GME Patient Safety Quality and Innovation Symposium

Background:

Primary care providers (PCPs) address many issues, including cancer prevention and screening, within the limited time available during appointments. Across the San Diego VA Healthcare System, rates of individuals who are up to date with cancer screenings are below the national VA rates. With PCPs being the first line of defense against screening for cancer, it is essential to address this gap in healthcare. This quality improvement project aimed to increase the percentage of up-to-date cancer screenings across multiple cancers (breast, colorectal, cervical, prostate, and lung) among patients at the VA La Jolla Primary Care clinic.

Methods:

We standardized workflow by incorporating cancer screening into the primary care note template to prompt the primary care provider to screen for breast cancer, colorectal cancer, prostate cancer, cervical cancer, and lung cancer. A customized after visit summary (AVS) that included cancer screening was created as part of this project and was given to the patient. The primary outcome was the proportion of cancer screenings completed between October 2023 and March 2024. We analyzed the trend of up-to-date cancer screenings across our patient panel from December 2023 to March 2024.

Results:

Through October 2023 to March 2024, 28 patients were found to be eligible and due for age-appropriate cancer screening, and 43 cancer screening tests were ordered. As of March 2024, 27 of these 43 (63%) tests were completed. Among the study sample, 5/5 (100%) of mammograms were completed, 5/9 (56%) of fecal immunochemical tests were completed, 1/8 (13%) of colonoscopies were completed, 14/16 (88%) of PSA labs were completed, 1/1 (100%) of Pap smears were completed, and 1/4 (25%) of low-dose CTs were completed. From December 2023 to March 2024, screening uptake improved in the three cancer types recorded on the Almanac database. Colorectal cancer screening increased from 48.6% to 50.2%, breast cancer screening increased from 70.4% to 76%, and cervical cancer screening increased from 69.8% to 72.6%.

Conclusions:

Incorporation of cancer screening into the AVS creates a tool that is patient-centered, and this tool has been distributed across the primary care clinic. However, further efforts are needed to increase completion of screening tests. The addition of an automated reminder for lung cancer screening is in progress, and future projects could study the effects of this reminder on screening rates. Completion of cancer screening requires steps outside of the primary care visit, such as scheduling with other departments, and may need to involve further interventions, such as sending a reminder to the patient if a test is not completed within a specific period of time.

Background:

Inhaled corticosteroids (ICS) are the recommended controller therapy of choice for pediatric patients suffering from mild persistent asthma. In this study, the goal was to identify which asthmatic children were more or less likely to respond to ICS, as defined by improvement in lung function, in the context of a pediatric pulmonology practice. We hypothesized that baseline bronchodilator response (BDR) is a significant predictor of an individual’s response to ICS.

Methods:

This retrospective study analyzed children between 5 and 18 years of age from the Rady Children’s Hospital San Diego pulmonary clinic from January 2019 to May 2022 who had been diagnosed with asthma. These patients had baseline pulmonary function tests (PFT) which were used to calculate a BDR before initiating ICS therapy. Follow-up PFTs obtained at least 3 weeks after initiating ICS were used to assess changes in lung function, indicating a response to therapy.

Results:

Among 16 patients, baseline BDR and change in FEV1% while on ICS were positively correlated, r(16) = .73, p < .05. The 6 patients who had high BDR at baseline (M = 15.7, SD = 12.8) compared to the 10 patients who had low BDR (M = 1.1, SD = 8) demonstrated significantly higher changes in FEV1%, t(16) = 2.8, p < .05, following ICS. Furthermore, patients with high BDR at baseline were 12 times more likely to have a notable lung function response to ICS.

Conclusion:

Baseline BDR is associated with response to ICS in pediatric patients with asthma. As baseline BDR increases so do the changes between FEV1% in follow up visits while on ICS therapy. Furthermore, patients who have high baseline BDR have significantly higher responses to ICS. Overall, BDR may be an adequate parameter in identifying asthmatic children who could be considered responders to ICS in the real-world clinical setting.

Background: Medical errors are a major cause of morbidity and mortality in the healthcare industry. Human factors make errors much more likely to occur. However, explicit instruction on mitigating human factors is underrepresented in graduate medical education. The Naval Aviation community has systematically evaluated the risk posed by human factors and implemented specific approaches for reducing error, an intervention which has exponentially decreased preventable aviation mishaps over decades. Applying those principles from Naval Aviation to the way in which healthcare is delivered will reduce errors and improve safety.

Description of the Project: Human factors are a broad category within error analysis. Naval Aviation has grouped human factors into four broad categories: active factors, preconditions, supervisory factors, and organizational factors. Naval Aviation applies frameworks such as Threat and Error Management (TEM) and Crew Resource Management (CRM) to reduce the risks posed by these factors and prevent human error from contributing to mishaps. TEM and CRM directly apply to the medical industry and could immediately reduce dangerous mistakes that adversely affect patient outcomes.

TEM is a system designed to correct deviations from a standard. Deviations consist of threats, errors, and undesired states. Threats are risks which are known ahead of time (such as the risk of infection). We control threats by preparing for them appropriately (by giving perioperative antibiotics). Errors are harmless, but unintended, deviations that cannot be prevented (such as marking a wrong site for surgery). We control errors by identifying and repairing them (confirming the surgical site with the patient and perioperative team prior to induction of anesthesia). Undesired states are situations in which serious harm is imminent (such as excessive uncontrolled bleeding). We control undesired states by recovering from them (massive transfusion, IR embolization, etc). Effective TEM application requires the seven critical skills of CRM: Situational Awareness, Assertiveness, Decision Making, Communication, Leadership, Adaptability, and Mission Analysis.

We presented these principles to second year UCSD anesthesia residents as part of the professional development didactic series. We utilized analogies from real aviation disasters, description of aviation’s culture of safety, and group discussion on healthcare examples to illustrate how to apply TEM and CRM.

Lessons Learned/Expected Outcomes: 80% of respondents reported no prior knowledge of how the principles of CRM existed within their clinical duties. After presenting on TEM and CRM, 100% of respondents agreed that the information would positively influence their professional practice. Continued TEM and CRM training will improve team members’ ability to ensure patient safety in any situation or environment.

Recommendations/Next Steps: Educational emphasis on TEM/CRM, human factors, non-hierarchical communication, identification of cognitive bias, single provider CRM, and other Naval Aviation topics will empower members of the healthcare team and reduce preventable errors in patient care.

Figures/Tables: Diagram of TEM and CRM.

Background

Atrial fibrillation (AF) is a common arrhythmia with two general treatment approaches: rate or rhythm control. Rate control in AF is achieved by decreasing AV nodal conduction velocity with beta blockade or calcium channel inhibition. Based on the result of the AFFIRM trial, beta blockers (BBs) were more commonly used, and a higher percentage of the patients achieved adequate heart rate (HR) control (< 110 bpm) compared to calcium channel blockers (CCBs). In addition to the choice of medication, the dosing strategy of diltiazem is explored. Guidelines The 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation recommend 0.25 mg/kg IV bolus. An additional bolus of 0.35 mg/kg can be given if no therapeutic response within 15 minutes.  Which body weight to use (actual vs. ideal) is not specified by the guidelines but actual body weight (ABW) is commonly used. However, in an obese patient, the use of ABW may lead to more side effects as the dose is larger.  Our project aims to evaluate the use and dosing of BBs and CCBs in the Emergency Department (ED) of Jacobs Medical Center (JMC) for patients presenting in atrial fibrillation with rapid ventricular response (AF-RVR). 

Methods

This retrospective chart review included adult patients who presented to the ED of JMC in AF-RVR and who received rate-controlling drugs between 01/01/2021 to 09/01/2022. The primary objective was the percentage of patients who achieved adequate rate control (HR < 110 bpm) within the first 90 minutes after drug administration. The secondary objectives included the prevalence of bradycardia (HR < 60 bpm) or hypotension (SBP < 90 mmHg) within 90 minutes of drug administration. Lastly, the decrease in HR was evaluated by drug, route, and weight-normalized dose. 

Results

In the predefined time frame, 241 patients were identified with 126 meeting inclusion criteria. The main reason for exclusion was HR < 110 bpm prior to drug administration. Sixty percent of the study population was male with a mean age of 69 years and weight of 82.2 kg. The most prevalent comorbidities were hypertension (54%) and heart failure (38.9%). Sixty-one percent of patients had atrial fibrillation listed in their medical history. More studied patients (39.7%) were on BBs prior to admission than CCBs (5.6%).

More patients (71%) received BBs than CCBs (23%). Many (45.8%) achieved the primary objective. Of those, more (77%) received BBs than CCBs (15%). Few experienced hypotension (6.8%) or bradycardia (2%). Failure to achieve HR rate less than 110 bpm was 50% for BBs and 71.9% for CCBs. The average dose of IV diltiazem per weight was only 0.15 mg/kg.

Conclusion

BBs were used more frequently at the JMC ED for patients who presented in AF-RVR. A higher percentage of failure to achieve target HR goal was seen with CCBs, however, the CCBs were suboptimally dosed when normalized by body weight. This study highlights the importance of appropriate CCBs dosing when treating patients presenting to the ED in AF-RVR.

Figures/Tables

My abstract includes tables of figures that will be displayed on the poster.

Title: Implementation of Medication Abortion in UCSD Family Medicine Continuity Clinics

Author: Kenya Lyons

Specialty: Family Medicine

Background:

Nationwide, access to abortion has been significantly restricted due to the Supreme Court’s ruling in Dobbs v. Jackson Women’s Health (June 2022), which overturned Roe v. Wade (1973). This has led to the activation of “trigger laws” effectively banning abortion in many regions throughout the United States, leading to an influx of patients into neighboring pro-choice states such as California. Prior to the Dobbs decision, 89% of U.S. counties did not have an abortion provider[1]. The vast majority of abortions are performed at stand-alone clinics that prove ready targets for restrictive anti-choice legislation[1]. Thus, the integration of abortion into primary care clinics has the potential to relieve strain on the healthcare system, shorten patient wait times, facilitate presentation earlier during pregnancy, reduce stigma, and safeguard access to abortion.

Methods:

We are in the process of designing and implementing a protocol for medication abortion (MAB) for the three primary care teaching clinics affiliated with the UCSD Family Medicine Residency Program. Pre-existing protocols by multiple organizations, including RHEDI, RHAP, and Gynuity, are being used to create our protocol[2-6]. Challenges include overcoming lack of on-site transvaginal ultrasounds, identifying stakeholders and champions among clinic support staff, obtaining authorization for mifepristone prescribers, and instructing residents and faculty on safe execution of the protocol. This writer presented the protocol to FM faculty and residents as part of a teaching lecture in February of 2023. This session included the piloting of a preand post-survey questionnaire assessing participants’ interest in providing miscarriage and abortion management, confidence in identifying eligibility for and contraindications to MAB, and familiarity with medication dosage and timing. We anticipated an improvement in the survey participants’ familiarity and comfort level with providing MAB as a result of this intervention.

Results:

Eighteen participants completed the pre-intervention survey, while 16 completed the postintervention survey. The percentage of participants who reported feeling “very” or “moderately” interested in providing medication abortion increased from 72.2% to 87.5% after the intervention. Fifty percent of participants felt “very” or “somewhat” familiar with the two drug regimen prior to the presentation, versus 100% afterwards. Those reporting that they were “very” comfortable in describing contraindications to medication abortion and instructing patients of reasons to seek emergency care increased from 5.6% to 37.5%, and 22.2% to 37.5% respectively. Prior to the intervention, 5.5% of participants reported feeling “very comfortable” with evaluating patient eligibility to undergo medication abortion and prescribing/administering the medications involved, while an additional 16.7% felt “somewhat comfortable.” Post-intervention, 43.8% of participants felt “very comfortable” and 31.3% felt “somewhat comfortable.”

Conclusions:

The results of this pilot study suggest that even brief educational interventions can significantly improve family medicine physicians’ understanding of and comfort with providing medication abortion. Current efforts are focused on further sessions to increase resident and attending familiarity with the medication abortion protocol and credentialing.

Resources: 

1. Jones RK, W.E.a.J.J., Abortion Incidence and Service Availability in the United States, 2017. Guttmacher Institute 2019.

2. Medicine, T.C.f.R.H.E.i.F., Medication Abortion Checklist 2022.

3. RHEDI, Medication Abortion Protocol 2020.

4. Project, R.H.A., Telehealth Care for Medication Abortion Protocol 2021.

5. Project, R.H.A., Mifepristone/misoprostol abortion protocol 2021.

6. Raymond, E.G., Grossman, D., Mark, A., et al. , Medication Abortion: A Sample Protocol for Increasing Access During a Pandemic and Beyond. Contraception 2020. 101(6): p. 361-66.

Efficacy of Radiation Reduction Protocols for Diagnostic Angiography and Basic Interventions in Endovascular Neurosurgery

Arvin R. Wali MD, MAS, Michael G. Brandel MD, MAS, Sarath Pathuri BS, Brian R. Hirshman MD, PhD, Javier Bravo MD, Jeffrey Steinberg MD, Scott Olson MD, J. Scott Pannell MD, David R. Santiago-Dieppa MD, Alexander A. Khalessi MD, MBA

Background

Safe radiation practices and “As Low As Reasonably Achievable” (ALARA) principles are critical to mitigate unnecessary radiation to patients, providers, and staff. Radiation has stochastic and deterministic effects that have deleterious effects on health and lead to complications such as cancer, leukemia, and cataracts. As the indications for neuroendovascular procedures continue to grow, Neurointerventionalists must have a strong command over practices that reduce unnecessary radiation dose. We applied a quality improvement protocol to manipulate default pulse rate and frame rate settings on our Siemens Artis Q biplane to determine if radiation safety practices could allow for quality diagnostic angiograms and the performance of safe and effective interventions.

Methods

We implemented a radiation reduction protocol January 1^st 2022 in which the default pulse rate and frame rate in our Siemens Artis Q biplane was reduced from 15 pulses per second (p/s) to 7.5 p/s and 7.5 frames per second (f/s) to 4.0 f/s. We performed a retrospective review of prospectively acquired data to calculate the impact of our radiation reduction protocol on total radiation dose, radiation per angiographic run, total radiation exposure, and exposure per run.  We examined 29 consecutive diagnostic angiograms (16 prior to intervention, and 13 post intervention) and 16 consecutive, unilateral middle meningeal artery embolizations (MMAEs) (8 prior to intervention, and 8 post intervention). A blinded neuroradiologist reviewed the angiograms to determine if there was sufficient diagnostic information in the angiograms before and after intervention. Univariable and multivariable log-linear regression were performed to account for patient body mass index (BMI), number of angiographic runs, and number of vessels catheterized. Statistical analysis was performed using STATA MP Version 17.0 (Stata Corp LP, College Station, Texas). Significance was defined as p < 0.05.

Results

For the diagnostic angiograms, univariable analysis revealed that radiation dose (550.5 vs. 353.3 mGy, p=0.005), radiation dose per angiographic run (34.6 vs. 21.9, p<0.001), total radiation exposure (7050.7 vs. 4490.7 mGym2, p=0.013), and exposure per run (429.8 vs. 281.9, p<0.001) were all significantly decreased after the protocol. On multivariable log-linear regression adjusting for BMI, number of runs, vessels catheterized, and fluoroscopy time, the protocol was associated with a 45.4% decrease in the total radiation dose (p<0.001) and a 53.3% decrease in radiation dose per run (p<0.001). For the MMAEs, univariable analysis revealed that radiation dose (660.9 vs. 407.5 mGy, p=0.002), radiation dose per angiographic run (40.3 vs. 25.7, p<0.001), total radiation exposure (8825.8 vs. 5510.4 mGym², p=0.002), and exposure per run (537.9 vs. 353.5, p=0.002) were all significantly decreased after the protocol. Both groups were well balanced in terms of clinical characteristics (Table 1 and 2). No changes in image quality were identified by an expert interventional neuroradiologist. Fluoroscopy and procedural time did not differ between MMAE groups (20min vs 21min p=0.65).

Conclusions

Radiation reduction protocols are highly effective for neuroendovascular interventions. We strongly encourage all interventionalists to be cognizant of pulse rate and frame rate when performing routine interventions to avoid unnecessary radiation towards patients, providers, and health care staff.

Background

Many patients who have been infected with SARS-CoV-2 continue to experience a constellation of symptoms for months following the initial phase of the infection, often referred to as “Long COVID.” Symptoms include fatigue, shortness of breath and cognitive dysfunction, which may impact daily functioning. The true incidence and comprehensive characteristics of Long COVID symptoms are currently unknown. This is the first population-based outreach study of Long COVID symptoms in patients within an entire health system, conducted to determine operational needs of the health system to care for patients with Long COVID at our multidisciplinary Post-COVID Care Clinic and in the primary care setting.   

Methods

We conducted a survey of patients in our electronic health record (EHR) via email or SMS message who met these inclusion criteria: age 18 years or older, tested positive for COVID-19 at UCSDH between March 1, 2020 and July 1, 2021, and not deceased. Our survey identified patients experiencing symptoms consistent with Long COVID, and characterized the nature and severity of these symptoms and their impact on daily functioning. Rates of Long COVID symptoms were tabulated from patient responses and aligned with demographics from EHR.

Results

The survey was sent to 9,619 patients and achieved a 10.4% response rate. The average age of respondents was 51.5 years (range: 18 – 89 years), and 525 (53%) identified as White, 229 (23%) as Other Race or Mixed Race, 91 (9%) as Asian, 44 (4%) as Black or African American, five (0.5%) as American Indian or Alaska Native, 5 (0.5%) as Native Hawaiian or Other Pacific Islander, and 100 (10%) were unknown. Of the 999 respondents, almost half (46.3%) replied “yes” or “maybe” to currently having symptoms believed to be caused by having COVID-19. The breakdown of symptoms is depicted in Figure 1, with weakness/tiredness (77.8%), sleep disturbances (67.2%), and difficulty thinking/concentrating (“brain fog”) (64.3%) reported most frequently. Of those experiencing chronic symptoms, 343 (83.9%) had at least three symptoms, with a mean, median and mode of six symptoms (range: 0 – 16). 75/216 (34.7%) of patients reported absences from work/school due to symptoms, 143/216 (66.2%) reported disruption of daily activities, but only 123 reported seeking medical care. 130 (14.8%) reported being hospitalized due to COVID-19, and 74 (8.4%) reported being treated with monoclonal antibodies for COVID-19. 21.7% and 22.6% of respondents screened positive (score of 3+) on the PHQ-2 depression and GAD-2 anxiety screening tools.

Conclusion

To our knowledge, this represents the first population-based study of Long COVID symptoms in this spectrum of patients within a health system, particularly as most were not hospitalized for COVID-19 (>85% of respondents). The results demonstrate that patients experiencing Long COVID symptoms have a significant impact on their daily functioning and mental health, with about 1/3 reporting absenteeism and 2/3 reporting daily impact on functioning, and ¼ screening positive for depression and anxiety, which has major implications for population-based screening for post-COVID morbidity. Large population-based surveys like ours can be utilized across health systems to better triage patients with Long COVID who may need closer follow-up care.

TITLE: Physicians as “Patients”- Use of immersive simulated patient experiences to foster physician empathy and compassion

AUTHORS: Aaron M. Lee, DO; Sean Kenmore, MD; Supraja Thota, MD; Constance Chance, MD; Anand Jagannath, MD

INSTITUTION: Internal Medicine, University of California-San Diego Medical Center

BACKGROUND

The importance of fostering physician empathy has become increasingly recognized as a critical aspect of physician training; among many things, increased physician empathy has been shown to lead to improved clinical outcomes, higher patient satisfaction, and decreased physician burnout. Despite this, there remains a paucity of interventions to effectively promote compassion and empathy in medical education. To address this void, we propose a set of novel immersive role-reversal simulation exercises which place resident physicians into patient roles to simulate the inpatient experience. We propose that increased appreciation of the patient experience through simulation can lead to improved physician empathy and compassion and thereby improved delivery of patient-centered care.

PILOT INTERVENTION

While the ultimate goal is to develop a formal curriculum involving numerous simulation didactics, we developed a pilot program to study the initial feasibility and effectiveness of this intervention.

Aim: Use of a 1-hour noon conference to expose end-of-year interns to numerous aspects of the patient experience to increase appreciate of the inpatient experience

Methods: Several different stations were developed that each highlighted a single aspect of the patient experience. At each station, a prompt provided a simulated patient context/perspective associated with a physical item. These stations included a hospital bed, patient foods, glucometers, bedpans, common patient foods, urinals, nasal cannulas/facemasks, incentive spirometer, oral secretion device, foley and urine leg bag. Participants were given patient gowns, telemetry leads, pulse oximeter leads, to simulate common patient attire. Interns rotated through these stations and were encouraged to discuss openly with their partners their thoughts and feelings from the perspective of the patient. A debrief session was held to reflect on the experience as a group. Learners were asked to complete surveys before and after intervention, evaluating their own empathy and compassion ratings, as well as their appreciation of patient experience.

Results: All 9 participants reported the activity to be useful, and all would recommend to future residents. Overall self-reported empathy and compassion ratings increased post intervention. Notably participants reported increased familiarity with the lived patient experience, increased appreciation of patients’ backgrounds and contexts, improved ability to empathize with patient complaints, and increased importance on the physician-patient interaction.

NEXT STEPS:

While initial data was limited due to small number of participants, results were universally positive. Currently, this overall proposal has been accepted past phase 1 for consideration of a Seed Grant with the UCSD Center for Empathy and Compassion. We hope that this funding will allow this novel simulation intervention to be tested and expanded further, and if effective, anticipate it may provide great benefit for patients in the future.

CONCLUSIONS

The use of patient experience simulation with resident physicians can be an effective, feasible, and fun modality for promoting physician empathy and compassion. This novel teaching modality has the potential to increase high-value and patient-centered care if adopted across GME.

Introduction: Since the ACGME first instituted duty hours restrictions in 2003, surgery training programs have faced challenges balancing resident wellbeing, quality of education, and quality of patient care. Despite prioritization and significant effort, our general surgery residency continues to be challenged with compliance related to the 80-hour work week.  We sought to explore whether sophisticated quality and process improvement techniques borrowed from industry could be successfully applied to this complex problem in an effort to improve resident well-being and compliance. 

Methods: Lean process improvement methodology was applied to examine the structure of our program, identify best practices in scheduling and day-to-day workflows, uncover variations and opportunities for improvement, and develop targeted countermeasures.

The team reviewed our work hour reporting system, work hours logged, work hour violation occurrences, reasons listed for violations, surgical case volumes and staffing resources on each surgical rotation.

The daily workflow and call schedules for interns, juniors, and senior/chief residents were outlined in a detailed stepwise approach. Pain points and barriers to complying with work hour rules were identified. A resident survey was administered to prioritize which issues had the greatest impact on prolonged work hours or unhealthy working environment. A root cause analysis for each major contributor to non-compliance was conducted. A PICK chart was used to prioritize identified opportunities to improve.

Countermeasures were developed and implemented. Our prospective measurement plan included monthly duty hour logs, monthly rotation evaluations, yearly ACGME survey, and a faculty survey on resident preparedness.

Results: Thirty-six improvement opportunities were identified. Root causes included a tendency to schedule a near-maximum amount of hours, new patient consults that come late in a shift, variability in resident and attending expectations, clinical volume, inefficient workflows, and a culture of work over self. In response to identified issues, there were 15 actionable items.

Figure 1 demonstrates improvement in duty hour violations since implementation of proposed countermeasures.

Conclusions: Lean process improvement methodology can be applied to complex challenges present in our educational programs.  Such an approach led to a significant reduction in work hours and a sustained improvement in duty hour compliance. We are currenty exploring similar methods to address additional challenges in our educational programs.