 So welcome back everyone to our QI session. Okay, so our next team is Marshal Wang and again Catherine Hu and the topic is assessment of mid-year changes to the VA intern role. Also, mostly Marshal, just here for moral support. Very great, thank you. Well, Catherine is an integral part of this project both for emotional support here and for the entire residency program. It's always good to have around. So I'm going to be talking about improving the VA intern experience. The primary objective of this project was to reduce the administrative burden of our intern on the VA rotation. So the main problems are interns spend a significant amount of time on administrative tasks during the VA rotation, which leaves them a lot less time for clinical learning. One of the main aspects of this is when we sign any of our patients up for surgeries at the VA, the VA patients be scheduled for a separate visit that they would come back usually on a separate day with the intern to perform a pre-optistry and physical sign consent forms as well as providing the patient with their surgery day and their surgical packet. So we surveyed our two interns who basically did their normal procedure that we've always been doing prior to the change. And we separated into clinical activities and administrative activities. And we asked them to break it down into approximate time that they spend on all of these activities. Overall, you can see that the biggest grouping of time that's spent is for walk-in patients and follow-up patients that are scheduled into their clinic. And here the blue is just the first intern, then the red would be the second intern. You can see most of the time spent on these activities are pretty consistent. And the area of interest here are the HNPs and consent. In both of those situations, both interns found that they spent about 5% of their time each, so about 10% of their time total at the VA doing the HNPs and consent. So when we tried to decide on what interventions to do, the first thing we wanted to do was move the HNPs for routine cataract and cataract plus mixed procedures to the same day. And that would be performed by the chief resident who will also be the primary surgeon. Two, the patient will sign the consent form on the same day as their cataract evaluation immediately after the resident evaluates them and discuss the risk benefits and alternatives of surgery. And three, the patient will schedule surgery and receive their packet on the same day. And that will be done by our surgery coordinator, Jay. So immediately after they sign the consent form, they will be brought over to Jay who will schedule them for surgery and give them their packet on that same day. So not only does it decrease the burden on our interns, but also decreases the burden on the veterans by saving them an extra visit. And here we surveyed our two interns that were at the VA after the intervention. And the intervention happened right at the end of November beginning of December around when they were switching. And here, again, directing your attention to the HNPs and consents, they dropped significantly. So from about 5% to more around 2%. And that allowed additional time for clinical activities. And here we see a comparison where the purple are the two interns before the intervention averaged, what with the green being the two interns averaged after the intervention. And again, you can see significantly more time available for resident clinic and the walk-in follow-up patients and significantly less time, about half as much time spent on the HNPs and consents overall. And here, this is just kind of an overall cumulative amount of time spent for the clinical and administrative activities, showing a corresponding increase in clinical and self-study time for having a decrease in administrative time for about a third of their time to about a quarter of their time. During the survey, we asked the interns for additional suggestions that they thought would be beneficial to their learning. And the most suggested change would be increased structure teaching by the attendings and fellows. You can kind of see before that there's really not much time noted by any of the residents that's dedicated to structure teaching from attendings, residents, or fellows. So that was probably the most commonly requested change. They also was, in addition to these changes, they were like to decrease their medication refill burden, decreasing the paper required for surgery packets, and updating the pre-op order set to make them more accurate with the surgeries that we're currently doing. And overall, all the interns agreed that they would still want more clinical time and less administrative time as you might expect. So these are some potential future directions as we continue to modify the intern experience. And special thanks to Jay Gibson, our new surgical coordinator, all of our interns who are excellent, Mubarak, Nana, Jordan, and Ashley, and the remaining residents who are being willing to make these changes this year to their workflow. Thank you. Thank you, Marshall. We have a comment from Judith Warner. Would you like to unmute yourself? I'm sure that I just read it from, yeah. Yeah, I mean, it was just, we had a really terrific M&M a couple of months ago about the potential communication breakdowns between scheduling a patient for surgery and them turning up and having the surgery. And I think that if the person who is going to be doing the surgery actually physically present during the surgery does the consent, then there's a much greater possibility of mutual understanding. There is always still the possibility of mutual confusion, but I think that it's definitely a step in the right direction. That's fantastic. Thanks, Dr. Warner, for that comment. I totally agree. As an intern, I always thought it was kind of silly for me to have these patients scheduled in that come in. I hadn't previously met them. I'm not looking really at their cataracts. They're not dilated. And here I all of a sudden just start talking about the surgery. And that's kind of my only role that's separate from everything else. So I think having it be in the workflow, the resident that talks to them about the risk and benefits and following that with the consent makes a lot more sense. And Dr. Huang asked, what do they mean by structure teaching? So that's a good question. What they mean is kind of more specific teaching for how to do examination skills, such as using a footlamp, doing the dilated fund exams, basically having an attending or fellow tell them that they're doing the right thing to double check their examinations that they're seeing what they think they're seeing. Because right now there's a lot of teaching that's just passed on from one intern to the next. And they worry about possible future propagation of errors that aren't corrected by someone more senior. And we are in the process of making big changes to that. So next year our interns experience will include a more structure teaching, some experience with the triage department, as well as a boot camp to kind of get go through all of that. Okay. So Dr. Wang, one more comment. The only problem is getting consent on the day of surgery in OR, on the way to the OR is the potential for pressure. Yeah. So we actually are still getting the consent done prior to surgery. So the consent are being signed on the day that they are scheduled for surgery when they're having their cataract evaluation. So they're signed by the residents that is examining them and scheduling them and signing them up for surgery. So the consent aren't done on the same day, unless the exception is when we basically can't find the consent, because sometimes there are electronic errors or paper errors. And then the, and in that situation, then the chief who is the primary surgeon does do the consent on the same day, but they've already signed it generally. Okay. So let's move on. Sure. Our next speaker is Mike Murray without Catherine who, and Mike is going to speak to us about improving postoperative patient flow at the Veterans Hospital. Dr. Murray. All right. If you're recovered. Don't try me. Okay. Okay, let's do this. So I'm going to talk a little bit about improving the VA postoperative patient flow. This is a project that stemmed from a lot of past chief classes. And I'll describe to you a little bit about, we've been talking a lot about the preoperative consent process and how to take care of patients before they get to the OR. Currently at the VA, there's a morning surgery block and an afternoon surgery block. And many of the patients will either be seen for their postoperative day one visit the next day, or they'll be seen if they opt for a same day postoperative visit at either the end of the day or in the middle time during lunchtime before the afternoon surgery block begins. As we kind of looked at this process and some of the problems, many veterans ended up waiting a significant amount of time if they had a same day postoperative visit. In addition, we had many veterans who, if they had a visit the next day, decided that they didn't need to come in. And so it kind of led to a situation where you feel like you were searching and rescuing for missing children on the milk carton. And it's surprising just on a side note to see how well a patient can do with taking no postoperative drops and showing up about two months later and having a great visual outcome, but that's definitely not ideal to try that experiment. And so some of the quotes we heard from veterans, they said, you know, I felt fine, so I didn't think I had to come in. Was it one day or was it one week? For some of these same day postoperative visits, they'd say, well, I have diabetes, I had to go get food. And once I went to get food, then I saw some of my buddies and you know how it can go from there. So we changed our system from making the patients wait for a long period of time or having them have to come back the next day, especially for some of these patients who had a long distance to drive and travel to doing a same day postoperative visit that really kind of mirrors the system that is done at the Moran Eye Center. And we wanted to look at some of the outcomes to see if this was safe to do, if it was appropriate for PGY4 surgeons to do, and if it was cost saving for the veterans. So we surveyed the chief residents after kind of this intervention and we had really interesting results. This is on the Likert scale, highly positive about saving the veterans money, about loss to follow up prevention. We basically have like a zero patient loss to follow up the rate and in being appropriate for PGY4's and safety. And this is important because the chief residents of the ones who were able to see, kind of like Arianna was talking about, some of their outcomes over time and to see if there's complications that they're missing etc. I thought it was interesting, one of the questions we asked the chief residents, how frequently do you deviate from same day postoperative visits after routine cataract surgery? And it varied from kind of like zero to 10%. In addition, listing some reasons why they would deviate from the postoperative protocol with some of the responses that you expect megs with significant high fema as a combination cataract surgery or other complications. And so some comments from some of the chief residents, they talked about the positives of this method is that it's a way to really go over all of the appointments with the patient and confirm they can make it to the next appointment and also confirm that they have a one week post-op visit. I included just a small cost estimate analysis. This is hypothetical, it's not survey data. But if the patient lives about 200 miles away, you can cost them about $130 with gas and food round trip, $100 hotel stay if they're not traveling. Even if they're on 100 miles away, it's not ideal. Some of these patients in the past were having to get admitted to the hospital for observation. And there's been a change recently with a medical companion system that's reduced costs there. So I think it's important to look at our healthcare system. What's safe, we don't necessarily have to be the most efficient if it's compromising safety, but we do want to decrease cost and time savings for our patients. I think a presentation like this wouldn't be complete with kind of next steps. So a detailed cost analysis for veterans going through a couple of months of patients and estimating of all the patients, how much they're saving. And then a continued evaluation of the post-operative process. And especially, I can't have a QI presentation without Catherine who making her way into the presentation. This is our post-operative area at the VA. So thank you all take any questions. That was great Mike. Are there questions? I know there's look at the comments or the chat please. There are a lot of good things flying around in the chat. I think it'd be a good time to do that. And otherwise, we'll forge on. Thank you. Okay, so we go on with from Colin. Utah community tele-othermology project. The stage is yours. Sorry, I admit I was trying to get a photo of Catherine who to put into my presentation last minute, but I couldn't do it. I didn't get it. Let me pull up mine. Give me one sec here. All right. Okay, can people see it? Yes. Perfect. All right. So yes, my quality improvement project calling the Utah tele-othermology project pretty adequately describes the gist of it, I think. It's something I started a few years back with Eric Hansen. And more recently, we've been joined by Mubarak and Jordan. Two of our interns who have been mentioned, I think in almost in every other QI talk so far. And then one of our 30-year medical students, Natalia Polikov. And the point of the project for the objective of the project is really to bring tele-othermology and tele-retina screening to community clinics specifically to federally qualified health centers and free and charitable clinics throughout the state. In terms of a smart aim, we would like to increase diabetic retinopathy screening rates in participating community clinics to 80% within one year of initiating a diabetic retinopathy tele-othermology screening program at that clinic. It's ambitious, but I think with the protocol that we are working with, something that's feasible. But realistically, we also need to have a much broader aim because increasing or improving screening rates really won't take any steps towards really preventing or reversing unnecessary vision loss from diabetic retinopathy in Utah. So at the same time, focusing on things like education, creating a referral network that I spoke about earlier in the ARCHIS project, ensuring that patients have access to treatment options once they are screened, and then ensuring that patients have the necessary financial and logistical support. We have started working so far with several clinics and umbrella organizations. We started with People's Health Clinic in Park City a few years back. Moab Free Clinic as well, shortly thereafter. We've been working with community health centers, Inc., of the Greater Salt Lake area, and have done really our pilot project there. The Association for Utah Community Health, which has dozens of fairly qualified health centers and community clinics throughout the state, and most recently started conversations with the Midvale Student Run Clinic. We don't have any formal partnerships with any companies, certainly no financial disclosures, but it is, I think, worth saying that these companies, Inuk, which is one of two FDA-approved diabetic retinopathy AI programs, as well as OptiMed and iCare, have been very supportive and seem to really share our goal. Our pilot project was with Community Health Center, Inc., so this is a clinic in the Greater Salt Lake area that has six clinics, serves 40,000 patients, 55 percent of which are uninsured and 99 percent of which are below 200 percent at the federal poverty line. 83 percent are racial or ethnic minority. There are about 4,000 patients that they see annually with diabetes, and they approached us with the goal of improving their diabetic retinopathy screening program, which they had in place, but that was maybe not optimized. So we started talking with them in June of 2021. The diabetic retinopathy screening rates for all of Community Health Center, Inc. was 32.3 percent. As of April of 2022, it was 36.1 percent. Not a huge change, certainly not approaching 80 percent that we're hoping for, but if we look at the one clinic that we actually had the pilot project in, which was the 72nd Street Clinic, only one of their six clinics, their diabetic retinopathy screening rate increased by 20 percent over just six months. So that included 230 exams, and within those exams, we identified 27 patients that had moderate or worse non-proliferative diabetic retinopathy, so those patients were recommended to be referred for eye exams. We found 84 patients with any type of identifiable pathologies that include nerve cupping, drusen, macular degeneration, and other pathology. And then there were also 51 unreadable photos, which is something that we definitely need to improve upon. As far as next steps go, with this pilot project having been quite successful, the next steps are for expansion. So to the five additional Community Health Center clinics, and as we expand to the additional clinics, we're actually changing technology, switching to the DRS Plus, hopefully to decrease that number of unreadable photos. We're also working with OUCH and planning to initiate a program with four of their clinics, and then again potentially the Midvale Student Run Clinic and possible involvement with the UNHS, the Utah Navajo Health Services, although they seem to have a teleophonology program in place that they're satisfied with. Some of the biggest barriers right now are just integrating the technologies. So this INOC program, which has AI capabilities with electronic health records of the clinics and cameras, that's what we're working on primarily at the moment. Once that's worked out, we'll want to do a financial sustainability pilot project because a big aspect of this being sustainable is it providing revenue for these clinics and for any providers that are involved in interpreting the images. And to that end, eventually our goal is to have artificial intelligence playing a large role in this process, that patients in these clinics can be getting photos, getting results on the spot, and removing sort of the physicians that have historically had to volunteer their time to read images. That's all I have for now. Happy taking questions. Sean, thank you so much for this great work. Bob, I'm sure you would like to comment on this. Well, I think this sounds wonderful. I think you've done a lot of work on this. I'm very impressed. It's good and it's going to make a difference. So please keep it up. We'll expect another report back on this next year. You bet. I see Dr. Warner asked, does Midvale Student Run Clinic not have a camera? I thought I read about a study. I'm not sure about the study you're referring to. My understanding is that they do have a clinic and a lot of these clinics do have cameras. The cameras are difficult to use. The clinics have decided they're too difficult to use. They don't take good enough photos. So we are doing many very small PDSA cycles and really working through these projects. It's really a continuous sort of adaptation process. Another comment from Judith Warner. Sean has a special skill in getting companies to give him expense. Well, maybe. Who's reading the rental images? Right now it's primarily Dr. Hansen and I read them with oversight from Dr. Hansen. But we're hoping that we can make this something where the reading physicians get reimbursed and also create a system wherein residents can read images which will then be cosigned by attendees. Great. All right. Well, let's move on. Next up, we have Allie Simpson. She is going to speak to us about the resident perspective on feedback during training. Dr. Simpson. Great. Thanks. So this is a project that I started working on as part of the MOL committee. And this is I'm just presenting the idea today and hopefully we'll have data next year. But feedback during training, for sake of time, I won't go into it, but it is essential for resident growth. And despite it being so vital, it's a really difficult topic and something that most people don't like to give or receive because it can be kind of uncomfortable. The ACGME has kind of developed this 360 degree evaluation which blends itself well to these large annual reviews. However, I hate to say it, but it's a sign of changing times. A lot of the residents are millennials and there's been studies that have shown that residents currently aren't liking these large annual reviews. They're favoring more frequent informal feedback that's more personable on a one-to-one basis where they can use that information kind of in real time to make changes. And so it has been kind of the MOL committee's focus for improvement for feedback at Moran because from an academic team standpoint and from a MOL committee we have heard that some residents at the Morana felt like they don't know what's how they're doing until it's too late to really make any changes so that's where this is stemming from. So my role in this was that I have developed a resident feedback survey which showed the residents, this will be coming to you soon, but it's short, it's about 12 questions. And it's modeled off of a survey that the Department of Dermatology sent their residents at UC Davis and it's kind of just looking at laying the groundwork. So we're looking for resident responses on the frequency nature and subject of feedback that they're receiving now, their preferred methods, any barriers that they perceive to receiving fed feedback and their overall satisfaction, and also gathering their perspectives on the ACJME 360 degree evaluations that we get through Med Hub once a year. And so this will be used at kind of concurrently, we've also developed as a MOL committee this form, which is some of you may know or recognize hopefully there are a few out here do that we've recently started within the past one to two months. It's initiative called Feedback Friday, in which we're giving this form to residents to go seek out informal feedback every few weeks to kind of prevent this lack of feedback until the end of the rotation. And while this form isn't necessarily needed to use it in its entirety, or to fill it out completely, it is used, you know, hopefully to help guide the discussion and maybe bridge some of those more uncomfortable topics or asking for feedback in certain ways. And the good thing about this is that this form is completely separate from formal evaluations. By no mean will this go in a resident's academic record, it's truly just for their use and for their benefit. So this shout out to residents and faculty to continue to do this and start doing this this year. Because the next steps will be that we'll continue this Feedback Friday initiative. And then we will reevaluate the resident survey next year and see how we're doing as far as feedback is going and if their perspectives have changed at all. I'm happy to take any questions. Thanks to the MOL committee, there are quite a few members, Dr. Petty, Dr. Simpson, Jardine, Laura Shell. I know I'm missing a few, Dr. Long, Dr. Rachel Tell. And then, of course, got to put in Catherine Who is on the committee, as well as Ariana and Brandon, among others. Sorry if I missed you, who have been working to improve this part of our training. All right, thanks very much. That was very good. I think we, you know, this is a good thing. And trying to formalize this and having it occur regularly is a good thing. Oh, let me let me just make one quick comment there. You know, I want to just just reiterate and, you know, I really agree with you, Allie. It's challenging when, you know, you feel like the first time you hear, you know, some things, you know, someone's had a perception or you're not doing something well is the first time you hear about it is the resident, you know, once or twice a year meeting with me. And this feedback Friday, I think it could be the most significant change that we make in the program because what it allows you to do is sit down and say, Hey, this is actually fully off the record, right? This is, but if you would take your differential diagnosis and just narrow it down to one, just choose the one you're going with, make your plan based on that, that's going to help you so much instead of just talking around things over and over and over in a circle, something like that. Then by the time, you know, you fill out your formal feedback that gets the CCC that gets to me, you know, they really should be aware of essentially any type of, you know, area they need to improve by the time they get to that meeting. So I really enjoy this whole notion of just, yeah, off the record, you and me hanging out just chatting and I think it's going to be a big, you know, big step forward. So just want to, you know, laud you Ali and wholeheartedly agree. Should we go on? Yes. Okay, so Abby Gale with her presentation, making virtual a reality part two 2021-2022, Moraine, I sent a virtual residency interview. Thanks, Dr. Flickenstein. Hi again, everyone. My QA project this year was a continuation of last year's evaluation of a virtual residency interview process in the setting of COVID-19 pandemic restrictions. You may remember from my presentation last year we evaluated all parties involved with this. And the main issue that we found out was figuring out how to connect residents to applicants and vice versa. And this is a really important part of our process, because we are able to assess kind of fit meaning whether an applicant would integrate well into our program's culture and be someone that we'd like to spend the next four years with or three, really four. So in terms of changes this year, it was a wild year. Some changes were made, applicants could come away for rotations with us, although interviews were still virtual. We did hold instead this year as opposed to last year two pre-interview virtual Zoom sessions as opposed to a large generic open house before interview season that was open to anyone interested in coming here. This was specifically shut, more restricted for people who were just going to interview with us. So a smaller number of people, we did have that as our main intervention this year. In addition to those things, we also had resources available such as online information for applicants, specifically interviewees and a small gift bag. An exciting change this year that unfortunately didn't come to fruition for many programs, unfortunately, and was very limited for us was the in-person program visits during the surge of the Omicron variant that really would have helped applicants experience our program in person, which I think is a huge strength that we have. But unfortunately, this was severely limited and data on this was excluded from the study because of that. So let's dig into the findings. We had a good response rates from the applicants, 100% participation from residents and selection committee members. Here are the resources utilized by applicants that they found helpful from most popular to least in terms of deciding whether or not to interview and rank us. In addition to things that are to our benefit that are kind of unmodifiable, such as reputational location, applicants really appreciated resident interactions and the resident made resources that we have that were led by many residents, but Ariana Levin really took the forefront of making some videos for us. Interestingly, and kind of surprising for me, but consistent with last year's data, was that social media was still not super high on the list. And then unfortunately, the pre-interview social still was ranked pretty low in its effect, although applicants did find these helpful. Overall, the technical quality of the interview was high, residents ranked quality of communication as lower as opposed to other groups. The perception of the ability to assess that fit I was talking about was mixed. Applicants felt that they were able to get a really good idea. And I think a lot of that stems from the waiting room and the pre-interview social being able to just see how the interactions between residents and things like that, as opposed to only half of the committee members felt like they were able to and only two of our residents felt like they could. There was also a distribution of desired format for the interview. Applicants liked the idea of the campus visit as a separate event, selection committee members and residents preferred in-person interviews overall. Briefly, I know I didn't have time to review last year's results compared to ours this year, but our results were very similar. We're still working on ways to connect applicants and residents successfully virtually. Residents in the past really, really valued our pre-interview dinners and being able to speak one-on-one with applicants. So how do we fix this? What do we do in the future? As we know, the pandemic is a dynamic situation that's constantly changing. Given applicants' preference for resident interactions and resources the most, our goal for next year, regardless of what the format may be, is finding ways to maximize this, whether it be pairing prospective applicants with residents one-on-one with phone calls or emails. Also, a good point brought up by Dr. Vigunta was some programs have been utilizing rooms where you walk around with an avatar and are able to select people to talk with so that you can have more one-on-one interactions, which will be the main thing that we will be working on this coming year, regardless of what the interview format may be. And then more resident-made resources available. These are really heavily utilized by our prospective applicants. And so really getting to know us, I think, is very important as well. But these are two specific actionable things that we can go for next year. I would like to thank the following people. Dr. Vigunta has been really, really instrumental in mentoring me through this process. I'd like to also thank Dr. Tyler Etheridge, the All-Star Academic Team, for really coordinating the interview process and making it all work smoothly. And like I said, the technical quality was really high. Dr. Judith Warner, who has really led our resident selection committee for years and the residents as well for their participation. And I'm going to jump on the Catherine Who bandwagon by adding a photo from her wedding at the end here. And then this is a picture I took at the beach. I'd help you to take any questions. Thank you so much, Abigail. We have very important to comment in the chat from Arianna. Surely more people would have voted for social media if they had seen the Instagram video of Tony May dancing to the Bee Gees. It was very true. It was before, the survey was distributed before that was public. So I'm sure it's, you know, through the roof now. All right. Let's move on. Okay. Okay. So next up is Cole Swiston. Cole is going to talk to us about prevention of exposure keratopathy in the intensive care unit. Dr. Swiston. Okay. There we go. I'm unmuted now. All right. You're unmuted. Okay. We've got you. So this is kind of an update on the project I introduced last year because we know how some data to talk about. So the main problem is that we didn't have any sort of preventative measure in our ICUs to prevent exposure keratopathy among ventilated patients. So we mirrored an intervention that was performed at Iowa for an automatic EMR-based lubrication order set. So every ventilated patient now in our medical ICU gets QID ointment. And so we then asked the question, does this actually reduce the rate of exposure keratopathy in the number of ophthalmology consultations, which actually the primary outcome was, does it lead to QID ointment use or what amount ointment then gets placed in patients' eyes in the ICU? And so we had three different periods. So there were two stratified by COVID pre-intervention and then one post-intervention period after the order was put in place in 2020. We used a mixed effects progression framework to look at the use of lubricating ointment, the number of ophthalmologic consultations, and the rates of exposure before and after. So this is our descriptive statistics. Over that 18-month period, there were 974 ventilated patients in the medical enhancement ICUs, who on average had a mortality rate of 44%. Those patients were ventilated for about five days each. And then right to our primary outcome, we saw a steady increase in ointment use, 0.3 to 0.7 doses per day. And then after the intervention, 2.6 doses per day. I'll talk about a little bit why it went up steadily, even pre-intervention in a bit. And then the rates of ophthalmology consultations didn't change. However, the rates of exposure keratopathy did. We also saw a steady decrease 33% to 20 and then down to 8% after the intervention was put in place. But as you remember, it was a QID order set. So whereas patients should have been getting ointment four times daily, the average after the order was put in place was still 2.6 per day. And this is just a different graphical representation of the estimated doses per day for each period. So this middle one here is still pre-intervention, but that's post-COVID. And that was due to an existing protocol in the ICU for any patient put in prone positioning. They would automatically get Q4-hour ointments. So with the increase in COVID patients, that accounted for that increase there before our order set went in place. And so then we asked the question because patients didn't get QID ointment. They got 2.6 doses per day. Why is this the case? So we surveyed 50 different ICU nurses and asked them about the barriers to applying this every six hours. The most common response was that they had no issue with it. But then the next two where I didn't think it was important or I was busy with other patient responsibilities. And so to kind of summarize, this certainly was an effective EMR-based order to prevent exposure in the ICU. It did lead to a significant increase in ointment for ventilated patient. And then targeting nursing education may increase this further. We did see decreased rates of exposure care atop at the after the intervention. And it was a very cost-effective measure as well, costing a ventilated patient about $3. And that wasn't per day. That was the total number of days they were on the ventilator. And so that added up to $1,500 a year in the MICU and $500 in the Huntsman ICU, which I think overall is a very cost-effective measure. We were obviously limited in this being retrospective. So we're vastly underestimating the diagnosis of exposure. That kind of compounded with the high mortality rate is going to limit that. And because the diagnosis was relatively rare, we had limited statistical power as a result. I'd like to thank Dr. Lynn as the PI for this project, Dr. Simpson, Ali Burton, who was mentioned earlier. She matched at UVA, as well as our ICU team and Vendrin as our statistician. And then of course, Catherine, who if you forgot what she looks like, here's a picture of her. Take any questions? That was also outstanding. Questions for Cole? Let's look at the chat. Dr. Warner says, oh my God, write it up. Well, there you go. Actually, I didn't mention with everyone's help, this was accepted for publication in the Journal of Academic Ophthalmology. So this will be published. So there you are, Dr. Warner. Okay. Shall we move on? Okay. Dr. Warner has one comment. I unmute. That's clapping. That's not a comment. Ah, sorry. Hard to tell the difference. Okay. So our last team for today, Brandon Kennedy, Tony May, Lydia Zawa is missing in this video. There she is. And they are talking about flattening the curve and new PGY1 experience. All right. Can everyone hear us? Yeah. Oh, it says host disabled participant screen sharing. Do you again using the mech from? No. This is now my computer. Yep. Said I disabled. Wait, let's try it one more time. All right, there you go. I got kicked out. So he's the host now. I think I'm bad luck probably. All right. So again, I'm Tony May and I'm a second year. And then we also have Lydia and we'll be presenting a discussion on flattening the curve, a new Moran PGY1 experience. So we're going to start off with this video that we created for our intern year and this starring many of our star residents. During intern year, we rotate at a number of different hospital systems, including a veterans affair hospital, community hospital, the university system, a cancer hospital, which is a great opportunity for anyone interested in health care policy. So by the time we finish intern year or even during intern year, we'll have done about 10, yeah, capsulonomies and unlimited amount of intramural injections. During intern year, we spend four months on ophthalmology. So there's an opportunity to get involved in outreach, research, and quality improvement. Because of the elected time during my intern year, I got involved in international club home and tantrum year project. This led to me presenting at Argo and being able to travel the tantrum year during PGY2. We have one whole month of self-draft for the left of time for the intern, which we can spend at clinic or on the OR. One of the nice things about intern year was that it let me find a work-life balance. Additional work I was able to continue to play trumpet in an orchestra that I was a part of and also play pickup basketball with my friends that I've been doing prior to intern year. During intern year, I guess I'm with my best friends of the human art etherology program. So you can see from this intern year video that the year encompasses a wide variety of ophthalmology experiences as well as providing a good work life balance too. But let me just go next here. But next we wanted to take a look at what we are currently doing at the intern year. So this here jumping ahead a little bit is a project from Lydia's hour looking at the time spent at the VA clinic and what time is spent doing clinical work versus doing administrative work. And this was a vital part of our project because even though we had plenty of time on consults and doing triage and being able to work in the different ophthalmology departments in the intern year, we found that most of the time was spent doing administrative work. So anywhere between 60 to 70% of it was doing things like scheduling, copying papers, doing H&Ps without actually examining the patient and doing medication refills and telephone calls. Only about 27 to 37% of it was doing clinical work and learning in lectures. So this leads us to the new ECGME mandate that came out saying that ophthalmology programs needed to have an integrated intern year by 2021. And even though our program has been doing this for a long time, we felt this is a great opportunity for us, given the fact that we were pretty administrative heavy to find ways to revamp the program so we can be ahead of the curve. And so we wanted to start from scratch and to do that, we'd want to bring over the benefits from our old curriculum while trying to maximize the education that the interns get and minimize administrative duties that they have. So in other words, what we really wanted to do is flatten the curve. And what we mean by this is here's how we felt this year, the current PGY2s, and we were hoping to get to kind of the greener area under the curve there where we're below that threshold of survival mode. Oh, crap, help me out chief. So that was kind of the goal. And what we wanted to do is we wanted to focus on three different pillars. What three things would be most important to help prepare the intern for that transition come July 1st, when they're taking primary call, when they're on consults, how can we help make this look more smooth sailing. So here are the three things we focused on. We'll kind of walk you through each one here. First is curriculum development. So here is Dr. Petty, Dr. Simpson, and all of us residents. I think that's myself there in the middle. In regards to the curriculum, we were thinking of what could we incorporate to kind of help smooth out that transition to help the interns see as many triaging patients, emergency patients as possible, so they're better prepared for next year. And we decided that the consult service and the triage service at the Moran and not the VA would be a good way to incorporate this. So that's exactly what we did. And you can see here is a revised schedule. So previously the intern while in ophthalmology would be at the VA every single day. And now on every Tuesday and every Friday for the first six weeks, they'll actually be over at the Moran helping out triage and doing essentially zero administrative duties and only seeing patients. Then the second half of the rotation, the six weeks, every Tuesday and every Friday will be on the consult service with the consult resident at the Moran Eye Center, seeing patients having graded autonomy and hopefully by the end holding the pager by themselves. Then we also wanted to reserve some of the things we had previously such as ACAD or the academic half day where interns can go to OR, they can shadow, they can study, they can go to different clinics, they can go to the wet lab, IC, work on research, etc. Next is we wanted to develop some type of orientation that is more a little bit more structured. And this was Dr. Sauer did a lot of heavy lifting here, so kudos to her. So we're incorporating a one day boot camp where in the beginning of the day the first half we're going over more of the logistical things, touring the Moran, finding out where to find what kind of what buttons to click for encounters, who to call, kind of smoothing out that transition. Then the second half of the day we go over going over simulated patient encounters, common things we see on call, emergencies, how to handle certain things. Then you can see there is a picture of us saying chief yes chief instead of serious sir. And lastly wanted to incorporate some type of mentorship program. We feel like the mentorship is very strong here, but having some type of structured program to help the intern out, just having someone as a go to, and we thought the chief would be a good idea to help them out with scheduling, help them out with getting research opportunities, just to kind of help guide them along their intern year experience. And you can see here is Tony myself working with Ariana, she's been a great mentor to both of us. So those are the three big things we wanted to incorporate. Ways to kind of track our progression and moving forward to see how much of an impact this has had. We have a couple ideas. We can always kind of reevaluate and reconduct that study that Dr. Sauer did where we evaluate how much time is spent doing administrative versus clinical duties and all of this new schedule. We could also do other things we could do resident satisfaction surveys. This would be a little bit limited because we don't have surveys prior to the changes. And then we could also talk to the faculty, talk to the fellows over the years and see if they think that this, these changes that we're making, if this has helped the incoming PGY2s feel more prepared for call. And that is our presentation. And we would like to thank the whole kind of intern year committee. This has been a long work in progress here over I think a year and a half. A lot of people involved and most of all we wanted to thank Dr. Petty and Dr. Simpson. Imagine kind of coming into a program that's had a great intern year that's integrated for the past 30 to 40 years that has proven to work and look at them and say we want to change it. So that was a pretty tough but they were actually very opening, very welcoming and actually kind of pushed us to think big. So without their support and their acceptance none of this would have been possible. So thank you all. And Lydia Tony, this was great work or is great work. Thank you so much. Are there any additional comments? Just a general comment, you know, about everyone that's relevant to this, you know, Tony and Brandon, the best improvements we've had in our program over time have been when people are willing to again, you know, raise their voices say, yeah, this is something we can do better. You know, I think are as I noted previously are human natures a little bit, you know, where we want to complain about it. But then the question is we're going to do anything about it and just want to commend you all, you know, as soon as we start resting on our laurels and, you know, no longer really push forward to do better than, you know, we're destined for mediocracy and definitely appreciate what everyone's done to, you know, step forward, let us know where we can do better and keep keep the program moving forward. So thank you everyone. So I want to give another shout out to Elaine and Ethan for getting us through another resident research day and to them. And thanks to all of you for sticking through this. I know it's not easy when it's on zoom and the tendency to turn off the sound turn off the video and do something else for a while is very tempting. I am very grateful that you have stuck with us. Everybody have a good rest of your day and thank you for being here.