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By Chris Cai, MS1
As part of their Clinical Microsystems Clerkship (CMC) in the Bridges Curriculum, first-year UCSF medical students spend 16 months immersed in a clinical environment, where they learn clinical skills and complete a longitudinal quality improvement project to address urgent healthcare challenges. CMCs build upon knowledge of foundational sciences gained in the classroom, and provide students the opportunity to make a difference in a clinical setting early in their training.
“Projects led by learners and faculty in the School of Medicine are savings lives, helping children, and improving the experiences of patients and providers,” said Professor of Medicine Catherine Lucey, MD, Vice Dean for Education and Executive Vice Dean for the School of Medicine.
The inaugural CMC Health Improvement Symposium on November 16 showcased the work of over 150 medical students who conducted 82 projects over the course of the clerkship.
Several teams of UCSF medical students worked to improve safety for patients with chronic opioid use. In 2015, more than 15,000 people died from overdoses involving prescription opioids. Naloxone is a medication that can reverse the effects of an acute opioid overdose, yet it is often underprescribed in primary care clinics. Medical students Jon Freise and Elizabeth McCarthy worked to increase naloxone prescription rates in the Division of General Internal Medicine at the UCSF Medical Center, Mount Zion.
After conducting a needs assessment, McCarthy and Freise sent tailored emails to providers and appended naloxone orders prior to patient visits. As a result of their efforts, the percentage of chronic pain patients on high-dose opioids with a naloxone prescription doubled from 28% to 56%.
Students Sacha Finn, Jessie Margolis and Vidhatha Reddy also focused on safety of chronic opioid use during their CMC. Working with a team of nurses, physicians and pharmacists, they sent weekly emails to providers and ensured that opioid safety agreements were available in provider rooms. They also arranged naloxone prescription deliveries.
Their project also showed excellent results (see figure 1 below). Pain agreement rates more than doubled, urine toxicity screenings increased seven-fold, and Narcan training rates improved from just 1.6% to over 25% of patients.
Figure 1. After intervention, the percent of patients with opioid pain agreements increased from 21% to 55.7%, urine toxicity screenings increased from 6.6% to 49% and Narcan training increased from 1.6% to 26% (360 wellness clinic, Finn, Margolis, Reddy, Coach Bryn Boslett MD)
“Before they have written a prescription, before they have consented a patient for a procedure, and before they have admitted or discharged a patient, [first-year medical students] have already helped improve things for patients, individually and collectively,” said John Davis MD, PhD, associate dean for curriculum. “We know the role of a physician in the greater health care context is constantly in flux. This work in quality and health systems improvement will equip our students for their roles as leaders in medicine.”
“By asking great questions, struggling as a team, listening and learning from everyone, our students are encouraging experienced clinicians to take a closer look at our work,” commented CMC director and professor of medicine, Anna Chang, MD. “Our medical students spend time listening to and learning from nursing assistants, house-staff, social workers, pharmacists, and physical therapists. This kind of learning would have been unimaginable for us, back in our own medical school days. We are thrilled to be able to make it a reality for our medical students today.”
The role of a physician may be changing, yet School of Medicine Dean Talmadge E. King Jr., MD, affirmed that addressing healthcare disparities and promoting social justice will remains central to medicine’s driving mission and UCSF’s values.
“As a public university we are driven by the purpose to address the needs and issues of all our patients. These projects bring these priorities to life,” said Dr. King. “You all will soar much higher than we have. You have the tools, the interest and the commitment.”
Antibiotic Stewardship in the Neonatal Intensive Care Unit
Medical Students: Jose Lopez, Jessie Mai
Coach: Andrea Marmor MD
Newborn infants are susceptible to rare, rapidly progressive systemic infections such as sepsis. However, overtreatment with antibiotics can cause adverse effects, including interference with immune system development and maternal-infant bonding, as well as population-wide antibiotic resistance. To address this problem, second-year medical students Jessie Mai and Jose Lopez developed a quality improvement project to reduce antibiotic use in the Neonatal Intensive Care Unit (NICU). As a result, NICU staff safely reduced the rate of antibiotic treatment from 13% to 7.87%, a 39% decrease from baseline. More importantly, no cases of sepsis were confirmed during this protocol's implementation period and nearly 80% of residents, nurses, and attendings reported feeling comfortable using their protocol.
Reducing Infectious Outbreaks in a Veteran Affairs Skilled Nursing Facility
Medical Students: Andrew Yousef, Elaine Hsiang, Talia Mahony
Coach: Kathryn Eubank MD
This team identified the root causes of infectious outbreaks in a skilled nursing facility and developed a protocol that reduced response time to outbreaks by 31%. They worked with infection control, housekeeping, registered dietitians and nurse managers to implement the protocol.
Bypassing the ICU: Streamlining Care for Low Acuity Neurological Surgery
Medical Students: Ezekiel Adigun, Gabriela Weigel
Coach: Catherine Lau MD
Almost all neurosurgery patients at UCSF are moved to the ICU after surgery. Adigun and Weigel worked with the Neurosciences Unit Based Leadership Team to implement a “Safe Transitions Pathway” that identified patients who could instead be safely transferred to the post-anesthesia care unit (PACU) and neuro-transitional care unit (NTCU) post-op, saving significant costs without compromising quality of care. The group received a $50,000 grant from Caring Wisely™ to expand their project.
“Students are using clinical microsystems to understand and identify opportunities for improvement and work effectively with other healthcare providers to improve quality and value.”
Edgar Pierluissi MD, Professor of Clinical Medicine, Medical Director of the Acute Care for Elders Unit, and CMC Co-Director, CMC Health Systems.