Quality improvement education incorporated as an integral part of critical care fellows training at the Mayo Clinic.

PROBLEM: The Accreditation Council for Graduate Medical Education emphasizes quality improvement (QI) education in residency/fellowship training programs. The Mayo Clinic Combined Critical Care Fellowship (CCF) program conducted a pilot QI education program to incorporate QI training as a required curriculum for the 2010-2011 academic year. APPROACH: CCF collaborated with the Mayo Quality Academy to customize and teach the existing Mayo Quality Fellows curriculum to the CCF fellows with the help of two quality coaches over five months starting July 2010. All fellows were to achieve Bronze and Silver certification prior to graduation. Silver required passing four written exams and submitting a health care QI project. Five projects were selected on the basis of the Impact-Effort Prioritization matrix, and DMAIC (Define, Measure, Analyze, Improve, and Control) methodology was used to complete the projects. The primary outcome was to assess learners' satisfaction, knowledge, and skill transfer. OUTCOMES: All 20 fellows were Bronze certified, and 14 (70%) were Silver certified by the time of graduation. All five QI projects were completed and showed positive impacts on patient safety and care. Surveys showed improved learner satisfaction. Graduates felt the QI training improved their QI skills and employment and career advancement. The QI curriculum had appropriate content and teaching pace and did not significantly displace other important clinical core curriculum topics. NEXT STEPS: The pilot was successfully implemented in the CCF program and now is in the fourth academic year as an established and integral part of the fellowship core curriculum.

Clinical review: allocating ventilators during large-scale disasters--problems, planning, and process.

Catastrophic disasters, particularly a pandemic of influenza, may force difficult allocation decisions when demand for mechanical ventilation greatly exceeds available resources. These situations demand integrated incident management responses on the part of the health care facility and community, including resource management, provider liability protection, community education and information, and health care facility decision-making processes designed to allocate resources as justly as possible. If inadequate resources are available despite optimal incident management, a process that is evidence-based and as objective as possible should be used to allocate ventilators. The process and decision tools should be codified pre-event by the local and regional healthcare entities, public health agencies, and the community. A proposed decision tool uses predictive scoring systems, disease-specific prognostic factors, response to current mechanical ventilation, duration of current and expected therapies, and underlying disease states to guide decisions about which patients will receive mechanical ventilation. Although research in the specifics of the decision tools remains nascent, critical care physicians are urged to work with their health care facilities, public health agencies, and communities to ensure that a just and clinically sound systematic approach to these situations is in place prior to their occurrence.

Engendering enthusiasm for sustainable disaster critical care response: why this is of consequence to critical care professionals?

Disaster medical response has historically focused on the pre-hospital and initial treatment needs of casualties. In particular, the critical care component of many disaster response plans is incomplete. Equally important, routinely available critical care resources are almost always insufficient to respond to disasters that generate anything beyond a 'modest' casualty stream. Large-scale monetary funding to effectively remedy these shortfalls is unavailable. Education, training, and improved planning are our most effective initial steps. We suggest several areas for further development, including dual usage of resources that may specifically augment critical care disaster medical capabilities over time.