though that was a subclavian line, just becoming comfortable with the equipment and having been able to practice it a couple of times (during the session and later during the testing session) was of great benefit.
So thanks for the teaching! I hope it's standard for our new interns.
Arash Mostaghimi, MD MPA
Internal Medicine/Dermatology PGY-1

As with the procedure service, the success of this simulation project is due to the efforts of many, including Dave Fobert (who sent the e-mail below); Dr. Grace Huang (Shapiro Institute and co-investigator of procedure service and simulation projects); Lori Newman (co-director of the Rabkin Fellowship and co-investigator of the simulation project); Drs. Ennaceril, Cho, Miller, Cobb and Leder (all 5 are senior fellows who helped with the simulation teaching over the last year); Drs. Clardy and Weiss (who have supported these project and have allowing interns to leave their ICU rotations for this training); Drs. Zeidel, Strewler, Schwartzstein, Aronson and Reynolds (for their continued support of these projects).

Not infrequently I have colleagues from other institutions inquire about our procedure work. What impresses them most is the degree of collaboration and cooperation that exists among colleagues at BIDMC!
Best wishes,
Chris Smith


From: Fobert,David V. (BIDMC - Res Academic Affairs)
Sent: Friday, May 30, 2008 5:31 PM
To: Smith,Christopher (HMFP - Health Care Associates)
Subject: Central Line
Just a quick question. Is Paul Levy aware of the central line simulations done in the simulation center? I noticed his blog entry from earlier. Given that it looks like we'll be able to do the training as part of the rotation for next year, I hope it can help to bring the infection rate even lower!
Anyway, saw his post and wanted to mention it. Have a great weekend!
David V. Fobert

Administrative Manager for Operations, IT
Carl J. Shapiro Simulation and Skills Center at
Harvard Medical School and Beth Israel Deaconess Medical Center

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