QI Project Team ESTRO-JEN Clinic A & Medication cheat sheet Chen, Cowan, Levin, Mostafavi, yang, Ziaee and Quach

How can Clinic A be improved? More beds, more computers, more attendings, healthier patients. No big deal more prescription printers, more printers. effectively each room should have a printer, a prescription printer, a resident, 6 assigned patients and every 3 rooms should have an attending better medication organization (when trying to find out what the patient was actually last prescribed), and easier ways of ordering things than yellow forms, etc. The forms are never in the right places. They are always empty. The patients are not showing up ready to be seen at 8am, oftentimes we are waiting for them to clear financial, be vitaled by the nurses, and then 9am rolls around by the time the housestaff start seeing them. We need more staffing. We need more rooms. More rooms--one room per housestaff. Continuity continuity!!!!!! It's an acgme requirement. It improves efficiency bc we already know our patients and how to read our previous notes and it improves provider satisfaction. It's so rewarding to take care of a panel of patients and simply providing continuity will fix a lot of the problems in clinic a not feeling pressured to work through lunch! Less emphasis on how many patients each person saw and more about how much we learned. If we are supposed to see more pts please let us know what to cut out. Should I not use an interpreter (which takes more time)? Not ask a ROS (which inevitably opens a can of worms)? Do a more pointed exam? If we move to a system where we have to account for number of pts seen then I think that should be addressed as well. Don't overbook the clinic! If at all possible, it would be nice to have clearer expectations about how in depth to go. Efficiency always comes at the cost of thoroughness. Survey Says: How can Clinic A be improved?

Survey Says:

Clinic A…needs help Continuity  Rick’s on top of this Work space/equipment  QI project for next year Patient load  Only going to get worse. Brace yourself. Efficiency  we’re here to help

Clinic A – Patients are kept waiting

Because the chart rack looks like this…

Because the patient you’re seeing looks like this…

Here’s a close-up of that list:

Your response by patient #4:

…in the end

Our little contribution… Please list 3 things you would like to discuss at today's appointment:    Please list the medications, with name, dose, and how often you take this. Please circle the medications you want: Do you have any allergies to medications? IF you have diabetes, please answer these questions: Fasting blood glucose values: Blood glucose values 2 hours after meals When do you take insulin? What kind of insulin do you take How many times a week do you skip your medicines In the last month, has your sugar been <90 or >250 When was the last time you went to the eye doctor Do you check your feet routinely? If you have high blood pressure, please answer these questions: Home blood pressures (if you have a cuff at home) How much salt do you have in your diet Eating Habits: What do your typical meals consist of Circle thos items which you have regularly: soda, juice, bread, tortillas, fast food Do you exercise? Yes No IF yes: How many times a week do you exercise How long What type of activity Our little contribution… A questionnaire to be given to patients at check-in that will address some of the more common problems we see

Residents were asked: BRIEF TRIAL PERIOD Did you find the questionnaire helpful for your Clinic A interview? BRIEF TRIAL PERIOD Questionnaire (available in Spanish and English) was tested in Clinic A for ten days recently. Feedback was then requested from 21 residents on Amb rotation during those ten days…. Unfortunately only 8 people responded.

How effective/helpful was the form in stream-lining your Clinic A interview?

Please rate the usefulness of sections:

Do you think Clinic A should use the form next year?

FEEDBACK SUGGESTIONS/CONCERNS Form needs to be shorter and less complicated Issues with patient completing only limited parts of the form and/or not submitting the form at all Issues with handing out the form – not all patients received the form at time of check-in Some patients did not receive the spanish version FEEDBACK SUGGESTIONS/CONCERNS

CLINIC A is a constant work in progress. Thank you Rick and all of our attendings who helped with continuity in Clinic A. BOTTOM LINE…..

Medication Cheat Sheet For those moments on wards and hospitalist when the 1st, 2nd, and 3rd medications you tried haven’t worked yet….

Survey Says:

As an example… --Constipation-- Colace (stool softener) 100mg PO bid Dulcolax (stimulant) 10mg daily, can be given PO or PR Fleet enema (lubricant) 197mL PR daily **caution renal impairment** Metamucil (fiber) 1 packet (3.4gm) PO daily-tid Milk of Magnesia (saline laxative) 30-60mL PO daily **avoid in renal failure** Miralax (osmotic)17gm PO daily Senna (stimulant) 8.6mg tabs, start with 2 tabs PO qhs, max of 8 tabs PO daily Tap water enema, one PR daily prn --Nausea/Vomitting-- Ativan 1mg SL q6hr x2 doses Chlorpromazine 10-25mg PO q4-6hrs Compazine 10mg PO q3-4hrs Dexamethasone 8mg PO or 12mg IV daily Dramamine (for vertigo/motion sickness) 1-2 tabs PO q4-6hrs, max 8 tabs/24hrs Erythromycin (for gastroparesis) 250mg PO tid qac **caution prolonged QTc** Meclizine (for vertigo/motion sickness)25-100mg PO daily divided bid-tid Phenergan 12.5-25mg PO/IM/IV q4-6hrs Reglan 10mg PO/IM/IV qac and qhs **renally adjust** Zofran 4-8mg PO/IV q4-12hrs **caution hepatic impairment and prolonged QTc**

Just one more thing…

We are so glad you’re here, new interns!!!!