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Dome - From Patients to Process

June 2010

From Patients to Process

By: Jamie Manfuso
Date: June 7, 2010

One department is making time for its residents to work on quality-improvement projects, as well as patients.


Anesthesiology and Critical Care Medicine’s revised residency program gave Jim Rothschild the opportunity to work on a quality-improvement project to eliminate blood waste in the ORs.
Anesthesiology and Critical Care Medicine’s revised residency program gave Jim Rothschild the opportunity to work on a quality-improvement project to eliminate blood waste in the ORs.

Like many anesthesiology residents, Jim Rothschild routinely requests blood products for surgery cases. He’s also witnessed how units of blood sometimes must be thrown away before they get to the patient, because they sit for too long at room temperature.

Busy house staff typically have little time to tackle such problems—more commonly taken on by nurses, administrators, managers and physician leaders. But this year, Rothschild and a half-dozen other residents at The Johns Hopkins Hospital have been working to find a solution to blood waste.

The opportunity to work on this project is the result of a revamped residency program in Anesthesiology and Critical Care Medicine (ACCM) that sets aside two days a month when residents have no patient care duties—a rare approach that is the brainchild of program director Deborah Schwengel. While some of that time is spent in board exam preparation, a journal club and simulation exercises, a significant portion is devoted to quality and safety-improvement efforts.

The 71 residents are working on 11 projects. Along with other efforts, they’re studying ways to improve communication among health care workers, prevent postsurgical nausea and vomiting, increase recycling, and reduce incidents of hypothermia in pediatric patients, which can occur during long transports.

“We typically come to work and focus on the patients we have that day,” says Rothschild. “And that’s good to a point, but this is forcing us to take a step back and say: How can we improve how health care is delivered?”

Anesthesiologists Sean Berenholtz and Brad Winters direct this component of the training program. Berenholtz says that house staff are keenly aware of the hazards facing their patients, and they’re constantly steering patients clear of harm. Many would rather tackle the source of problems.

But, he notes, “Their schedule is packed. They often don’t have the necessary skills, the connections at the hospital or the infrastructure to fix potential patient safety hazards.”

The training program helps them to clear those hurdles. The residents get instruction in how to design safer, less wasteful systems. They learn how to find the best medical evidence and turn it into practice, and how to improve teamwork and communication, among other lessons in the “science of safety.”

The group also was asked to identify sources of potential harm to their patients. Based on those responses and what efforts were already under way, the residents were assigned to teams, each led by a faculty mentor. Within this framework, they work across departments and the hospital.

The blood-wastage team, which includes members of the blood bank, is a good example. Their project, building on earlier successes at the hospital, is targeting one stubborn cause for waste: When a patient case requires just one or two units of blood, they aren’t packed in coolers but are kept in the OR at room temperature, giving them a shelf life of just 30 to 45 minutes.

It might sound like an easy fix, but a closer look proved otherwise. It became clear that packing the red blood cells in large coolers—used throughout the hospital to deliver up to six units—wasn’t the solution. The bank simply didn’t have the storage space.

The team came up with another fix—working with an outside vendor to develop a small, soft cooler that can increase the shelf life for smaller shipments. They plan to pilot the cooler in coming months.

While such projects may not be what residents bargained for when they signed up for the program, Berenholtz believes the skills that these physicians develop will serve them well.

“Patient safety and quality are priorities across the country,” he says. “And it doesn’t matter if you’re in an academic medical center or a community hospital. You will be asked to participate in efforts to improve them.”

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