Keeping an Eye on the Next Patient
August 25, 2021
Riley Grosso, MD, Director of Quality and Peer Review and a recent “Dinner with the Doc” winner, finds new ways to raise the bar in Emergency Medicine
UH Clinical Update | September 2021
Riley Grosso, MD, sees all kinds of patients as an emergency medicine physician at UH Cleveland Medical Center, from the garden-variety broken bone to the life-threatening MI. But what really motivates her is the next patient – and how to make that patient’s care at UH better.
As Director of Quality and Peer Review in the Department of Emergency Medicine, Dr. Grosso has spearheaded several initiatives to ensure that the department is always improving over past performance, achieving new levels of quality and excellent outcomes for patients.
A big part of success with this is adopting the proper mindset, she says.
“We start every quality and peer review meeting with the same two lines – one, we’re doing this to take care of the next person better,” she says. “And two, we assume that everyone who took care of this patient was doing the best they could with the resources they had at that moment. That’s how we approach every peer review case, every quality case.”
One recent enhancement to the quality review process in Emergency Medicine, developed by Dr. Grosso and adopted by the Emergency Medicine Quality Network, is a more expansive template for considering potential opportunities for improvement – opportunities that go beyond just the individual provider. Now, the team considers individual provider factors, as well as departmental, hospital and UH system factors that could lead to better outcomes – a tiered approach that provides important context for individual cases.
“You have to contextualize it,” Dr. Grosso says. “Dr. Jessica Goldstein and I came up with that, CMC piloted it, and now we are asking quality meetings around the ED system to do it as well. It’s a way of always asking what the provider, department, hospital, and UH system do better to take care of this patient better next time.”
Another important initiative championed by Dr. Grosso is a new procedure for emergency medicine physicians to sign out and hand off care to another physician. Dr. Grosso assembled a committee of APPs, nurses, residents and attending physicians, and the group proposed a “sterile cockpit” procedure for signing out – where non-critical interruptions to the physician signing out were prohibited.
“Sterile cockpit means you are doing the task in front of you only and we don’t get interrupted,” she says. “There’s a study in emergency medicine that says attendings in the community get interrupted on average every 6 minutes, although it often feels more frequent than this when you add learners into the mix. The goal always is to make handoffs as safe as possible, and this helps with that.”
In fact, this approach has led to better transitions of care in Emergency Medicine and a decrease in errors – one fact that recently led to Dr. Grosso winning a “Dinner with the Doc” award from UH CEO Cliff Megerian, MD.
Beyond developing and promoting new procedures to boost quality, Dr. Grosso also is actively engaged in education, with a special eye toward training nurses, residents and emergency medicine peers in challenging procedures so as to always achieve better outcomes. Thanks to her leadership, team training simulations are now offered once a quarter at every UH community hospital. With a generous donation from UH emergency medicine physician Howard Dickey-White, MD, the team is taking its show on the road, complete with a van, mannequins, central line trainers, airway equipment for ED physicians, nurses and APPs to practice on and more.
The latest addition to the curriculum is extracorporeal cardiopulmonary resuscitation (ECPR) in the ED at UH Cleveland Medical Center.
“We’re starting an ECPR program at CMC where we’re going to try to place appropriate patients on ECMO in the ED, and they’ve been doing simulations of the logistics – how the nurses are going to run the machines, how they’re going to assist the cardiothoracic surgeons in actually cannulating the patient,” Dr. Grosso says. “Dr. McCloskey, who is one of our ED ICU dual-trained physicians, has a 3D-printed pelvis that he attached to one of the mannequins so they could practice cannulating a patient for ECMO in the department. They’ve had a couple of Saturday morning, in-department simulations for that to try to get that off the ground.”
For Dr. Grosso, this kind of hands-on education is invaluable, both in terms of pure learning and in terms of achieving high-quality outcomes for patients.
“My passion lies in education,” she says. “For me, the best way to learn is to critically analyze a patient who already presented. To look at a case and say, ‘How can we do this better when the next person shows up?’ is by far the best way to learn, and I just extrapolated that to help other people learn as well. Whether it’s peer review or sign-out best practices or simulations, it’s looking at how we can do it better for the next person.”
Dr. Grosso will keep scouring policies and procedures for opportunities for improvement. As Director of Quality and Peer Review, that’s her job, after all. But after five years at UH, she says she’s incredibly energized to continue with this ongoing, important work. The source of this feeling? Her UH colleagues.
“My team is the reason for showing up every day,” she says. “As an Emergency Medicine physician, I don’t get the continuity of patient care like other people do. But the reason we do all the things we do is our team is so good. It’s really easy to do that work when your team wants to do what’s best for the patient as well.”