STANDARDIZED ORDER PROTOCOLS:EFFICIENCY AT THE EXPENSE OF RESIDENT

EDUCATION?

Ambarish Bhat, MDMartina Jelley, MD

University of Oklahoma College of Medicine - Tulsa, Department of Internal Medicine, Tulsa, OK

INTRODUCTION

• Standardized Order Protocols:– Predefined order set for the management of a

particular illness.

INTRODUCTION• Background:

– Efficient and Convenient– Outlined in step-by-step instructions for staff– Proven to improve outcomes– Allow executive management of complex illnesses in a

standardized approach– Used Nationwide

– Often allow management of illness to proceed without physician intervention

– Many require nothing more than a signature for activation• Residents use these standardized order protocols

INTRODUCTION

• Common Sense:– Adequate comprehension of the pathophysiology

of a disease process is required for its management

• Is a resident’s understanding of a particular disease process dependent on whether that illness is managed using a protocol?

HYPOTHESIS

• A resident’s understanding of a particular illness does depend on whether that illness is managed using a protocol.

METHODS42 IM Residents

22 IM Residents(Non-Protocol

Group)

ACS Quiz

20 IM Residents(Protocol Group)

DKA Quiz

Calculate & Compare %

correct

METHODSSample ACS QUIZ Question:

54yo AAM with PMH of HTN, DMII, and tobacco abuse, presents to asmall outlying medical center with complaints of crushing substernal chest pain for the last 4 hours, troponin level of 1.86, normal renal function, and EKG findings of ST-segment elevation in lateral precordial leads. Currently, the patient is hemodynamically stable. The closest hospital capable of percutaneous coronary intervention is 120 minutes away. What is the next step in management?

a) Fibrinolytic therapy (assuming no contraindications)b) IV Heparin infusion onlyc) Transfer to hospital 120 minutes away for Angioplasty/PCId) Treat only with Aspirin, Statin, beta-blocker, and ACE inhibitor therapy.e) Administer high-dose Plavix and Aspirin only.

Knowledge Tested: Knowing the indications for PCI vs. fibrinolytic therapy

METHODSSample DKA QUIZ Question:

A patient previously in DKA now has Na =137, Cl = 105, HCO3 = 22, BG = 121, is NPO and is currently on an insulin drip and a D5 1/2NS infusion. She denies nausea. In regards to the next step in management, choose the correct letter choice below that corresponds to the correct statements listed.

I) Continue Insulin drip nowII) Discontinue Insulin drip nowIII) Administer dose of weight-based Novolog (immediate-acting insulin) now.IV) Administer dose of weight-based Lantus (long-acting insulin) now.V) Start an oral ADA diet if she is not at risk for aspiration now.VI) Keep patient NPO (patient not at risk for aspiration).

a) I, VIb) I, IV, Vc) II, IV, Vd) II, Ve) II, III, V

Knowledge Tested: Knowing how to transition from IV to SQ Insulin

RESULTS

ACS DKA

PGY Level# of

Subjects % correct # of Subjects % correct

PGY-1 7 85.7% 10 76.0%

PGY-2 8 67.5% 4 80.0%

PGY-3 + PGY-4 6 +1 65.7% 6 56.7%

Total / Average 22 72.7% 20 71.0%

Table 1:

RESULTS

ACS DKA

PGY Level# of

Subjects % correct # of Subjects % correct

PGY-1 7 85.7% 10 76.0%

PGY-2 8 67.5% 4 80.0%

PGY-3 + PGY-4 6 +1 65.7% 6 56.7%

Total / Average 22 72.7% 20 71.0%

Table 1:

Does not meet statistical significance

RESULTS

No difference

overall

ACS DKA

PGY Level# of

Subjects%

correct# of

Subjects%

correct

PGY-1 7 85.7% 10 76.0%

PGY-2 8 67.5% 4 80.0%

PGY-3 + PGY-4 6 +1 65.7% 6 56.7%

Total / Average 22 72.7% 20 71.0%

Table 1:

↑ Variability

RESULTS

ACS DKA

PGY Level# of

Subjects % correct# of

Subjects % correct

PGY-1 7 85.7% 10 76.0%

PGY-2 8 67.5% 4 80.0%

PGY-3 + PGY-4 6 +1 65.7% 6 56.7%

Total / Average 22 72.7% 20 71.0%

Table 1:

RESULTS

ACS DKA

PGY Level# of

Subjects % correct# of

Subjects % correct

PGY-1 7 85.7% 10 76.0%

PGY-2 8 67.5% 4 80.0%

PGY-3 + PGY-4 6 +1 65.7% 6 56.7%

Total / Average 22 72.7% 20 71.0%

Table 1:

RESULTS

ACS + DKAPGY Level # of Subjects % correct

PGY-1 17 80.0%

Upper Level Residents (PGY-2/3/4) 25 66.4%

Total 42  

Table 2:

RESULTS

ACS + DKAPGY Level # of Subjects % correct

PGY-1 17 80.0%

Upper Level Residents (PGY-2/3/4) 25 66.4%

Total 42  

Table 2:

P = 0.0098

95% confidence interval: 3.47 – 23.73

DISCUSSION

INTERNS

SENIORRESIDENTS

DISCUSSION

Comprehension &

Memory of Disease

Management

Use of Standardized

Order Protocols

Resident Training Level

DISCUSSION

Comprehension &

Memory of Disease

Management

Use of Standardized

Order Protocols

Resident Training Level

STUDY LIMITATIONS

- Comparison of data using 2 separate illnesses- ACS > DKA- Sample size

• Administration of each quiz to each participant– Comparison of competency of different classes.

DISCUSSION

• POST - HOC ANALYSIS– Study findings (Table 2) warrant further research.

• Do residents lose knowledge of disease management once they stop directly managing patients during intern year?

• Should Upper Level Residents manage patients independently alongside their supervisory duties?

INTERVENTION

• IMPLEMENTATION:– Change to the OU-Tulsa Program: 2012

• Senior Residents will:– Supervise Interns– Manage personal patients independently

– Follow-up Study comparing Intern vs. Senior knowledge

CONCLUSION

If you don’t use it… …you lose it!

QUESTIONS

REFERENCES• 1. Kollef M, Micek S. Using Protocols to Improve Patient Outcomes in the

Intensive Care Unit: Focus on Mechanical Ventilation and Sepsis. Semin Respir Crit Care Med. 2010;31(1):19-30.

• 2. Rawn A, Wilson K. Standardized network order sets in rural Ontario: a follow-up report on successes and sustainability. 2011;14(2):95-100

• 3. Ballard D, Ogola G, Fleming N, et al. The Impact of Standardized Order Sets on Quality and Financial Outcomes. Agency for Healthcare and Research and Quality. 2007 Sept.

• 4. Marinaro J, Tawil I, Nelson MT. Resident guideline development to standardize intensive care unit care delivery: a competency-based educational method. 2008 Mar-Apr;65(2):109-11.

Thank You