Medical school course emphasizes importance of quality improvement in real world medicine
June 05, 2017
By Brian Whepley
To fourth-year medical students, antsy to move on to residency, the Population Health in Practice class initially sounded a bit dry compared to their clinical training.
But once their team dug into a project involving sepsis and "you start talking about preventing deaths, you get excited about it," said Andrew Weaver, who will do his internal medicine residency in Wichita.
"It's a really good time to do it. This is the real world of medicine," said Brent Deibert, who will do his residency in ophthalmology at University of Nebraska Medical Center. "This is one of the most valuable classes I had."
"Dr. Badgett's passion rubbed off on us," Weaver said.
Taught by Dr. Bob Badgett, a professor in the Department of Preventive Medicine and Public Health, Population Health in Practice is a month-long required course for all fourth-year KU School of Medicine students. As the school's new curriculum comes into place, the hope is to include elements of it in coursework and electives.
In the class, teams of students are assigned a quality-improvement project at a clinic or hospital. Weaver and Deibert's team, for example, looked into how a local hospital met the fluid-administration amounts called for in the Sepsis Bundle, a multistep protocol that is the international standard of care for the life-threatening condition. Another team also focused on sepsis while others examined birth spacing and screening for postpartum depression.
"They get out to the practice or the hospitals within a day or two of starting the course," Dr. Badgett said. "They then agree on the specific aims on the project. Over the first two weeks, they learn how the current care is done, including chart reviews of relevant patients. The last two weeks they work with the site to come up with suggestions and ideas on how to further change their care."
At the end of the four weeks, they present their findings and proposals to fellow students. Most reports include a cost analysis of proposed changes.
"They experience how to put a project together where you have to balance money and mission," Dr. Badgett said.
They also learn about teamwork, how to write to-the-point, one-page summaries and business emails, and how to more readily assess the quality and importance of the mounds of studies that go with the medical profession. Popcorn-and-movie sessions each Friday cover working in teams, creating an engaging workplace and managing conflict. Overall, they learn to appreciate the complexity of the health care system they are entering, and how to work collaboratively within it.
Deibert, Weaver and Clay Jarrell, bound for a pathology residency at Creighton University, recently described their team's work and findings at KU School of Medicine-Wichita's April 20 research forum.
After familiarizing themselves with the specifics of the Sepsis Bundle, the students did an extensive literature search. Next, students reviewed charts, zooming in on 59 patients who had come to the emergency department with sepsis symptoms. They looked at when cultures were ordered, lactate was measured, and whether the patients got the rapid infusion that was recommended. They looked at patient demographics and, of course, the greatest measure of all - whether the patient lived or died.
They concluded that no patients had died if they received adequate fluids. They looked at lag times - the time between ordering and administering care - to see if there was a barrier to achieving the best care. They found no serious problems on that front, but discovered a systemic issue.
The students, Weaver said, learned that the electronic health records (EHR) system, as a default, had a box checked to order fluids but it was lower than the recommended amount. Also, the first three options a doctor could select would not satisfy that amount, while appropriate ones were farther down the list.
Among their proposed changes: Eliminate the default option and make the top choices ones that achieved the standard for rapid fluid infusion. Also, if a doctor chose an option that didn't meet the standard, the records system would flag it. They also calculated the expense of changing the EHR system, estimating it would cost $150 in programming time.
"The hospitals have been great," Badgett said. "They let students see what the current level of care is and what we can do. Sepsis is another one of those topics that no one really thought about five to 10 years ago. Now, the hospitals want to evolve the best practice."
Other projects have occurred in Wichita medical practices and focused on prescribing the anticoagulation drug Warfarin and screening for pre-diabetes, the latter in partnership with the Health ICT program that addresses diabetes and other chronic conditions.
"The practices that let us come in are a pretty special group in that they're willing to kind of step back and say, 'How can we improve ourselves?'" Badgett said. "Ideally it becomes a win-win. The students learn and the clinical sites feel like they've gotten some help evolving their practice."
Brett Hartkopp, market director for quality and infection prevention at Wesley Medical Center, has worked with students on a number of sepsis projects.
"They have been able to look at things in ways we can't. Those numbers come in handy," Hartkopp said of putting six or seven students to work over a short period.
A given project can show areas to improve, but also can quantify that, yes, best practices are being met. "Any project that we have that we put resources to, we always move the needle in a positive direction."
"I'm hoping it gives the students a better understanding of how care and quality work," Hartkopp said. "It's not just making a difference for that one patient but for all the patients."
Hartkopp said the other Kansas hospitals benefit from the work done in Wichita. "We take the knowledge that the students help us with, we apply it here and then we go out and share it."
"It's really rewarding because we have a chance to make a difference right now," Weaver, the doctor-to-be, said of his team's work.
"If I can show that from the work they did, I saved one life over a year, then that work was worth it," Hartkopp said. "If that were my wife, it would be priceless."KU School of Medicine-Wichita