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

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.

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.

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. 

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:

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: 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.