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.

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

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: 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/Background: The quality and efficiency of surgical operations are crucial for both patient outcomes and healthcare institutions. Despite advancements in surgical techniques and technology, operational issues persist, leading to suboptimal performance, increased costs, and patient dissatisfaction. Surgeons in the UCSDH operating rooms (ORs) under-report adverse events and process improvement concerns through the existing iReport system, hampering the ability of the system to provide safe and efficient patient care. Traditional surgeon feedback methods are often too broad given inclusion of patient safety issues (e.g. iReport), have a high access barrier, and/or limited in effectiveness, necessitating an innovative approach to address these challenges.

Description of Project: This project aims to design and implement a specialized surgeon feedback platform tailored to address operational issues in the perioperative environment. The platform was developed using a multidisciplinary approach, integrating insights from surgeons, healthcare administrators, and information technology experts. Features included secure submission of feedback, automated input of relevant case information where applicable, and the ability to promote closed-loop communication as well as identify trends and patterns in operational issues. Additionally, the platform enabled the sharing of best practices and the development of targeted solutions. A survey was sent to surgeons before and after implementation of this platform to gauge trends in reporting and impact of the platform.

Lessons Learned/Expected Outcomes: The implementation of the surgeon feedback platform has demonstrated several key benefits. First, the streamlined submission process encouraged more frequent and detailed feedback from surgeons, leading to increased engagement and a heightened sense of ownership in resolving operational issues. Second, the real-time analysis and visualization tools enabled faster identification of trends and patterns, and decrease in average days to close, which allowed surgical teams to proactively address recurring problems. Third, the facilitated communication among surgical teams fostered a culture of collaboration, promoting the exchange of innovative ideas and solutions.Preliminary survey data from the pre-implementation phase are demonstrate that surgeons used a diverse array of venues to escalate operational issues, and the most common specific complaint was the lack of knowing if and when a solution to the report was made. Post-implementation survey data is forthcoming, and we hypothesize that the new platform will be utilized forreporting operational issues appropriately, and increase satisfaction with closed-loop communication.

Recommendations: Based on the success of the specialized surgeon feedback platform, we recommend the following: (1) Encourage healthcare institutions to adopt similar feedback platforms for a more targeted approach in addressing operational issues in the perioperative environment. (2) Prioritize a multidisciplinary approach when designing feedback platforms to ensure they cater to the unique needs of the perioperative community. (3) Promote a culture of continuous learning and collaboration among perioperative teams, enabling them to share best practices and innovative solutions. (4) Conduct further research and survey continue to gauge impact and refine the platform, and the exploration of applications in other medical specialties.By embracing such innovative approaches, healthcare institutions can further enhance the quality and efficiency of perioperative care, ultimately benefiting patients and healthcare providers alike.

Figure 1. Surgeon Feedback Platform a. QR code for access, b. computer reporting screen, c. mobile reporting screen.

Figure 2. Pre-Implementation Survey Results – “If any, what platform or method do you currently use to report OR operational issues, such as with surgical equipment, sterilization, or operating room staffing?”

Issues Addressed/Background: Urgent and emergent cesarean deliveries remain an important intervention to reduce maternal and neonatal morbidity. Recent studies suggest that initiatives to reduce the decision-to-incision time (DTI) can improve neonatal outcomes without compromising maternal outcomes. Presently at UCSD, documentation of the DTI is inconsistent, which limits our ability to track and evaluate this metric. A preliminary analysis of cesarean deliveries between August-October 2022 showed that only 185 out of 380 (49%) of non-scheduled cesareans were appropriately documented in the medical record.  Therefore, we aim to develop and implement a DTI protocol to streamline communication, team-based roles, and improve documentation for cesarean deliveries at UCSD.

Description of Project: Multidisciplinary Cesarean Practice Guidelines were developed to define categories for cesarean deliveries: 1) Emergency, 2) Urgent, 3) Non-emergent/indicated, and 4) Scheduled cases. Goal DTI timeframes and communication steps are specified for each category, including documentation of the DTI and reasons for any case delay. A web-paging team was created to promptly alert all team members (obstetric, anesthesia, surgical technicians, primary and charge nurses) of an urgent cesarean delivery. The protocol includes a preoperative huddle to confirm surgical timing and other clinical considerations. For emergency cases, the current “Code Pink” system was enhanced with additional role assignments for nursing, physician, and technician team members. Operating room posters specific to Hillcrest and Jacobs Medical Centers were created to outline roles and responsibilities in emergency cesarean deliveries. Hands-on simulations for emergency deliveries were conducted prior to implementation.

Lessons Learned/Expected Outcomes: The protocol was fully implemented on March 13, 2023. Pre- and post-implementation variables to be assessed include: DTI, proportion of non-scheduled cesarean deliveries with DTI appropriately documented, number of cases with delays charted, and reasons for delay. We also plan to analyze the proportion of cesareans in each category that achieve designated time targets, i.e. urgent cases < 60min, emergency cases < 10min. We anticipate that improved communication and role clarification outlined in the protocol will improve our ability to expedite non-scheduled cesarean deliveries and conduct processes improvement for the unit. 

Recommendations/Next Steps: Data will be collected and analyzed for the above variables for the 4-month period before and after protocol implementation. Labor & Delivery leadership will review the analysis to identify ongoing areas for improvement. Future analysis could explore the impact of the protocol on clinical outcomes such as NICU admission, APGAR scores, umbilical cord gasses or maternal morbidity. In addition, measures of team communication and efficiency metrics  (i.e. reasons for case delay) can provide valuable data for systems improvement.

Background: 

Best practice advisories (BPAs) are integrated into the electronic health record (EHR) to implement evidence-based practices, but not all alerts are effective and can even contribute to alert fatigue and burnout. This project focuses on optimizing the admission medication reconciliation (AMR) alert, which is the most common alert UCSD Internal Medicine residents face. Medication reconciliation is a pillar of patient safety, especially during the admission process. A reconciliation completion rate of >90% within 24 hours has become a UCSD Health performance metric. This alert is triggered when a medication reconciliation is not finished within 24 hours of admission and appears every time orders are opened until the reconciliation is completed. This project aims to analyze this alert to understand its high fire rate, maximize its effectiveness, and improve patient safety and overall provider experience. 

Methods: 

This retrospective analysis evaluates the medication reconciliation BPA using Epic SlicerDicer. Tutorials on completing the medication reconciliation and processing the alert were created and distributed to all residents. Residents were also sent their individual medication reconciliation rates as feedback. A survey was distributed pre and post intervention to evaluate the efficacy of the tutorials. Medication reconciliation rates were analyzed 6 months pre and post tutorial for each senior resident and 1 month pre-intervention for interns. Statistical significance was determined using chi-squared and interrupted time series analyses. 

Results: 

Medication reconciliation rates were evaluated for 134 UCSD internal medicine residents. The >90% reconciliation rate was achieved in 57/134 residents pre intervention and significantly increased to 85/134 residents post intervention (p <0.001). The survey demonstrated a statistically significant (p <0.01) increase in resident understanding on how to complete a medication reconciliation and process the AMR alert from 50% to 90%. The interrupted time series analysis showed an increase in the proportion of medications reconciled within 24 hours at the time of intervention (+0.02) and a positive trend (slope change +0.006/month) post intervention. 

Conclusions: 

1. Reliable admission medication reconciliation is important for patient safety. 

2. Evaluating BPAs to understand barriers to action is a key first step in optimizing them. 

3. An educational intervention to improve action taken based on our AMR BPA has been effective. 

Although the total number of AMR alert firing per month did not decrease post intervention (was not standardized for changes in hospital census), we did demonstrate a statistical improvement in >90% reconciliation rate and understanding of how to process the BPA. The change in proportion of medications reconciled within 24 hours improved but was not significant, which may be due to the small number of time points. Another limitation of this study includes survey response rate (n=20). For future work, we aim to further optimize this BPA by limiting the time of day during which it fires (covering night teams are unlikely to complete medication reconciliation), targeting the alert to first call providers, and streamlining the entire process. We hope to extend this approach to other high-frequency interruptive alerts, further improving efficiency, patient safety, and physician well-being. 

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.

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.

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.