# 61 –Sustainability – 2011 original project
The PS2 Rotation: Integrating Training in Invasive Bedside Procedures with
training in Patient Safety/QI
By Patricia I. Wathen MD, FACP
Megan Freeman MD
Background
Residency programs have been challenged to develop innovative approaches to teaching
patient safety and quality improvement. At UTHSCSA the need to teach these concepts
was paired with the goal of improving the safety of invasive procedures performed by
internal medicine residents. This initiative, called the PS2 rotation, is in its third year
and represents a sustained effort that has had a positive effect on resident education and
the quality of patient care.
Description of Project
The PS2 rotation(Patient Safety/Procedure Service) is a required rotation for first year
internal medicine residents. Two or three PGY-1 residents, led by a Chief Resident.
perform procedures such as paracentesis, thoracentesis, and lumbar puncture for
inpatient teams and affiliated hospital emergency department and clinics. Training
includes instruction in a simulation lab and use of bedside ultrasound. Residents also
participate in root cause analysis and longitudinal QI projects. Since the inception the
PS2 residents have measured the impact of the procedure service on the safety and
timeliness of invasive bedside procedures performed by the team.
Outcomes
In the first year of the program, residents on the PS2 rotation performed 300 paracentesis,
121 thoracentesis, 76 lumbar puncture and 30 arthrocentesis. Sixty-seven procedures
were deferred due to patient safety considerations, most commonly coagulation
parameters. Residents participated in eight root cause analysis. All 25 residents
completed the IHI Open School basic certification. Scores on the QIKAT improved from
8.4 to 11.5.
Additional outcomes included:
1) reduction in pneumothorax rates after thoracentesis from 12% to 4%
2) reduction in time to paracentesis from 15 hours to 12 hours
3) prevention of admission by performance of procedures in the emergency department,
for an estimated cost savings of $120,000.
4) reduction in need for radiologic 'marking' of fluid for paracentesis, from 79% to 47%,
for an estimated cost savings of $20,000.
Based on the initial data, coagulation parameters were developed to guide teams
requesting invasive procedures (see supporting documents). In the second year residents
performed 371 procedures . Rates of pneumothorax after thoracentesis declined to 3%.
Sixteen admissions were prevented for an estimated cost savings of $90,000. Final
scores on the QIKAT rose to 12.5.
The average rating for the learning value of the rotation a 4.58 on a 5 point Likert scale
(average for all rotations is 4.3/5). Chief residents and residents participated in scholarly
work related to the rotation with one published article, two podium presentation, and four
posters presented by residents at regional and national meetings.
Conclusion
The PS2 rotation has improved resident training in bedside procedures, introduced
residents to important concepts and approaches to patient safety. It has resulted in
measurable improvements in patient safety, costs, and the efficiency of care. Ongoing
projects of the PS2 rotation include studying appropriate test ordering related to
procedures and participating in an outpatient quality improvement project.
Supporting documents
Table 1. Procedures performed by the PS2 Team July 2011-June 2012
performe Unsuccessf Complications Declined/deferre
d
ul
*
d due to safety
attempt
concerns
Paracentesis 300
2
7
19
Thoracentesi 121
2
6
20
s
Lumbar
76
10
2
23
Puncture
Arthrocentesi 30
3
0
4
s
CVC
9
3
0
1
I and D of
4
0
0
0
abscess
TOTAL
540
19
15
67
Insufficien
t fluid by
US
65
41
106
Table 2: Coagulation parameter developed by PS2 team
Procedure Type
Platelet
INR
DVT
Count
Prophylaxis
Paracentesis
10K1
None1
Can be given2
Thoracentesis
25K3
Lumbar Puncture
40K 4
Arthrocentesis
25K6
Central Line
20K7 8
INR
<2.02 3
INR
<1.55
INR
<2.02 6
INR
<2.08
Can be given2
Hold 12 hours
prior2
Can be given2
Can be given2
Therapeutic
Lovenox
Hold 12 hours
prior2
Hold 12 hours
prior2
Hold 24 hours
prior2
Hold 12 hours
prior2
Hold 12 hours
prior2
Therapeutic
Heparin
Hold 6 hours
prior2
Hold 6 hours
prior2
Hold 6 hours
prior2
Hold 6 hours
prior2
Hold 6 hours
prior2
ASA
Plavix
Can be
given2
Can be
given2
Can be
given2
Can be
given2
Can be
given2
Can be
given2
Can be
given2
Hold 7
days2
Can be
given2
Can be
given2
Runyon, B.A., Management of Adult Patients with Ascites Due to Cirrhosis. Hepatology, 2004. 39(3): p.841-856.
Malloy, P.C., Grassi, C.J., Kundu, S, et.al. Consensus Guidelines for Periprocedural Management of Coagulation
Status and Hemostasis Risk in Percutaneous Image-guided Interventions. Journal of Vascular Interventional Radiology,
2009. 20: p.S240-S249.
3 Patel, M.D., Joshi, S.D., Abnormal Preprocedural International Normalized Ratio and Platelet Counts Are Not
Associated With Increased Bleeding Complications After Ultrasound-Guided Thoracentesis. American Journal of
Roentgenology, 2011, 197: p.W164-W168.
4 Van Veen, J.J., Nokes, T.J., Makris, M., The Risk of Spinal Haematoma Following Neuraxial Anaesthesia or Lumbar
Puncture in Thrombocytopenic Individuals. British Journal of Haematology. 2009, 148: p. 15-25.5
5 Layton, K.F., Kallmes, D.F., Horlocker, T.T., Recommendations for Anticoagulated Patients Undergoing ImageGuided Spinal Procedures. American Journal of Neuroradiology, 2006, 27: p.468-470.
6O’Connor, S.D., Taylor, A.J., Williams, E.C., Winter, T.C., Coagulation Concepts Update. American Journal of
Roentgenology, 2009, 193: p.1656-1664.
7 Zeidler, K., Arn, K., Senn, O., et.al. Optimal Preprocedural Platelet Transfusion Threshold for Central Venous
Catheter Insertions in Patients with Thrombocytopenia. Transfusion, 2011, 51: p.2269-2276.
8 Haas, B., Chittams, J.L., Trerotola, S.O., Large-bore Tunneled Central Venous Catheter Insertion in Patients with
Coagulopathy. Journal of Vascular Intervention Radiology, 2010, 21: p.212-217
2
Figure 1: Effect of PS2 team on time to paracentesis
35.0
25.0
20.0
15.0
10.0
5.0
Date/Time/Period
12/8/2011
11/24/2011
11/10/2011
10/27/2011
10/13/2011
9/29/2011
9/1/2011
9/15/2011
8/18/2011
8/4/2011
7/21/2011
7/7/2011
6/23/2011
6/9/2011
5/26/2011
5/12/2011
4/28/2011
4/14/2011
3/31/2011
3/17/2011
3/3/2011
2/17/2011
2/3/2011
1/20/2011
1/6/2011
12/23/2010
12/9/2010
11/25/2010
11/11/2010
10/28/2010
10/14/2010
0.0
9/30/2010
Triage to Labs (hrs)
30.0