Resident's Passion for Quality Improvement May Lead to System-Wide Change

From left to right: Ann Van Heest, MD, Benjamin Williams, MD, PGY-5, Lauren Williams, James House, MD

Increasingly, orthopedic surgeries are being performed in an outpatient setting, yet there is limited knowledge about how many of these patients return to urgent care or the emergency department (ED) before their planned clinic visits. Benjamin Williams, MD, PGY-4, wanted to design a study evaluating the unplanned care utilization rate following these orthopedic surgeries along with potential risk factors. 

His research generated excitement throughout the University of Minnesota community. Every year, the University of Minnesota Medical Center Medical Executive Committee presents a Contribution to Quality Improvement Award to selected residents and fellows who have improved the University through quality improvement. Ann Van Heest, MD, professor and residency program director, nominated Williams for the award. He had not one, but three quality improvement projects recognized at the ceremony. “Dr. Williams has demonstrated prodigious initiative in his research and quality improvement efforts and is well deserving of this award,” Van Heest said. 

With the support of Professor Marc Swiontkowski, MD, and Assistant Professor Brian Cunningham, MD, Williams found that the HealthPartners database would allow him to collect data on the most patients. He compared in-network patients that had an outpatient surgery with their corresponding claims over a four-year period, allowing him to analyze ED visits postoperatively. “We found a significant number of patients who presented postoperatively,” Williams explained. “About ten percent returned, typically around day eight.” Williams analyzed the data based upon procedure, including arthroscopies, trauma-based cases, and general elective cases.

“There wasn’t a difference among them, which was interesting,” he noted. “We are going to look at the data again based on body location, because that may capture patient trends more specifically.” Williams found that in some scenarios, having patients return sooner than day ten could reduce unnecessary visits to the ED. “A visit to the ED consumes a lot of time, resources, and money, and it’s something that can easily be addressed,” Williams explained. “The most common complaint was pain, so there may be a way to ensure patients aren’t running out of pain medication by seeing them at an earlier time.” 

Williams plans to use the findings to influence when patients are scheduled back in clinic and to better use nursing triage phone lines for pain management and wound questions. The study is currently being written with the goal of creating a prospective change to reduce ED utilization. “The impact of this in the big picture would be increasing patient satisfaction while saving hospital resources and money,” Williams said. “These visits are quite disruptive for patients and reducing them would increase satisfaction.”

Williams has also made significant improvements at the Veterans Affairs Medical Center (VA), where he noticed that the order sets for preoperative evaluations and postoperative care were outdated. “The order sets for hip and knee replacements hadn’t been updated in about 15 years,” he said. “We completely revamped the system and included more appropriate multimodal pain medication.” With the help of V. Franklin Sechriest II, MD, adjunct associate professor and chair of orthopedics at the VA, Williams worked with the orthopedic department and the pharmacy to update the order sets with appropriate medications and DVT prophylaxis. One of the goals was to decrease inpatient issues with pain management by integrating the order set automatically, instead of manually entering the postoperative medication regimen. 

“We get paged a lot about pain management and having the updated recommendations appear automatically increases efficiency,” he said. Apart from efficiency, the updated order sets help patients manage pain more effectively, potentially decreasing the necessity for postoperative narcotics. “We are hoping to decrease the number of narcotics used pre and postoperatively,” Williams said. 

Williams’ natural propensity for detail led him to notice another trend: an increased likelihood of femoral head collapse following intra-articular steroid injections in the hip. “The VA probably does more hip injections than elsewhere, so it likely happens more often than people think,” he said. “The rate of collapse has been fluctuating between 6 and 20 percent.” As there is very little data regarding this complication, Williams, along with co-resident Brandon Kelly, MD, PGY-2, implemented a quality improvement initiative to determine the incidence and risk factors of femoral head collapse. “We are conducting an ongoing study to determine if there is a direct association between injection, number of injections, and femoral head collapse,” he said. “We are also looking to see if this occurs based upon some other factor.” He hopes to prevent premature surgical complications and infections using the results of the study.

Williams’ excitement about research has been contagious. “Ben has been infected with the academic virus and it appears to be a lifelong disease,” Swiontkowski quipped. “I predict his work over the next 20-30 years will have a major impact on foot and ankle surgery worldwide.” After graduation, Williams will complete a foot and ankle fellowship and hopes to bring his passion for research and education to an academic health system. 

“It seems like more of the residents are engaged in quality improvements and research than when I entered the program,” he said. “If someone’s doing something, it gets other people excited to do the same thing.”

“It seems like more of the residents are engaged in quality improvements and research than when I entered the program. If someone’s doing something, it gets other people excited to do the same thing.” - Benjamin Williams, MD

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