GME Patient Safety Quality and Innovation Symposium

Background: America is in the midst of a syphilis epidemic. The CDC documented 207,255 new cases of syphilis in 2022, representing the highest incidence of disease observed since 1950 and a 17.3% increase from 2021. Treponemal central nervous system (CNS) invasion is estimated to occur in approximately 25-60% of infections, however, the current standard of care for non-neurologic syphilis does not provide antimicrobial dosing sufficient to achieve CNS clearance. This raises concern for a preventable burden of neurologic morbidity secondary to treponemal CNS persistence and subsequent neurosyphilis. Our central hypothesis is that individuals with a history of syphilis infection will experience greater odds of neurologic morbidity relative to their uninfected counterparts.

Methods: A preliminary 10-year retrospective analysis (01/2013-12/31/2022) of deidentified electronic medical records (EMR) from an academic health system was undertaken. The exposure of interest consisted of grouped ICD-10 codes representative of syphilis infection, with neurologic outcomes defined as ICD-10 diagnoses reflective of the principle clinical manifestations of neurosyphilis. Exploratory analysis of psychiatric outcomes was performed understanding psychiatry to be a property emergent of neurology. Unadjusted, bivariate analysis was performed for preliminary assessment of exposure-outcome association.

Results: 3,619,941 distinct patient EMR were included in the final analysis. 5,943 patients were found to have a diagnosis of syphilis. Patients with a history of syphilis had a higher prevalence of diabetes mellitus (DM), hyperlipidemia (HLD), and HIV relative to patients without a history of syphilis. Additionally, patients with syphilis exposure were found to have significantly higher odds of neurologic morbidity outcomes including stroke (OR = 5.14; 95%CI = 4.71-5.61), dementia (OR = 20.68 ; 95%CI = 19.27–22.19 ), sensorineural hearing loss (OR= 5.75; 95% CI= 5.07-6.2), and blindness (OR= 15.74 ; 95%CI = 14.31-16.54) relative to unexposed patients. Exposed patients also had significantly higher odds of psychiatric morbidity across all mental health outcomes assessed. Sensitivity analysis was performed whereby bivariate exposure-outcome associations were reassessed within a cohort restricted to patients without the potential confounding diagnoses of DM, HLD, and HIV. All neurologic and psychiatric outcomes studied were observed to retain significance during confounder-restricted sensitivity analysis.

Conclusion: Syphilis infection was associated with significantly increased odds of neurologic and psychiatric morbidity across all outcome measures queried after controlling for several potential confounders. These data are concerning as they suggest the possibility of a clinically significant limitation to the neurologic coverage provided by the current standard of care for non-neurologic syphilis. We plan to more rigorously evaluate our hypothesis in a follow-up study that will utilize multivariate logistic regression analysis to more precisely determine the independent effect of syphilis exposure while adjusting for a number of potential confounders.

Background:

Bridging the communication gap between General Surgery and Anesthesiology residents is critical for enhancing team performance in emergent situations within the perioperative setting. Historically, these residents have practiced simulation training independently, despite the necessity for interprofessional collaboration in their daily practice. This disconnect can lead to compromised patient safety, poor work relations, and physician burnout.

Description of the Project:

To address this, we introduced an interprofessional simulation training program. The program utilizes high-fidelity mannequins for anesthesiology training and box trainers or live pigs for surgical training. Designed to be appropriate for various training years (Table 1), the simulations were written by anesthesia attendings and residents to focus on joint decision-making, enhancing communication, camaraderie, confidence, and respect among participants. General surgery attendings collaborated with the authors to ensure final simulations were of appropriate complexity and included actionable surgical concerns. Funding is supported by a $10,000 Academy of Clinician Scholars grant.

Lessons Learned/Expected Outcomes:

Post simulation surveys include the NASA Task Load Index (TLI) and questions related to perceived team performance. The TLI is used to measure the effectiveness of the purposefully induced stress response. The remaining questions will be used to assess participants’ perception of their communication, camaraderie, confidence, respect, and understanding of the skills of other team members in the perioperative environment. Longitudinal participation is expected to show significant differences where a single interprofessional simulation event may not. The first series of simulations are incomplete with live animal sessions pending. Once completed, TLI values from live pig sessions will be compared to sessions when they were unavailable or inappropriate. Live animal simulations are expected to increase the stress response of all participants.

No statistically significant differences were observed nor expected with current sample size (62 survey respondents, 45 anesthesia, 17 general surgery). However, interim data analysis does suggest emerging trends. Reported mental demand, temporal demand, effort, and frustration on the TLI decreased with seniority (Figure 1). Surgery reported lower mental demand, temporal demand, effort, and frustration but higher performance demand than anesthesia (Figure 2). Average scores within specialties showed: decreased temporal demand with increased anesthesia year; increased physical and performance demand with surgical year. The data revealed trends of increasing measures of perceived team performance with class year in nearly all categories (Figure 3). No overall trends were observed between specialties (Figure 4). However, increasing averages were observed in all categories when comparing within specialties.

Recommendations/Next Steps:

The project will continue over multiple years to assess longitudinal interprofessional simulation training on medical education. Additional specialties, starting with OB/GYN in the ’24-’25 academic year, will be incorporated. Annual interim data analyses will ensure the program's adaptability and effectiveness. Continuous improvement in simulation scenarios and training methods will be prioritized, with the ultimate goal of establishing a best-practice model for interprofessional simulation training in medical education. This model will be made available to simulation programs at other institutions via a Joint Simulation textbook with Springer Nature.

References:

Not applicable. All content is original authorship by the project team.

Background: Healthy lifestyle behaviors during pregnancy strongly influence maternal and neonatal outcomes. The UCSD/SDSU General Preventive Medicine Residency (PMR) program partnered with San Diego Family Care, a Federally Qualified Health Center (FQHC) to identify patients’ understandings, barriers, and needs to meet the recommendations for healthy lifestyle behaviors during pregnancy.

Methods: The needs assessment followed the PRECEDE-PROCEED model, and the first three phases used a mixed-method design consisting of social, educational, and ecological assessments. PMR residents and students conducted interviews and focus groups with key stakeholders of the FQHC including maternal health patients, clinicians, and clinic staff and leadership. An environmental survey of the clinic’s catchment area was also performed by PMR residents guided by experts in urban design to assess walkability, safety, and available amenities.

Results: Findings suggest that improved nutrition resources during pregnancy are needed but solutions differed between patients and staff. Clinic staff and leadership were interested in more workers to provide education, while patients requested more information directly from providers. The ecological assessment identified areas of greater walkability and access to healthy food. Overall, the microenvironments discouraged a healthy lifestyle in the local community surrounding the FQHC.

Conclusions: The preliminary results solidify the need to improve resources for maternal nutrition during pregnancy at SDFC. Themes and results from the assessments will be used to inform and design a future intervention. The methods can be used by other sites and FQHCs for ongoing quality improvement and research projects.

Background:

Mental health (MH) engagement after discharge from hospitalization is considered an important outcome measure for MH patients. The VA San Diego Healthcare System (VASDHS) has implemented mental health aftercare calls (MHACs) for psychiatric patients discharged from the emergency department, the psychiatric unit, and the medical floors. While every patient discharged from the medical floors receives a primary care aftercare call, only a subset of patients admitted to the medical floors receive MHACs. These patients are identified by a mental health admission diagnosis. In this quality improvement study and innovation, we assess the association between MHACs and the probability of post-discharge MH visits in patients discharged from the medical floors who were seen by the inpatient consult-liaison (CL) psychiatry service.

Description of the Project:

This project is a retrospective review based on encounter codes of an electronic health record for patients admitted to the medical floors at the VASDHS between January-December 2022 who were also seen by the inpatient CL service. The patients who were seen by the CL service were grouped into those who received MHACs and those who did not. Cox regression was used to evaluate the relationship between MHAC and post-discharge likelihood of mental health visit.

Lessons Learned/Expected Outcomes:

386 patients seen by the CL service were identified for analysis. 362 patients did not receive a call and 24 patients did.  After controlling for gender, age, and the number of CL encounters, we found that 51% of patients without a call had a MH visit within 6 months post-discharge, compared with 75% in those patients who were called (HR = 1.3, p>0.05). We found that 33% of patients without a call had a MH visit in the first month post-discharge, compared with 54% in those patients who were called. While these findings were not statistically significant, likely due to low power, this may indicate an increased probability of a MH visit with aftercare calls. 

Recommendations/Next Steps:

Our findings support further analysis and utilization of MHACs for psychiatric patients discharged from the medical floors. The availability of trained mental health nursing staff to conduct MHACs is currently a highly limited resource. Our plan is to develop a systematic protocol for the inpatient CL service to identify patients who they’ve seen who may benefit from a MHAC. This protocol would be used in conjunction with the existing systems-based metrics used to identify patients for MHACs and allow for conscientious utilization of MHACs in post-discharge engagement for psychiatric patients admitted to the medical floors. To identify patients most likely to benefit from MHACs, this protocol should account for patient characteristics such as age, number of recent admissions, MH diagnoses, and/or treatment complexity. Further analysis to assess the efficacy and conscientious use of this valuable staff resource can then be repeated after protocol implementation.

Authors: Rachel Dhillon MD, Jessica Kriksciun MD, Ashley Clark MD, Alison Reminick MD, Michelle Singh DO

Background: Breastfeeding rates have increased worldwide following advocacy efforts that emphasize the benefits for mother, baby, and society. In the United States there are approximately 500,000 pregnancies in women who have or develop psychiatric illnesses (1). Many of these illnesses benefit from psychotropic medications, and oftentimes these medications are safe to continue during pregnancy and while breastfeeding. Misinformation about the safety profile of psychotropics during lactation can lead to premature discontinuation of medications and worsening of psychiatric symptoms. This can have detrimental consequences for the mother-child dyad and the broader family, as well as societal implications. The aim of this project was to assess the views among psychiatry residents towards psychotropics and lactation before and after a short education intervention. 

Methods: We designed a 30 minute lecture for our educational intervention. The topics covered included the benefits of breastfeeding, a summary of key psychotropic medications and their risk/benefit profiles during lactation, key resources to find accurate and comprehensive medication safety data during lactation, and University of California San Diego (UCSD) hospital policies regarding lactation on the inpatient psychiatric unit. The presentation was given two consecutive years to psychiatry interns during protected didactic time; once in February 2023 to seven students and again in March 2024 to six students. Interns were asked to complete a 6 question survey before and after the presentation regarding their views on lactation and psychotropics. Responses were measured using a 5-point Likert Scale and pre and post intervention data was analyzed using paired sample t-tests. 

Results: All 13 students completed the pre and post educational intervention questionnaire. There were statistically significant differences (p < 0.01) between pre and post survey ratings for 5 out of the 6 questions. The responses to these questions indicate significant improvement in interns’ comfort and knowledge about the benefits of breastfeeding and considerations for psychotropic medications in this population. There was no statistically significant difference (p = 0.05) in a question about the value of understanding breastfeeding for psychiatric practice. 

Conclusions: Our findings suggest that a short educational intervention on psychotropics and lactation can have a profound positive impact on the comfort psychiatry trainees feel addressing and managing such complex considerations.

[1] Crawford-Faucher, A. M. Y. (2010). Safety of Psychotropic Medications in Breastfeeding. American Family Physician, 81(11), 1369-1370.

OBJECTIVE An order set was created to optimize the time to administration and ensure proper dosing of benzodiazepine and anti-seizure medications in patients with status epilepticus (SE).

BACKGROUND The Neurocritical Care Society and American Academy of Neurology have developed expert consensus guidelines and quality measures on management of acute SE which recommend that upon seizure onset, benzodiazepines and anti-seizure medications should be administered rapidly (within 5 and 10 minutes, respectively per NCS guidelines) with appropriate weight- based dosing.

DESIGN/METHODS A SE order set was designed in an electronic health record which included pre-determined loading dosages of anti-seizure medications and benzodiazepines in accordance with current guidelines. Education regarding status epilepticus and order set was given to emergency medicine, neurology, neurosurgery, and neurocritical care divisions prior to order set availability in July 2023. We tracked use of the order set in all patients with the diagnosis of SE from July 1, 2023 to October 10, 2023. Our goal was to track the proportion of patients who received benzodiazepines within 5 minutes and anti-seizure medication within 10 minutes of seizure detection, and appropriate first dose of benzodiazepine and anti-seizure medication, before and after order set implementation.

RESULTS The recommended loading dose was used 100% of the time (8/8) with order set use compared to 18% (8/44) without the order set. Recommended benzodiazepine dose was used 50% of the time (2/4) with the order set compared to 64% (28/44) without. Average time to anti-seizure medication administration with the order set was 33 minutes compared to 61 minutes without. Average time to benzodiazepine medication administration was 5 minutes with order set use compared to 9 minutes without.

CONCLUSIONS Our initiative shows there can be improvement in adherence to status epilepticus guideline execution in dosage and time to administration of benzodiazepines and anti-seizure medications with implementation of a standardized SE order set.

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:

Blood product transfusions are one of the most common therapeutic procedures performed in hospitalized patients. Currently, transfusion information is primarily available in UC San Diego’s electronic medical record, EPIC, in a “Transfusion” summary tab. Data available on this tab is incomplete and challenging to navigate. Furthermore, it is difficult to find pertinent blood product data and identify the status of blood product orders in an efficient manner, as data is dispersed throughout multiple locations in EPIC. As a result, delays in blood product transfusions are common. For instance, nurses and providers often call the Blood Bank directly to determine if ordered blood products have been prepared.  Not only does this increase the volume of tasks for clinical team members, the phone calls also disrupt the work of Blood Bank staff, affecting the turnaround time for all orders.  Consequently, blood transfusions may be delayed, at times with life-threatening or fatal consequences.  Another gap in the current EPIC layout is the absence of a quick way to determine if a patient has a history of red cell antibodies, transfusion reactions, or pertinent blood product restrictions.  Without this knowledge, providers may not be aware of patient-specific requirements or extended time required to procure compatible products, which may also delay patient care.   

Description:

The goal of this project is to create a “Blood Product and Transfusion Dashboard” within EPIC, to provide a more efficient way of gathering blood product and transfusion related data and, ultimately, to decrease delays in the transfusion workflow. This will be accomplished by synthesizing data populated in various areas of EPIC and presenting it to providers and nurses in a succinct and readily digestible manner (Figure 1). The dashboard will include pertinent hematologic lab data, with the patient’s hemoglobin, platelets, coagulation factors, haptoglobin, fibrinogen, and type and screen status. It will also include information regarding anticoagulant medications, presence of historical red cell antibodies, and if a consent for transfusion is on file. Beyond this, it will include more intuitive descriptions of product transfusion status: “Ordered”, “Being Prepared”, “Ready for Pickup”, “Transfusing”, or “Transfusion Complete”. Furthermore, the dashboard will leverage data that is actively entered into the patient’s medical record, such as when the clinical team scans a unit, initiates transfusion, and stops the transfusion.

Expected Outcomes:

Multiple benefits are expected with implementation of this dashboard, including decreased time from blood products being ordered to initiation of transfusion, decreased delays in initiating blood product preparation, and improved workflow for nurses, providers, and the Blood Bank staff when determining the status of a blood product order. Overall, these goals should lead to an increase in patient safety and fewer adverse outcomes related to delays in blood product transfusion.

Recommendations:

Next steps involve implementation of the dashboard, while obtaining both timestamp data from EPIC and user survey data to evaluate for potential decreased transfusion delays and improved user experience.