1. ED Knows MONA
Team Members:
Tonya Thompson, MD
Kim Nelson
Becky Liggins, MD
Taylor Bagwell, MD
Kris Saunders, RPh
Kristen Campbell, RN
Beth Storm, MD
Mentor: CJ Richards
2. Background
Residents have little experience and
low comfort in treating adults
ACH ED in 2014:
• 262 patients over the age of 21 were
seen
• 68 of those had cardiac related
complaints.
3. Noon Mock Code
• Adult Chest Pain Case - February to June 2015
• Comfort/Worry assessment before and after each course
• Knowledge-based quiz before and after each course
• Checklist evaluation by faculty based on ACLS protocols
• Key elements including MONA pulled for closer examination
M – Morphine
O – Oxygen
N – Nitrates
A – Aspirin
4. Project Aim
Increase the ACH Residents’ confidence in
ACLS protocols for adult patients with
chest pain in the ED by 25% by June 10,
2015.
5. Measurements
Outcome Measures:
• ACH Residents’ confidence in ACLS
protocols for adult patients with
chest pain
Process Measures:
• Pre and post comfort/worry
assessment
• Facilitator checklist
• MONA sub-checklist
6. ED Knows MONA
Project Aim Key Drivers/
Processes
Design Changes
SMART Aim :
Increase the ACH
Residents’ confidence in
ACLS protocols for adult
patients with chest pain in
the ED by 25% by June 10,
2015.
Resident and Faculty Buy-in
Consistent teaching
amongst Fellows compared
to MDs with ACLS
experience.
Consistent attendance of
Nursing and Pharmacy
Identification of key
elements in the ACLS
protocol that are critical in
proper patient care
Meeting with Faculty and
Residents to emphasize
importance of initiative.
Sending repeated emails to
faculty requesting
participation and personal
verbal invitations in staff
meetings.
Review teaching points and
objectives with Fellows or
have Tonya/Becky teach
course.
Met with Kris Saunders and
Kristen Campbell to insure we
have participation. We send
faculty to recruit nurses. Kris
is scheduling pharmacists.
Review checklist details
including key MONA elements
and modify to support
important teaching elements.
Measure:
• Confidence level based on pre and post confidence assessments
7. Pre/Post Confidence & Knowledge
1. Today’s Date
2. I am a Med/Peds resident (circle one):
Other: ___________________________________________________________
3. Did you read the teaching guide? No Yes
1= Not Confident at All
2= Somewhat Confident
3= Confident
4= Very Confident
1
Not
Confide
nt At
All
2
Somewh
at
Confide
nt
3
Confide
nt
4
Very
Confide
nt
4. I am confident I can perform an assessment on an adult with
chest pain
5. I am confident I can administer medications at the correct
dosages to an adult patient with chest pain
6. I am confident I can perform proper CPR on an adult
7. I am confident I can recognize a STEMI in an adult patient
8. I am confident I can correctly defibrillate an adult patient
9. I am confident I can treat an adult chest pain patient without
causing harm
10
.
I am confident I can give timely and proper information to the
adult receiving facility for an adult patient with a STEMI
11
.
How far do you depress the chest in Adult CPR (insert answer in
the box to the right)?
12
.
What is the initial energy voltage set for an adult patient with
unstable Ventricular
Tachycardia (insert answer in the box to the right)?
13
.
What is the target O2 saturation for an adult chest pain patient
after a return of spontaneous circulation?
14
.
Name a medication specific contraindication to giving nitrates in
adult chest pain patients.
15
.
What drug is indicated for shock resistant VT in adults
41% Average
increase in
knowledge from pre
to post
34% Average increase in
confidence from pre to
post Assessment
8. Confidence Scale by Date
2.18
2.61
1.75 2.25 2.05
1.71
1.86
1.90
2.50
2.46
2.57
3.25
2.68
2.96
3.05
2.29
2.61
2.64
3.50
3.00
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
3-Feb-15 3-Mar-15 17-Mar-15 26-Mar-15 21-Apr-15 30-Apr-15 5-May-15 19-May-15 28-May-15 2-Jun-15
Average Pre and Post Comfort/Worry Assessment
Pre Assessment Post Assessment Median
Feb 3:
2 Pharmacy
2 Nurses
5 Res/ 0 were
Med/Peds
No cognitive
aids
March 3:
0 Pharmacy
0 Nurses
5 Res/2 were
Med/Peds
No cognitive
aids
March 17:
0 Pharmacy
3 Nurses
5 Res/ 1 was
Med/Peds
Used
cognitive
aids
March 26:
0 Pharmacy
2 Nurses
4 Res/ 0
were
Med/Peds
Used drug
sheet
April 21:
3 Pharmacy
0 Nurses
3 Res/ 2 were
Med/Peds
Used cognitive
aids
(first run since
death of co-
resident with
cardiac
complications)
April 30:
1 Pharmacy
2 Nurses
4 Res/ 0
were
Med/Peds
Used
cognitive
aids
May 5:
3 Pharmacy
0 Nurses
4 Res/0 were
Med/Peds
Used
cognitive aids
May 19:
1
Pharmacy
0 Nurses
6 Res/1
was
Med/Peds
Used
cognitive
aids
May 28:
1 Pharmacy
5 Nurses
2 Res/0
were
Med/Peds
Used
cognitive
aids
June 2:
2 Pharmacy
0 Nurses
4 Res/1 was
Med/Peds
Used
cognitive
aids
9. Average Pre and Post Confidence Scale
1 - Not Confident at all
2 - Somewhat Confident
3 – Confident
4 - Very Confident.
0 0.5 1 1.5 2 2.5 3 3.5
I am confident I can perform an assessment on an adult with chest pain
I am confident I can administer medications at the correct dosages to an adult
patient with chest pain
I am confident I can perform proper CPR on an adult
I am confident I can recognize a STEMI in an adult patient
I am confident I can correctly defibrillate an adult patient
I am confident I can treat an adult chest pain patient without causing harm
I am confident I can give complete and proper information to the adult
receiving facility for an adult patient with a STEMI
Average Pre and Post Confidence level
Post Pre
10. Pre vs Post Knowledge
How far do you depress
the chest in Adult CPR
(insert answer in the box
to the right)?
What is the initial energy
voltage set for an adult
patient with unstable
Ventricular Tachycardia
(insert answer in the box
to the right)?
What is the target O2
saturation for an adult
chest pain patient after a
return of spontaneous
circulation?
Name a medication
specific contraindication to
giving nitrates in adult
chest pain patients.
What drug is indicated for
shock resistant VT in adults
Averages Pre Correct 49% 41% 43% 64% 47%
Averages Post Correct 74% 91% 92% 96% 94%
% Increase 25% 50% 49% 32% 48%
49%
41% 43%
64%
47%
74%
91% 92%
96% 94%
0%
20%
40%
60%
80%
100%
120%
Knowledge based questions
Averages Pre Correct Averages Post Correct % Increase
There was an
average 41%
increase in the
post test
11. Complete Checklist
2 = Done Well
1 = Attempted
0 = Not Done
These scores are averaged
from the completed
checklists
1.21
1.41
1.47
1.34
1.67
1.55
1.48 1.48
1.64
1.48
3-Feb
3-Mar
17-Mar
26-Mar
21-Apr
30-Apr
5-May
19-May
28-May
2-Jun
COMPLETE CHECKLIST AVERAGE SCORE
2 ☺= Done Well
1 Ο = Attempted
0 Ø = Not Done
These scores are
averaged from the
completed checklists
12. Performance Key Checklist Scores
Place on supplemental O2 (4 L+)
Brief targeted Hx, ask about last
use of Cialis
Order stat EKG (within 5 min of
arrival)
Give ASA 160-325 mg (within 5
min of arrival)
If no Cialis use- give SL NTG
(400mcg) x3 5 min apart
Give Morphine 2-4mg IV
Notify Adult Facility/Prepare for
transport (within 3 min of
obtaining EKG)
Recognize Unstable VT
Provide good quality CPR
immediately -30:2 (within 1
minute of arrest)
Shock at maximum voltage circle
one (120- 200J or 360J) (within 3
minutes of arrest)
1.6
1.7
1.9
1.7
1.6
1.8 1.8 1.8
2 2
0
0.5
1
1.5
2
2.5
3-Feb 3-Mar 17-Mar 26-Mar 21-Apr 30-Apr 5-May 19-May 28-May 2-Jun
Key Checklist Items Averaged
Averages
Median
2 = Done Well
1 = Attempted
0 = Not Done
These scores are
averaged from the
completed checklists
13. Interventions
• First run confusion: confidence scale changes
• Encouraging use of cognitive aids
• Time frames on key items
– CPR within 1 minute
– Notify adult facility within 3 minutes
• Course cancellations
– Weather
– Colleague death
• Confidence dip
14. Barriers and Lessons Learned
• Hawthorne effect May 19
• Cognitive aids March 17
• One or two facilitators
• Subjective checklist
• Meditech notes
15. Next Steps
• Follow-up course October &
January
• Adult stroke case
• 3-year rotation
• Analyze patient data
