The Ether Way

Innovative Idea #9: No More Spaghetti!

 

 

Managing  patients with multiple monitoring wires & tubing, and infusion lines constitutes a nightmare on tree street!  Astonishingly, not an anachronism.   I suggest we develop a system that incorporates wireless monitors, color coded pressure tubing, color coded intravenous lines, and methods to cable together multiple lines to create one  or two  input cables of infusion lines with power strips on IV poles to minimize cables on the floor and clotheslined power cables to wall sockets.     Also we need LARGE medication labels on the IV bags, color coded for important drugs like epinephrine, but large enough to read from 6 feet.  Lets get organized and decrease the entropy of patient transport.

Innovative Idea #8: Found Dead in Bed??

 

 

Why is it in 2012 that we still occasionally encounter patients found unexpectedly dead in bed in a modern hospital?   Such incidents of delayed discovery create difficulty with successful resuscitation and if successful the patient may not wake up.  Moreover, if a patient is transferred recently from ICU or he/she is triaged, then litigation can be problematic.   We need to invest in buying or developing wireless monitors on all nonICU patients in the hospital which will reliably detect hypoxemia/malignant arrhythmia .  The system will page or otherwise notify the nurse when something is amiss so a rapid code or rapid response team can be called

Innovative Idea #7: Small Grants Program for QI projects

 

 

 The health system should maintain a  program to evaluate and fund QI ideas from front line care givers.   These would be detailed proposals directed to either process or quality.   For example, a physician might propose an evaluation of the use of dexmedetomidine for delirium in the ICU, evaluating cost savings and morbidity.  An RRT might suggest a different staffing model to deal with transports of ventilated patients to improve efficiency.  An RN might suggest the approach that stops UTIs.  The health system  would provide resources to conduct the study and provide ethical oversight, which is especially needed for cost containment protocols.

Innovative Idea #6: Everyone's Lost!

Every day I walk into the very large hospital  complex and encounter family members and visitors bewildered and mesmerized with the complexity of getting around the medical center.  I suggest development of an in house GPS system.      Issue gps units to visitors and families in the lobby (swipe a credit card or something for deposit),  use their smart phones or issue free apps.  It should increase family and visitor satisfaction and make the medical center seem like a top ten futuristic place.  It may also enable security to track whereabouts of all visitors and help us find family for consents to also improve efficiency.

Innovative Idea #5: ETCO2 monitoring for all

 

 

 

Observation:  Patient undergoes anesthesia with 1:1 constantly-present anesthesiologist/CRNA with ETCO2 monitored.   Case ends; patient goes to ICU, often with continuation of the same anesthetic or neuromuscular blockade or gets put on  an opioid infusion.  The patient  is  now 1:2 to 1:4  or so nursing with no expectation of continuous nursing presence.  But now ETCO2 is rarely done.  How does this make sense?  I propose that every intubated or trached patient in the hospital have mandatory ETCO2 monitoring and that it be recommended for any patient receiving oxygen.  The technology is available; let’s use it for patient safety.

Innovative Idea #4: Emergency Checklists

Gawande in his recent checklist book discusses the role of emergency checklists for pilots.  We need this approach for medical emergencies.  Change the culture from one expecting caregivers to pridefully remember all aspects of managing a given emergency.  Create a set of the first five things that need done for common and uncommon emergencies.   For example for apparent anaphylaxis: 1. Give oxygen, 2, apply monitors, 3. Give epi, 4. Give H2 antagonists, 5. Call for Help.  Put on all PCs in the health system. Make an emergency checklist manual.   Make a smartphone app.  Sell the book and sell the app.

 

Larry Chu and colleagues at the Stanford AIM lab are proposing just that.  Modeling after the emergency checklists that pilots use for emergencies, they are introducing the notion that we in anesthesia and critical care should do the same.  Evidence for this notion was recently published in the NEJM:     Arriaga AF, etal: Simulation-Based Trial of Surgical-Crisis Checklists. N Engl J Med 2013;368:246-53.

 

You can get the cognitive aids by visiting Anesthesia Illustrated or clicking on this link (http://www.cognitiveaids.org).