1. STANDARDIZED ORDER PROTOCOLS: EFFICIENCY AT THE EXPENSE OF RESIDENT EDUCATION? Ambarish Bhat, MD Martina Jelley, MD University of Oklahoma College of Medicine - Tulsa, Department of Internal Medicine, Tulsa, OK

2. INTRODUCTION Standardized Order Protocols: –Predefined order set for the management of a particular illness.

4. 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

5. INTRODUCTION Common Sense: –Adequate comprehension of the pathophysiology of a disease process is required for its management Is a residents understanding of a particular disease process dependent on whether that illness is managed using a protocol?

6. HYPOTHESIS A residents understanding of a particular illness does depend on whether that illness is managed using a protocol.

7. METHODS 42 IM Residents 22 IM Residents (Non-Protocol Group) ACS Quiz 20 IM Residents (Protocol Group) DKA Quiz Calculate & Compare % correct

8. METHODS Sample ACS QUIZ Question: 54yo AAM with PMH of HTN, DMII, and tobacco abuse, presents to a small 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 only c)Transfer to hospital 120 minutes away for Angioplasty/PCI d)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

9. METHODS Sample 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 now II) Discontinue Insulin drip now III) 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, VI b) I, IV, V c) II, IV, V d) II, V e) II, III, V Knowledge Tested: Knowing how to transition from IV to SQ Insulin

10. RESULTS ACSDKA PGY Level # of Subjects% correct# of Subjects% correct PGY-1785.7%1076.0% PGY-2867.5%480.0% PGY-3 + PGY-46 +165.7%656.7% Total / Average2272.7%2071.0% Table 1:

11. RESULTS ACSDKA PGY Level # of Subjects% correct# of Subjects% correct PGY-1785.7%1076.0% PGY-2867.5%480.0% PGY-3 + PGY-46 +165.7%656.7% Total / Average2272.7% 2071.0% Table 1: Does not meet statistical significance

12. RESULTS No difference overall ACSDKA PGY Level # of Subjects % correct # of Subjects % correct PGY-1785.7%1076.0% PGY-2867.5%480.0% PGY-3 + PGY-46 +165.7%656.7% Total / Average2272.7% 2071.0% Table 1: Variability Variability

13. RESULTS ACSDKA PGY Level # of Subjects% correct # of Subjects% correct PGY-17 85.7% 10 76.0% PGY-28 67.5% 4 80.0% PGY-3 + PGY-46 +1 65.7% 6 56.7% Total / Average2272.7%2071.0% Table 1:

14. RESULTS ACSDKA PGY Level # of Subjects% correct # of Subjects% correct PGY-1785.7%10 76.0% PGY-2867.5%480.0% PGY-3 + PGY-46 +165.7%656.7% Total / Average2272.7%2071.0% Table 1:

15. RESULTS ACS + DKA PGY Level# of Subjects% correct PGY-11780.0% Upper Level Residents (PGY-2/3/4)2566.4% Total42 Table 2:

16. RESULTS ACS + DKA PGY Level# of Subjects% correct PGY-11780.0% Upper Level Residents (PGY-2/3/4)2566.4% Total42 Table 2: P = 0.0098 95% confidence interval: 3.47 – 23.73

17. DISCUSSION INTERNS SENIORRESIDENTS

18. DISCUSSION Comprehension & Memory of Disease Management Use of Standardized Order Protocols Resident Training Level

19. DISCUSSION Comprehension & Memory of Disease Management Use of Standardized Order Protocols Resident Training Level

20. 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.

21. 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?

22. 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

23. CONCLUSION If you dont use it… …you lose it!

24. QUESTIONS

25. 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.

26. Thank You