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.

Issues:Neutropenia can be classified based on pathophysiology as severe versus benign based on bone marrow reserve of neutrophil precursors, which determines the risk of serious bacterial infections (SBI). The current guidelines for management of fever in neutropenic patients are reliant on the knowledge gained in the oncology setting. There are no clear guidelines for management of fever in patients with benign neutropenia regarding evaluation or antibiotic administration, despite their lower risk of SBI. This leads to significant practice variation in management of patients with benign neutropenia who present with fever and may result in unnecessary hospital visits or antibiotic administration, leading to poor quality of life for these patients and avoidable use of healthcare resources. We initiated a quality improvement project to address this issue at Rady Children’s Hospital, San Diego, (RCHSD) with the goal of decreasing the percentage of emergency department (ED) visits for patients with benign neutropenia from a baseline of 60% febrile events to 30% febrile events by May 31, 2025.

Description: We collected baseline data via manual chart review from Jan 2023 to Nov 2023 to identify how febrile events were managed in patients with benign neutropenia at RCHSD (Table 1). None of the patients were identified as having a serious bacterial infection. We then sent a survey to all hematology providers at our institution to identify their practice of managing fever in patients with benign neutropenia. Based on the survey results, we created an Ishikawa chart (Figure 1) to identify barriers, and a key driver diagram (Figure 2) to identify possible interventions. We created an ideal process map based on the input from the hematology providers and the proposed algorithm (Figure 3) was agreed upon by the hematology providers.

Lessons Learned/Expected Outcomes: Some of the main barriers identified were variation in practices and lack of uniform guidelines in management of fever in patients with benign neutropenia. We plan to use the model of improvement methodology with the key driver diagram to guide improvement efforts.

Recommendations: Next steps include presenting the proposed algorithm to the fellows and other providers in the department of hematology-oncology, and to the ED providers before going live with the project. We also plan to present it to general pediatricians at the CPMG (Children’s Physician Medical Group) conference. We will post the algorithm in the inpatient and hematology/oncology clinic workroom and make it easily accessible to all providers on division shared folder. We plan to create a Smart Phrase on EPIC to have a standardized plan in the notes of all patients with a diagnosis of suspected or established benign neutropenia. We will discuss our progress and gain feedback in subsequent QI and division meetings.

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.

Background: 

Evidence based procalcitonin algorithms recommend discontinuation of antibiotics at values < 0.25 ng/mL for lower respiratory tract infections. A retrospective study conducted at our academic center in 2021 demonstrated that treatment was continued despite a low PCT value in 80.4% of patients on antibiotics. We examined the impact of a nudge intervention on clinicians' decision to de-escalate antibiotics in patients with a low procalcitonin value. 

Methods: 

We conducted a pre-post intervention study on adult inpatients with a procalcitonin result < 0.25 ng/mL receiving antibiotics for LRTIs. We excluded patients on antibiotics for non-LRTIs, COPD exacerbation, or VAP/HAP, as well as immunosuppressed and ICU patients. In the intervention stage, we used a dynamic EPIC procalcitonin report to identify eligible patients and contacted 1st call providers via EPIC Secure Chat with a standardized message suggesting antibiotic de-escalation if clinically appropriate. Our primary endpoint was antibiotic duration and time from procalcitonin result to antibiotic de-escalation. Differences in mean times were compared using paired t-testing. 

Results: 

We conducted a nudge intervention on 48 patients between August-December 2023, and identified 48 patients between June-July 2023 to serve as a baseline comparison group. The mean antibiotic duration was 105.84 hours and 123.24 hours for the pre-intervention and intervention groups respectively (p=0.29). The time from procalcitonin result to antibiotic de-escalation was 105.85 hours and 108.15 hours for the pre-intervention and intervention groups respectively (p=0.87). In the intervention group, 25% of providers de-escalated antibiotics within 24 hours after nudge intervention. 

Conclusions: 

Nudge interventions did not influence clinician decision making regarding procalcitonin-guided antibiotic de-escalation, when evaluating mean antibiotic duration or time from procalcitonin result to antibiotic de-escalation. Despite high utilization of the procalcitonin assay at our institution, results rarely impact clinical decision-making. The utility of procalcitonin as a tool for antibiotic stewardship, absent more effective decision support, is questionable. 

Recommendations/Next Steps: 

Lack of improvement following a nudge implies that knowledge gaps do not explain discordance between testing and antibiotic prescribing. Future interventions could focus on guidance at the point-of-care through indication-based ordering protocols or other forms of restricted usage. 

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.

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.

Background:

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

Methods:

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

Results:

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

Conclusions:

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

Background: 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:

 The incidence of induced labor has tripled from 9.5% to 31.4% between 1990 and 2020, due to an increase in the incidence of maternal and fetal indications for induction, as well as an increased recognition of the safety of induction of labor by maternal request at 39 weeks of pregnancy1,2,3. Induced labor has been shown to lead to decreased antepartum office visits and postpartum hospitalizations, with an overall neutral impact on healthcare utilization4,5. However, the increased time and number of interventions on labor and delivery for patients undergoing induction can be challenging for patients and the health care system.

 Induction of labor practices vary among physicians, midwives, and nursing staff, driven by both patient and provider preferences. Furthermore, UCSD cesarean birth rates for induced labor are higher than that for spontaneous labor. Given that induction itself is not thought to increase the risk of cesarean, this may be attributable to these patients’ comorbidities or differences in management practices during induction.

 There is a clear need to understand and increase the use of evidence-based labor induction practices that could decrease time to birth during inductions and decrease the rate of cesarean birth. 

Goals:

-Characterize patient characteristics, induction practices, and decisions leading to cesarean birth in birthing persons undergoing induction of labor

-Improve the implementation of provider and institution best practices for induction of labor and cesarean birth decisions

-Decrease the rate of cesarean birth in induced labor at UCSD

Interventions:

Implement an induction of labor education intervention consisting of evidence-based best practices for induction of labor. Educational talks and a handout on labor and delivery were rolled out in January 2024.

Preliminary Results:​

No apparent increase in cesarian rate since implementation of the labor checklist protocol. No apparent concerns for safety of interventions.

Next Steps:​

Granular data analysis of the impact on labor induction techniques with introduction of the labor checklist from Nov 23 – Feb 24. Analysis will include pre and post-intervention comparisons of:​

NTSV cesarean birth rate; ​Percentage of patients undergoing combination, individual, or staged approaches to cervical ripening​; Percentage of patients undergoing early amniotomy​; Maximum dose of oxytocin used; oxytocin discontinuation during labor​

Expected Outcomes:​

We expect that evidence-based induction of labor practices will increase in frequency in the period following the implementation of the checklist without an adverse impact on the cesarean delivery rate.​

Next steps:​

If evidence-based practices do not improve in frequency as expected, surveys of labor and delivery staff could be undertaken to identify challenges in implementing these practices and appropriate next steps.​