Creating Collaborative Care

1. Creating Collaborative Care Performed by • Heather Jensen, Spencer Lovelace, Justin Lowe, Margaret Maclin, and Poppy Markwell • Observed by • Donna Kern, M.D. Root Cause Analysis of Case: “A Tooth Gone Bad”

2. Our Team College of Dental Medicine Margaret Maclin Caring for Others Eating Healthy Exercising Being with Family College of Nursing Heather Jensen College of Medicine Spencer Lovelace Justin Lowe Poppy Markwell Hanging with Friends Love of Science Interacting With Others

3. The Site: Medical University Hospital Charleston, SC • Vision: to become a leading academic health center MUH is a fully accredited not for profit quaternary care center • level 1 trauma service • inpatient 24hr pharmacy • 16 staff interpreters providing round the clock coverage • Task: Train 600 residents and host 51 Graduate Medical Education training programs and two American Dental Association training programs

4. The Case: Juanita Dorantes 30 year old Hispanic female Day one: Presents to the MUSC dental clinic with a toothache A 4th year surgery student removes the tooth and prescribes antibiotic Day six: Presents to ER febrile with chills and edema @ extraction site and is admitted Day seven: Dr. Smith notes antibiotic allergy (w/o interpreter) Lab results show evidence of bacterial infection and antibiotic is ordered Due to the noted allergy the antibiotic is not administered Day eight Dr. Smith examines patient, noting the patient appears pale and is unresponsive w/ a BP of 78/40 Medical emergency response team is called Day nine and on: Juanita is unconscious for 7 days and shows signs of cognitive deficit on awakening She is transferred to the MUSC Transitional Care unit

5. Lack of Interdisciplinary Role Awareness & Communication Care Availability on the Weekends Juanita arrives in ER at 8 am on a Saturday and must wait 2 hours before being seen Patient is passed from ER to oral surgeon Failure of various health care professionals to take responsibility for direct patient care Antibiotic administration delayed Lack of quality care and overall inability to treat Juanita after being in ER for several hours Central line attempt without appropriate guidance results in perforated lung. Sub-Standard Care The dental student believed “yes” was enough of a response to assume that Juanita clearly understood how and why to take the antibiotic. Student had never placed a central line and was therefore not confident in his ability to do so. • Dr. Smith interviewed Juanita without a translator and falsely recorded that she had an antibiotic allergy. He did not clarify the allergy with the translator. The student did not speak up for fear of a negative impact on his grade. The resident left the student unattended to place the central line assuming he was capable of placing it. • Oscar was not allowed to contact the doctor directly and the doctor did not respond to the page. The mentality of “See One, Do One, Teach One” found in healthcare Patient-Provider Communication

6. Recommendations: Care Availability on the Weekends • Rotating weekend schedule for health care workers to increase the rate of patient admittance • Design a networking system for constant stream of communication between medical facilities • Establishing a required health care staff to patient ratio to promote a high quality of patient care

7. Recommendation: Shift Away From the “See one, Do One, Teach One” Philosophy. • The residents should not negate the students apprehension by instilling a possible false sense of security assuming that everyone is capable of performing a procedure if it has previously been watched. • A grading system should be in place that does not penalize students who are unsure of their skills. Especially regarding never before performed, dangerous procedures. But rather it should be one that encourages learning and expanding the student’s skills rather than punishing them for being hesitant or cautious. • An attending should never leave a student unattended to perform any procedure until the student has proven that they can perform the task with satisfaction and confidence. This should be documented for the resident to double check if necessary.

8. Recommendations: Interdisciplinary Role Awareness and Communication • Role Visibility: College coursework regarding knowledge/training of other disciplines to foster respect and to promote utilization of other’s expertise as a resource. • Awareness of the Professional Culture: Exploration of harmful misconceptions of the professional culture. We can’t change what we don’t acknowledge. • Critical Thinking: Quarterly hospital seminars for case study discussions. Example of job well done to recognize positive clinical decision-making and successful interprofessional collaboration. If the patient were your loved one, where would you stop? • Support System: Written information regarding the institution-specific hierarchy in place. Mentor programs for new employees.

9. Problem: Patient-provider communicationPart I. Translator • Development of telephone interpretation “on call” services for all languages (Reduces wait time) • Certification of medical interpreters (Quality) • Patient activated translator system • Patient satisfaction survey

10. Problem: Patient-provider communicationPart II. Patient education/ response to patient questions • Teaching communication skills in medical school • open ended questions • 5 A’s-- assess, advise, agree, assist, arrange • Cultural sensitivity • Require physicians to keep record of patient’s understanding of his or her illness and questions asked/answered • Reimburse physicians for preventative care • Provide relevant patient educational pamphlets and always include medication directions with prescriptions (not just “take as directed”) • In patient primary language • Ex: CDC, UpToDate, etc. • Patient satisfaction survey

11. Teamwork • 1) Appreciation of the value of team decisions and a positive regard for teamwork 3) Mutual trust 2) Respect for all team members 4) Openness to feedback and improving team effectiveness 5) Importance of a shared vision

12. The Value of an Interprofessional Approach • Using colleagues as resources • Creates a relational and caring environment • More patient advocates with specialized expertise • Diverse perspectives for problem solving • Facilitates critical thinking to maximize patient care