For years, physician assistant Stephanie Figueroa has worked with our Emergency Department and the sickle cell care team to improve the treatment of patients with this disease who arrive with acute pain crisis. When beds were unavailable in the busy adult ED, these patients might spend hours in excruciating pain before our staff were able to deliver intravenous opiates.
Figueroa and her colleagues knew things needed to improve. She just needed the protected time and resources to help make it happen.
Then Figueroa learned of the Armstrong Institute's Leadership Academy, a nine-month training program that prepares Johns Hopkins Medicine-affiliated staff, faculty and residents to eliminate preventable harm and create a culture of caring. As part of the program, each participant scopes out and conducts a quality and safety improvement project, supported by mentors and fellow participants. They apply concepts and tools that they learn in didactic sessions to make real-world improvements on the front lines.
Figueroa and colleagues rethought the approach and treatment options for the more than 100 patients with sickle cell disease who show up in the ED each month. For example, the team challenged the conventional assumption that they needed a treatment bed and an intravenous medication to care for these patients. Instead, they found ways to provide temporary relief — painkillers that could provide a "bridge" while patients awaited a bed or until they could receive additional treatment at the hospital's Sickle Cell Infusion Center the next day. Now, patients don't necessarily need a bed next to an infusion pump. They might receive the urgently needed medication in a chair, alcove or other treatment area within the ED's observation unit, the Emergency Acute Care Unit, via an injection or inhaled intranasal painkiller.
The results: The percentage of sickle-cell patients receiving rapid evaluation and a first dose of opiates within 90 minutes of presenting — the team's goal — has more than doubled. Meanwhile, the overall length of stay for these patients is trending downward, as is the percentage who must be admitted.
Figueroa's project was one of 28 presented on Friday, as she and other participants celebrated their graduation from the program. Among other achievements on display:
- Surgical-site infections among ovarian cancer surgical patients were reduced by more than 50 percent through implementation of a bundle.
- The length of time between when a MRI was ordered and when the scan began was reduced by one-third — or roughly three hours.
- A new protocol was created for heparin-allergic patients needing emergent cardiac or vascular surgery — a rare but dangerous clinical situation for which providers have had little guidance in the past.
The goal of the Leadership Academy is not only to further the participants' career development goals. We also want to help to build our organization's internal capacity to carry out patient safety and quality improvement work. Too often, frontline clinicians and managers have the enthusiasm for this work, but need additional support in areas such as project design, data analysis and measurement before they can lead efforts on their own.
Through some preliminary research, we have found that this program is helping to build needed capacity for patient safety and quality leaders. In a survey, 41 percent had moved into positions of formal responsibility for patient safety and quality. Another 29 percent already occupied such positions, while the remaining 30 percent had not made that move.
As one participant commented in the survey: "I believe the fellowship single-handedly has shaped the direction of my career at Johns Hopkins Hospital."