GME Patient Safety Quality and Innovation Symposium

Over the last few decades, pediatric visits for mental health concerns have been rapidly increasing in the United States with recent studies suggesting that the number of mental health emergency department (ED) visits from 2012 to 2016 was four times greater than ED visits for other medical concerns. This crisis has only worsened in the waning emergent phase of the COVID-19 pandemic; many patients experience extended wait times and often spend days in the ED awaiting placement and stabilization. Rady Children’s Hospital houses a psychiatric emergency department within the emergency department (ED) to evaluate and stabilize patients in acute mental health crises. Pediatric emergency departments rarely offer therapeutic interventions or protocols for patients awaiting evaluation or placement. Our goal is to implement psychosocial and therapeutic modalities as a crisis intervention to improve perceived stress and the ability to manage stressors.

Background:

The transition period between pediatric and adult care is a challenging time marked with high risk and vulnerability. This is especially true in adolescent patients with a transplanted kidney, which is described as the period with the highest rate of graft loss. Studies demonstrate that 83% of young adult with special health care needs (SHCN) and 86% of young adults without SHCN do not meet the national health care transition (HCT) measures published in a clinical report authored by the AAP in collaboration with the AAFP and ACP. Studies demonstrate that there are adverse effects associated with a lack of structured HCT interventions including medical complications, limitations in health and well-being, problems with treatment and medication adherence, discontinuity of care, patient dissatisfaction, higher emergency department use, and higher costs of care. Data are limited regarding HCT outcomes, but studies in the US and internationally demonstrate improvements in quality of care, terms of service use, and patient and family experience with a structured transition protocol.

Description of the Project:

Our project aims to assess how well patients are transitioned from pediatric kidney transplant clinic at Rady Children’s Hospital in San Diego (RCHSD) to adult kidney transplant clinic at UC San Diego Health (UCSD). A retrospective chart review of patients who transitioned from RCHSD to UCSD transplant clinic from the years 2020-2023 is currently being performed to examine metrics such as change in creatinine, blood pressure, rates of infection, and episodes of rejection during this period of transition. Additionally, we will look at the time elapsed between patients’ last visit at RCHSD and first visit at UCSD and time between labs to assess for possible areas of improvement. We will also conduct a telephone survey with patients who have completed this transition to understand their perspective of the transition process. We will look at outcomes prior to and following the implementation of our current transitions program which includes strutted transition-specific visits to assess and address individual areas of need before they transition.

Lessons Learned/Expected Outcomes:

We expect to have more data at the time of the presentation as a chart review is currently underway. We anticipate that the outcome of this project will reveal a few areas of improvement. One area of anticipated improvement would be in decreasing the time between the last visit and last labs performed at RCHSD and the first visit and first set of labs performed at UCSD.

Recommendations/Next Steps:

The next steps for this project are to further analyze the data collected from chart review and assess for patterns and areas of possible intervention in the current kidney transplant clinic transition process. Following this study which focuses specifically on transitions of care in patients with kidney transplant, the goal will be to perform similar studies assessing how effective our transitions are for patients with various forms of kidney pathology who are seen in other nephrology clinics.

Issue:

            The Society for Maternal-Fetal Medicine (SMFM), California Maternal Quality Care Collaborative (CMQCC) and the United States Preventative Task Force (USPTF) recommend low-dose aspirin (LDASA) for preeclampsia risk reduction in at-risk pregnancies. However, current evidence suggests that low dose aspirin (LDASA) prescribing practices for patients with risk factors for preeclampsia are inconsistent and preeclampsia risk screening practices vary. SMFM developed a checklist for preeclampsia risk factor screening and LDASA prescribing to make these practices more uniform. To our knowledge, there is no published literature of its use by prenatal care providers as it pertains to LDASA prescription patterns or medication adherence. The purpose of this intervention is to use electronic medical record (EMR) tools to increase appropriate preeclampsia risk screening and to increase evidence-based use of LDASA to reduce the risk of preeclampsia, particularly amongst patients with moderate risk factors² that may be inadvertently overlooked.

Description:

            Our project has the following aims: 1) incorporate the SMFM preeclampsia risk factor screening checklist as a smart phrase in the EMR during new obstetric care visits at our Women’s Health Clinic in Hillcrest and 2) increase risk-based LDASA prescribing to appropriate at-risk patients.

On September 6, 2022 we launched a system wide preeclampsia risk screen and LDASA eligibility smart-phrase within the EMR for use by all prenatal care providers (Figure 1). In addition, our new obstetric visit order set was modified to facilitate LDASA prescribing. Provider and patient educational materials were also developed. As part of the simultaneous LDASA initiative with CMQCC, we launched a department-wide campaign encouraging the use of the smart phrase to screen all new obstetric patients for preeclampsia. A retrospective chart review was performed of all new obstetric visits from September 6, 2022 – November 29, 2022 by all prenatal care providers at one prenatal clinic. Charts were reviewed for all the following: patient demographics, pre-eclampsia risk screen completion, risk factors met, eligibility for LDASA, prescription of LDASA and/or reason for why LDASA was not prescribed.

Results and outcomes:

            Of 158 new obstetric visits,12% (19/158) were seen by OB/MD providers, 41.1% (65/158) by NP providers, 7.6% (12/158) by CNM providers, and 39.3% (62/158) by MFM providers (Table 1). 37.8% (60/158) of new obstetric visits had the preeclampsia risk screen documented. The majority of preeclampsia risk screens were performed by NP providers 70% (42/60). 33% (20/60) of screened patients met eligibility criteria for LDASA by a high-risk factor alone, whereas 25% (15/60) met criteria for LDASA by two or more moderate-risk factors alone. BMI >30 (9/15), AMA (8/15), and Black race (4/15) were the most common moderate-risk factors present. 60% (9/15) of patients who met criteria by moderate-risk factors alone were prescribed LDASA, while 75% (15/20) of patients who met criteria by high-risk factors alone were prescribed LDASA. Of patients who met criteria for LDASA but were not prescribed medication at time of eligibility, 58.8% (10/17) declined, 17.6% (3/17) already had LDASA prescribed, and 23.5% (4/17) would obtain over the counter. Many patients who did not have the preeclampsia risk screen documented had LDASA prescribed by an alternative provider (36%, 35/98). Of the patients who met criteria for LDASA, 51% (18/35) received LDASA.

Recommendations:

Over one-third of new obstetric visits had a preeclampsia risk screen documented. Many of our patients were found to be at-risk by moderate factors alone, which demonstrates the importance of a thorough screening tool. In order to improve the consistency of our screening and documentation, we plan to perform additional provider education and plan to build the smart-phrase into more diversified clinic templates which may aid in uptake. We are expanding our audit of preeclampsia screening to all prenatal clinics. We plan to review obstetric deliveries, pre-eclampsia rates, and LDASA compliance rates following implementation of our intervention at UCSD Health through another EMR based smart-phrase that has been implemented.

Background: Systems-based practice is one of the core competencies that has been identified by the Accreditation Council for Graduate Medical Education (ACGME) as a foundational skill for resident physicians to learn so that they can “work in interprofessional teams to enhance patient safety and improve patient care quality.” In real-world practice, effective discharge planning is an important element of systems-based practice because delayed discharges are costly to health systems and harmful to patients. To prepare future resident physicians for this core competency, we developed an interactive workshop about discharge planning for graduating medical students during the Residency Transition Course.

Methods and Results: The interactive workshop consisted of a 30-minute didactic component that reviewed the importance of effective discharge planning. The didactics also introduced a systematic approach to discharge planning based on a modified version of the “4M’s” framework from the Institute for Healthcare Improvement. After the didactic component, participants engaged in interactive small group sessions during which they applied the “4M’s” framework to three case vignettes. A post-intervention survey was administered to evaluate participants’ growth in the domain of discharge planning.

Thirty-one participants attended our pilot workshop in March 2023. About 96% of participants felt that they gained knowledge about the general discharge process because of the workshop. Similarly, 93% and 90% of participants felt that they gained knowledge about home health services and the differences between discharging patients to home versus a skilled nursing facility, respectively. 96% of participants gained knowledge about who to consult for discharge planning purposes, and 96% of participants felt more confident after the workshop about facilitating safe, effective, and efficient discharges in the future.

Conclusions: Our pilot workshop was effective at increasing graduating medical students’ comfort with and confidence about effective discharge planning. Future iterations of this workshop might consider expanding the scope of the workshop to include more advanced cases and more participants. We might also consider evaluating discharge outcomes to assess the effect of the workshop on real-world patient care.

Issues addressed and background:

The landscape of pediatric epilepsy is rife with difficult medication decisions in a vulnerable patient population.  The decision of which antiseizure medications to use, dosage, the side effect counseling, and the idiosyncrasies of each medication can be overwhelming.  The barriers to prescribing these medications are even higher to new child neurology trainees with little experience prescribing seizure medications, as well as rotating adult neurology colleagues who do not typically have to consider weight-based dosing and pediatric-specific considerations.  The antiseizure medication handbook aims to improve trainees’ comfort on overnight call, decrease medication dosing errors, and improve identification and counseling of medication side effects by providing vetted weight-based dosing and clinical pearls for each medication.  Outcome measures will be obtained by end-user post-survey data on self-assessed efficiency on call, comfort answering seizure medication-related questions, and comfort prescribing new seizure medications.  Process measures will include handbook utilization rates and utilization circumstances.  Balancing measures will include assessment of any reported medication dosing errors or incorrect counseling, or medication side effects identified on admitted patients or patients seen at follow up visits.

Description of the project, protocol, experience, service, or innovation:

A comprehensive list of antiseizure medications was compiled and a team of multiple child neurology residents and child neurology faculty compiled key medication information from evidence-based resources (Lexicomp, FDA labels, etc…).  Ishikawa diagrams/surveys were used to determine greatest barriers for first call providers in initiating and counseling for these medications. This team performed an extensive review of each medication, highlighting clinical pearls when initiating the medication, counseling, dosing/discontinuing, or monitoring for side effects to address identified barriers.  This handbook was further reviewed by the pediatric epileptology faculty for verification and agreement.  The handbook was deployed to all trainees in the child neurology department on March 15, 2023, as well as rotating adult neurology residents.  The team plans to assess by surveys utilization of the handbook, usefulness and efficiency, and assess balancing measures of reported medication dosing errors. 

Lessons learned and expected outcomes:

Though feedback is still ongoing, early responses suggest trainees have found this handbook useful in multiple clinical settings.  Though initially targeting periods in which trainees were on overnight, the benefits of this handbook have extended to several clinical contexts.

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.

Background:

Peripheral intravenous (IV) line insertion is a common pediatric procedure performed in the emergency department (ED).  At an early age, painful IV experiences can have a long-term impact, leading to needle phobia, decreased medical adherence, and negative nurse and physician satisfaction.  Fast-acting interventions to reduce IV insertion pain are available. We aimed to decrease pain associated with non-critical IVs without increasing time to IV insertion in our pediatric ED. Our primary aim was to increase the proportion of “less ouch” IVs from a baseline of 8% to 50% within 12 months.

Methods:

A multidisciplinary team of pediatric ED nurses, physicians, child life specialists, and pharmacists created an evidence-based pain reduction algorithm for IV insertions. The algorithm is age-based and prioritizes fast-acting interventions, such as oral sucrose for patients under 1 year old and Buzzy® (a vibratory device) for patients over 1 year old. All IVs placed in the pediatric ED were included in the initiative. The initiative excluded IVs ordered as a “critical IV” and IVs placed in patients with an Emergency Severity Index of 1. An IV was considered “less ouch” if an age-appropriate pain reducing intervention from the algorithm was documented.

Initial interventions included the introduction of the algorithm at nursing and physician meetings. An IV order panel replaced the “insert IV” order on the ED preferred order list.  This order panel bundles the “insert IV” order with the recommended PRN pharmacologic orders and a nursing communication order recommending use of non-pharmacologic interventions.  “Buzzy® Hives” were implemented to house these devices in each nursing zone for easier visibility and use.

Monthly PDSA cycles were performed with nursing and physician feedback incorporated.  Subsequent interventions included posters near IV insertion supplies, team reminders during meetings and in newsletters, and order set integration of the IV order panel. The balancing measure was the average time from IV order to insertion.  We used statistical process control to examine changes in measures over time.

Results:

From October 2022 to February 2023, the proportion of ED IV insertions using a “less ouch” intervention from 8% to 15%. The average time from IV order to insertion remained stable at 48 minutes.

Conclusions:

We increased the proportion of non-critical IVs placed using age-appropriate pain reducing interventions without increasing time to IV insertion through implementation of an age-based algorithm, IV order panel, and periodic education. Future efforts will focus on increasing and sustaining adherence.

Gestational diabetes mellitus (GDM) that affects 2-10% of pregnancies in the United States is a harbinger of future GDM, type 2 Diabetes Mellitus, Hypertension, and cardiovascular disease. This risk can be significantly reduced with weight loss. Lifestyle changes are often intensive processes that require involvement in a program with skilled and certified educators such as Center for disease control and prevention’s (CDC) National Diabetes Prevention Program (DPP), however due to insufficient provider knowledge and the time lapse between GDM and development of type 2 DM, the risk is often forgotten or lost in the transition of healthcare from a women’s obstetric care to primary care. This QI project sought to address this issue with a multifaceted approach to the issue and incorporates community involvement, multispecialty collaboration, and health communication.A community needs assessment was conducted through focus group interviews of women with history of GDM. 8 demographically diverse women were interviewed. Key findings of the study were unawareness about DPP among women and interest and motivation to commit to these programs if provided the opportunity. A major aspect of the project is collaborations of Obstetrics, primary care, and population health departments at UCSD with CDC certified DPPs. Local and nationwide DPPs were contacted to gain information on program resources, referral requirements and cost. An external referral system to the various DPPs was proposed to representatives from Obstetrics and population health and is under consideration.Certified Diabetes Educators (CDE) at UCSD were educated in DPP. Educational handouts and PowerPoint slides were developed and provided to the health educators to pass on to their GDM patients. A webpage with DPP resources was developed and captured in a QR code that is printed on a magnet to be handed out during delivery. Behavioral changes require readiness in an individual, which sometimes takes time. The magnet will provide a steady, reiterating reminder for the women after delivery to enroll in a National Diabetes prevention program when they are ready. Evaluation of this QI project will be through data gathered from collaborating DPPs. Quality measures will include 1. Referral rates from UCSD, 2. Enrolment rates, 3. rates of completion of at least 9 months in the program and, 4. rate of accomplishment of weight loss goals. The evaluations will be performed at 6 and 12 months.

Issues Addressed/Background: Hospital readmissions are a significant problem in the healthcare industry, contributing to increased costs, decreased quality-of-care, and patient dissatisfaction. One potential solution to reduce readmissions is to improve the post-discharge process, including the use of after visit summaries (AVS) to help patients understand and follow their care plans. However, traditional inpatient AVS documents are often lengthy, confusing and lack patient-centered design, leading to poor patient comprehension and adherence. In response, our team undertook a redesign of the inpatient AVS to create a more effective and patient-friendly tool.In our current state, the inpatient AVS document contains unclear discharge instructions, misinformation, outdated information, conflicting information, duplicate information, and information that is simply too difficult for many patients to understand. Additionally, there is seemingly no prioritization for order-of-information, verbiage used is often not patient-friendly, and limited languages are available. At the same time, there is currently an increased burden on providers with a manual discharge instruction process.

Description of the Project: There is an opportunity to revise and reformat the inpatient AVS to better meet our patients’ needs. Epic has features which could be used to streamline content and workflow, but these are not in use at this time. In addition, the lack of a clear governance structure has allowed the information that gets included on an AVS to proliferate. The aim of this project is to optimize the content and creation process of the UCSDH inpatient AVS, ultimately to improve patient quality-of-care and prevent readmissions.UCSDH and its Transformation Health Team sponsored a Kaizen event for this project as a result of goals set forth by the larger readmissions 3P event conducted. The project teams have begun streamlining the existing AVS content while being mindful of patient-friendly language and translation to Spanish of static content. In addition, the teams have been working towards transitioning AVS creation to an orders-based process for providers with increased standardization of content and structure. We are currently rolling out a pilot orders-based AVS on the Women and Infants Unit.

Lessons Learned or Expected Outcomes: Through our redesign of the inpatient AVS, we are learning important lessons. First, we found that patient involvement in the design process is crucial to creating a tool that is truly patient-centered and effective. Secondly, we are learning and expecting that simplifying the language and formatting of the AVS can significantly improve patient comprehension and adherence to care plans. Finally, we are expecting that transitioning to an orders-based discharge instruction workflow forproviders will streamline their processes and increase efficiency, while decreasing outdated and redundant information in the document.

Recommendations/Next Steps: Based on our updated processes, we recommend redesigning the inpatient AVS to decrease readmission rates, increase patient satisfaction and cost-savings for the hospital. This project has the potential to inform and improve post-discharge care processes in hospitals nationwide. Though limited to the inpatient AVS at this time, the scope of the project remains quite large, and we anticipate ample requests for service-line specific content that will require time and effort to coordinate and build. Ultimately, we need to provide a document that gives clear and concise instruction on post-visit care, which is accessible and understandable for all patients and caregivers.

Background

UC San Diego Health has a diverse patient population with a large portion of its hospitalized patients speaking Spanish as their primary language. Several measures have been taken to overcome barriers to quality healthcare in this subgroup of patients, including easy access to medical translators and post-discharge follow-up efforts; however, there may be room for further improvement. One barrier that remains is providing written hospital discharge instructions for Spanish-speaking patients in their native language. The purpose of this study was to measure the overall perspective of physicians practicing hospital medicine at UC San Diego regarding our ability to effectively provide discharge instructions to Spanish-speaking patients that maximize positive health outcomes after hospitalization.

Methods

A seven-question survey was designed to measure the perspectives of hospital staff, including resident and attending physicians, practicing hospital medicine within the UC San Diego healthcare system. In March 2023, the survey was distributed electronically to all resident physicians enrolled in and select administrative attending physicians involved in the UC San Diego internal medicine residency program. Participants were given a two-week period to complete the survey. All participation was voluntary, and responses were collected anonymously. The responses were subsequently analyzed using descriptive statistics.

Results

Thirty-five participants completed the survey in its entirety, representing approximately a quarter of the internal medicine residency program. Data analysis revealed that 74% of participants “always” or “often” write discharge instructions for Spanish-speaking patients in English.  Furthermore, a majority 91% of participants felt that providing instructions in English to Spanish-speaking patients “always” or “often” represents a barrier to care. 100% of participants indicated that, at a minimum, they would “sometimes” use pre-written translator-approved Spanish phrases if provided, with over half of participants replying that they would “always” use these instructions. Lastly, a majority of participants felt that the use of these phrases in Spanish would improve overall follow-up and medication adherence, as well as reduce readmission rates.

Conclusions

Considering these data, it appears that the current method of providing discharge instructions written in English to Spanish-speaking patients is considered a barrier to adequate healthcare at UC San Diego hospitals by internal medicine house staff. Though unlikely to completely resolve the problem, using translator-approved Spanish phrases in discharge instructions may improve follow-up and medication use after discharge, and reduce readmission rates among Spanish-speaking patients. These data will help support current efforts to provide Spanish discharge instructions for Spanish-speaking patients.