1 / 41

Quality Improvement Put into Practice

Quality Improvement Put into Practice. Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation Assistant Professor of Medicine - Mayo Clinic College of Medicine. Case Presentation. 31 y.o. female History of present illness

lita
Download Presentation

Quality Improvement Put into Practice

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Quality Improvement Put into Practice Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation Assistant Professor of Medicine - Mayo Clinic College of Medicine

  2. Case Presentation • 31 y.o. female • History of present illness • Non-specific cough, tightness in throat and episodic shortness of breath following URI • No wheezing noted by patient or on exam • Exam normal other than obesity (BMI 38) • LMD orders CXR and spirometry with diffusing capacity

  3. Case Presentation • CXR • Spirometry & DLCO Pre Post Pred FVC 2.102.11 62% FEV1 0.89 1.36 31% Ratio 42.4 64.5 DLCO 8.0 30% Impression: Severe obstruction with a severe reduction in DLCO. Some improvement with BD

  4. Case Presentation • LMD Action Plan • Orders a CT scan • Referred to Mayo Clinic for further evaluation

  5. Case Presentation • Outside CT negative • Pulmonary, ENT, and GI consults scheduled • Pulmonary physician • Negative exam • Lungs clear, patient had coughing spell during exam, no wheezing or stridor noted • Questioned outside spirometry results and orders PFT’s

  6. Case Presentation • Spirometry & DLCO Pre Post Pred FVC 2.55 2.48 75% FEV1 2.27 2.25 79% Ratio 89 90.7 DLCO 24.2 99% Impression: Borderline restriction most likely 2 to obesity with no evidence of airflow obstruction or BD response

  7. PFT results affect people!!! • Further testing • Labeling (COPD, Asthma, etc) • Medicine • Disability

  8. Guidelines and Standards • American Thoracic Society • 1987 Revised Spirometry Standards • 1991 Reference Values & Interpretation • 1994 Revised Spirometry Standards • 1995 Diffusing Capacity • 1999 Guidelines for Methacholine and Exercise Challenge Testing • ATS/ERS 2005 Series; General Laboratory, Spirometry, Diffusing Capacity, Lung volumes, and Interpretation

  9. Guidelines and Standards • American Association of Respiratory Care (AARC) • Clinical Practice Guidelines (52) • Spirometry • Static lung volumes • Plethysmography • Diffusing Capacity • Infant/Toddler Pulmonary Function Tests

  10. Guidelines and Standards • American Thoracic Society • ATS Pulmonary Function Laboratory Management and Procedure Manual • Updated 2005 • www.thoracic.org • Education • Education Products

  11. Patient Patientassessment Clinicalinterpretation application Path of workflow QSE CLSI’s Quality System In Respiratory Care – HS4-A2

  12. Evidence of Quality Testing • Spirometry in Primary Care Practice* • 30 primary care clinics, 15 trained group /15 usual group • 3.4% in usual group and 13.5% in trained group met ATS acceptability and reproducibility criteria • 1,012 pt. tests, 2,928 blows (2.89) • * Eaton et al, Chest 1999; 116:416-423

  13. Evidence of Quality Testing • Improving the Quality of Bedside Spirometry • Audit of testing outside the PF lab - Cleveland Clinic • 15% - ATS acceptability/reproducibility criteria • CI Project - 63.5% acceptability/reproducibility • Stoller JK. Orens DK. Hoisington E. McCarthy K. Bedside spirometry in a tertiary care hospital: The Cleveland Clinic experience. Respiratory Care. 47(5):578-82, 2002 May

  14. Evidence of Quality Testing • Wanger J, Irvin C Resp Care 36 (12): 1991 • 13 hospitals, 7 different systems, 5 Bio-QC (3 men, 2 women) • DLCO CV 11.5 - 18.6 with the largest diff. 24 units

  15. Quality Improvement Put into Practice - Quality Assurance “Systematic” approach of monitoring and evaluating quality.

  16. Quality Improvement Put into Practice - Quality Assurance • CLSI’s “Path of workflow” Model • Pre-test • Testing session • Post-test

  17. Quality Improvement Put into PracticePre-testQuality Assurance • Pre-test instructions • Appropriate order • Questionnaire • Height* and weight • Networked systems • Equipment quality assurance program

  18. Equipment quality assurance Validation/Verification Preventive maintenance Documentation and records (logbooks) Mechanical models Biological models Quality Improvement Put into PracticePre-testQuality Assurance

  19. Quality Improvement Put into PracticePre-testQuality Assurance • Mechanical Model • 3-liter syringe • 0.5, 1-2, 6 second flows • Leak checked • Stored and used in such a way as to maintain the same temperature and humidity of the testing site • Validated based on manufacturer recommendations 2005 ATS/ERS Standards Standardization of Spirometry

  20. Quality Improvement Put into PracticePre-testQuality Assurance Mechanical Model - Plethysmography • Validation using a known volume should be performed periodically • Model lung with thermal mass to simulate isothermal conditions of the lung. • Accuracy 50 ml or 3% 2005 ATS/ERS Standards Standardization of Lung Volumes

  21. Quality Improvement Put into PracticePre-testQuality Assurance • Mechanical Model – Dilution techniques • Analyzer accuracy and linearity • N2 washout: Monthly, exhalation volumes should be checked with the syringe filled with room air, and inhalation volumes with the syringe filled with 100% O2. 2005 ATS/ERS Standards Standardization of Lung Volumes

  22. Quality Improvement Put into PracticePre-testQuality Assurance • Mechanical Models – DLCO • Syringe DLCO weekly or whenever problems occur • VA BTPS ~ 3.3L • DLCO Simulator or BioQC 2005 ATS/ERS Standards Standardization of DLCO

  23. Quality Improvement Put into PracticePre-testQuality Assurance • Biological Model • Normal laboratory subjects • Two individuals (13) • Establish mean and SD (minimum 20 samples)

  24. Quality Improvement Put into PracticePre-testQuality Assurance Biological Control - Plethysmography • At least monthly or whenever errors are suspect 2 reference subjects (biologic controls) should be tested 2005 ATS/ERS Standards - Standardization of Lung Volumes

  25. Quality Improvement Put into PracticePre-testQuality Assurance Biological Control – N2 washout • At least monthly or whenever errors are suspect 2 reference subjects (biologic controls) should be tested 2005 ATS/ERS Standards - Standardization of Lung Volumes

  26. Quality Improvement Put into PracticePre-testQuality Assurance Biologic Control – He dilution • At least monthly or whenever errors are suspect 2 reference subjects (biologic controls) should be tested 2005 ATS/ERS Standards - Standardization of Lung Volumes

  27. Quality Improvement Put into PracticePre-testQuality Assurance Biologic Control – Diffusing Capacity • At least weekly • Or whenever errors are suspect • Or whenever a calibration tank is replaced 2005 ATS/ERS Standards - Standardization of DLCO

  28. Quality AssuranceBiological Quality Control - PF Lab • Results “Out of range” • Repeat with another technologist • Second tech is within limits - record out of range data • Second tech out of range - trouble-shoot and document BioQC1: ULN LLN SD CV FEV1 2.95 2.73 0.05 0.02 FVC 3.62 3.35 0.07 0.02 TLC (Pleth) 6.09 5.65 0.11 0.02 DLCO 24.5 21.5 0.75 0.04

  29. Quality AssuranceBiological Quality Control - DLCO Model A versus B: Mean difference 0.5

  30. Quality AssuranceSubject comparisons: DLCO Model A versus B - Mean difference 1.5

  31. Quality Improvement Put into PracticeTestQuality Assurance • Testing room environment • Environmental interference • Technologist’s performance & training - QSE: Personnel • Second technologist • Meeting ATS/ERS acceptability and repeatability criteria (new guidelines)

  32. Quality Improvement Put into PracticeTest Quality Assurance - QSE: Personnel • Technologists • Job qualifications • Job descriptions • Orientation • Training • Competency assessment • Continuing education • Performance appraisal

  33. Quality Improvement Put into PracticeTest Quality Assurance - QSE: Personnel • Competence Assessment • Training and on-going performance evaluations • NIOSH Spirometry Training Course • cdc.gov/NIOSH/topics/spirometry • AARC’s Spirometry Training • National Board for Respiratory Care • CPFT and RPFT exams

  34. Quality Improvement Put into PracticeTestQuality Assurance • Lung volumes - DLCO VA 500 ml larger than TLC - ??? • Technologist Driven Protocols • Reference equations

  35. Quality Improvement Put into PracticeTestQuality Assurance • Technologist Driven Protocols • Flowcharting the process

  36. Quality Improvement Put into PracticePost-TestQuality Assurance • Maneuver selection • Quality review by second technologist • “While in-house training may achieve the desired goals, laboratory directors should strongly consider the benefits of formal training programs from outside providers.” • Feedback to the technicians concerning their performance should be provided on a routine basis 2005 ATS/ERS Standards General Laboratory

  37. 4.0 Volume grade 3.5 Flow grade 3.0 Quality controlfeedback started 2.5 Site visits andtraining update 2.0 1 2 3 4 5 6 7 Technician Training and Feedback Improve Test Quality GPA Year Lung Health StudyEnright: Am Rev Respir Dis 143:1215, 1991

  38. Quality Improvement Put into PracticePost-TestQuality Assurance • Turn-around time • Average TRT: <1 day (15%), 1-2 d (30%), 3-4 d (27%), 5-6 d (15%), >7 d (3%) • ATS PFL Registry Abstract AARC 2005, OF-05-037 • Electronic Medical Record

  39. Quality Improvement Put into Practice Does it Work? • Retrospective review of 18,000 consecutive pts. at Mayo Clinic • Ninety percent of the patients were able to reproduce FEV1 within 120 ml (6.1%), FVC within 150 ml (5.3%), and PEF within 0.80 L (12%). • Enright PL. Beck KC. Sherrill DL. Repeatability of spirometry in 18,000 adult patients. American Journal of Respiratory & Critical Care Medicine. 169(2):235-8, 2004 Jan 15.

  40. “This is fine as far as it goes. From here on, it’s who you know.”

More Related