podium presentations - uc davis health · 2016-03-03 · introduction: response: standardized...

6th Annual UC Davis Healthcare Quality Forum March 16, 2016

UC Davis Health System Education Building

Podium

Presentations

Submitted Tracking Number: 287 Abstract Title: Response: Establishing a new patient care protocol to improve outcomes for patients with ruptured abdominalaortic aneurysm

Main Contact:First Name: Samuel Last Name: Clarke Email Address: [email protected] Degrees: MD, MAS Title: Assistant Professor, Department of Emergency Medicine Main contact's role: Learner

Additional Participants

Name Degrees Title Role

Kathleen Behan RN, MS Clinical Quality and Safety Mentor

David Dawson MD Professor, Division of Vascular Surgery Mentor

ChristineMcBeth DO Resident, Department of Emergency

Medicine Learner

William Pevec MD Professor and Chief, Division of VascularSurgery Mentor

SamuelTurnipseed MD Assistant Professor, Department of

Emergency Medicine Mentor

Introduction: Response: Ruptured abdominal aortic aneurysm (rAAA) is the 13th most common cause of death in the UnitedStates, and overall mortality is greater than 90%. Endovascular repair of the aorta (EVAR) has become thepreferred operative strategy for managing rAAA, as there is evidence to suggest improved mortality in comparisonto traditional “open” repair. At UC Davis, EVAR requires the rapid deployment of operating room (OR) and CathLab Team (CLT) staff, as well as preparation of a specific operating room (OR 45) with equipment to support bothendovascular and traditional operative approaches. An analysis of our institutional performance at UC Davis overthe past five years has shown substantial variability both in time to diagnosis and time to OR 45 readiness. In orderto address these issues, an interdepartmental and interdisciplinary group from the Departments of VascularSurgery, Anesthesia, and Emergency Medicine endeavored to create a new process of care that would streamlinethe diagnosis and disposition of these critically ill patients.

Methods: Response: We devised a new treatment protocol based on work performed at other academic institutions showingthat a protocol-driven approach to EVAR for rAAA repair leads to improved mortality. After achieving initialconsensus on our protocol, we performed two full-scale simulations in the Emergency Department (ED) and OR45. We used data collected during these simulations to further refine the protocol. Additionally, we developed anorder set in the electronic health record to standardize the initial workup and approach to resuscitation for thesepatients. We also conducted point of care ultrasound training with the emergency medicine residents to improvetheir skills at detecting AAAs, and did on-site training with ED, OR and CLT staff to ensure their familiarity withthe protocol.

Results:

Results: Response: We conducted two full-scale simulations of the protocol on September 15th and December 9th, 2015.Our initial simulation revealed critical issues around the coordination of staff to prepare OR 45 emergently. Theseissues were addressed through revisions to the protocol and further staff training, and our second simulationsession resulted in substantially improved coordination of care (time from ED arrival to start of case in OR 45 was29 minutes). Since initiating this process we have also had one actual rAAA case present to UC Davis. The patient,an 83-year-old man, was transferred from an outside hospital with a 7.5 centimeter rAAA. The time from EDarrival to the start of the EVAR case was 45 minutes, and the patient was discharged to a skilled nursing facilityon post-operative day four after a successful repair.

Discussion: Response: Although this project is still early in its implementation, it has already proved to be a successfulcollaboration between multiple departments. We believe it represents an important step towards improving the carefor patients presenting to our hospital with rAAA, and that we hope that it will pave the way for UC Davis tobecome a leading institution in the management of this disease.

Submitted Tracking Number: 245 Abstract Title: Response: Improving Asthma Care in a Pediatric Teaching Clinic Through the Use of a Practice ImprovementModule

Main Contact:First Name: Julia Last Name: Lee Email Address: [email protected] Degrees: MD Title: PGY 3 Main contact's role: Mentor



Albina Gogo MD Pediatric attending Mentor

Ulfat Shaikh MD, MPH Pediatric attending Mentor

Daniel Tancredi PhD biostatistician Mentor

Introduction: Response: Standardized systematic approaches to asthma management result in increased compliance with asthmacare guidelines, creation of asthma action plans, documentation of asthma severity, appropriate prescription forcontroller medication, and decreases in medical service utilization. There is significant variation asthmamanagement in the outpatient setting. Our objective was to increase appropriate care for asthma in our pediatricteaching clinic, including spirometry testing, monitoring asthma control, and provision of asthma action plans.

Methods: Response: Our strategy for quality improvement addressed three domains. The first domain was provider educationwhich included teaching the national asthma care guidelines in terms of diagnosis and management, and makingthose guidelines readily available on a central resident resource website as well as visual aid in clinic with keynational guideline messages. This domain also included feedback on individual results every two months aftereach chart review in addition to feedback on group results every six months. The second domain was asystems-based intervention which included several electronic health record (EHR) modifications such as creationand universal sharing of a standardized asthma action plan and standardized asthma history template, creation of aflowsheet to document asthma control scores and creation of a pediatric asthma controller medication order-set.The third domain consisted of patient education through reformatting the standardized asthma control questionnaireand asthma action plan to increase understandability to patients with low health literacy as well as encouragingproviders to review written asthma action plans and appropriate inhaler technique with patients and their parents.After a series of outpatient based interventions, chart reviews were done every two months using Education inQuality Improvement for Pediatric Practice (EQIPP), a practice improvement module created by the AmericanAcademy of Pediatrics. At the end of each chart review, data from the EQIPP questionnaire was entered into theEQIPP Asthma module and then entered into SAS program for statistical analysis.

Results: Response: Several key measures showed statistically significant improvements over the course of theinterventions, specifically use of a standardized instrument to determine current level of control, use of nationalguidelines for treatment, providing written asthma action plans, and providing asthma self-management education.We noted statistically significant improvement in influenza immunization in months during which patients face thehighest risks for influenza.

Discussion: Response: Our University-based teaching clinic serves a large proportion of underserved children, who are athighest risk for complications related to asthma. Standardization and the use of EHRs improved adherence tonational clinical guidelines for pediatric asthma. Utilizing existing resources provided by the American Academyof Pediatrics, namely the asthma EQIPP module, allowed us to monitor process measures over the course of ourintervention. The use of an established practice improvement module allowed us to identify practice goals forimprovement, collect and analyze our group performance data over time, assess the impact of each change andre-design our process based upon feedback provided by the practice improvement module.

Submitted Tracking Number: 281 Abstract Title: Response: Improving Patient-Clinician Communication in Advanced Cancer: A Cluster Randomized Trial

Main Contact:First Name: Paul Last Name: Kaesberg Email Address: [email protected] Degrees: M.D. Title: Clinical Professor Main contact's role: Mentor



Camille Cipri n/a n/a Mentor

Richard Kravitz M.D. Professor Mentor

Daniel Tancredi PhD Professor Mentor

Guibo Xing n/a n/a Mentor

Introduction: Response: The “Values and Options in Cancer Care (VOICE)” study is an RCT testing the effect of patient andphysician communication training on the quality of communication regarding aspects of their care in patients withadvanced cancer. Poor communication between providers and patients with advanced cancer has been associatedwith unrealistic patient expectations regarding curability, survival time and the benefits of chemotherapy. Wehypothesized that a combined intervention targeting both oncologists and their patients would increase patientparticipation discussions and physician responsiveness to patients’ emotions while promoting discussions aboutprognosis and treatment choices

Methods: Response: Oncologists were randomized to receive a video on communication, mock patient interviews regardingan advanced cancer situation, identification of 4 communication goals, and feedback to the physician (interventiongroup) or no training (control group). Up to 10 patients of intervention-group physicians received communicationtraining, with follow-up phone calls. Up to 10 patients of control physicians received the NCI book “Coping withAdvanced Cancer.” The primary outcome was the Quality of Communication in Advanced Cancer Score, anaggregate of four measures matched to the four key goals of communication training and assessed using audiorecordings of enrolled patients’ first encounter with the study oncologists. Four specific communication skills wereassessed: ENGAGING patients and caregivers to identify and ask questions, express concerns and opinions, andrequest clarifications; RESPONDING to patients’ emotions, expressed as direct concerns and indirect cues;INFORMING patients about the disease, prognosis and treatments then checking understanding using an“ask-tell-ask” approach; and BALANCED FRAMING that presents the positives and negatives ofrecommendation.

Results: Response: 281 patients were allocated to intervention (n=139) or control (n=142); 205 (73.0%) had an enrolledcaregiver. Sixteen patients were withdrawn. The intervention had a significant effect in increasing the compositeprimary outcome (p=0.02). The intervention produced statistically significant increases in ENGAGING (p=0.03)and trending effects in RESPONDING (p=0.10) and INFORMING (p=0.11), while no effects were observed inFRAMING. There were only 8 instances of balanced framing in the entire dataset.

Discussion:

Discussion: Response: A combined intervention directed conversations to a more patient- centered focus where patients askedmore questions and were more assertive; physicians were more responsive to patients’ emotions and discussedprognosis and treatment choices with greater frequency. Patient activation behaviors were influenced by theintervention. Other behaviors - responding to patients’ emotions, discussing prognosis and balanced framing ofdecisions – may be more difficult to influence, and in the case of prognosis and framing, may not be appropriate atevery visit and difficult for even the most activated patient to elicit in physicians. There was a notable paucity offraming talk during the encounters; often, treatment decisions were presented as a fait accompli or requiring asimple assent rather than considering alternatives. Few patients selected prognosis to discuss in the visit with theirdoctor, and perhaps they didn’t want to discuss it at all. The intervention group experienced no decline in patients’ratings of their care or their relationships with their physicians.

Submitted Tracking Number: 269 Abstract Title: Response: Navigating Sickle Cell Pain so Crisis Doesn't Mean an ED Visit

Main Contact:First Name: Kerri Last Name: Stuart Email Address: [email protected] Degrees: RN, MSN Title: Nurse Manager Main contact's role: Mentor



Debra Burgess RN, BSN, HCA Quality Nurse Mentor

Natalie Merilus RN, BSN CNIII Learner

Calene Roseman RN, MSN Admin Nurse Learner

Ted Wun MD Divison Chief Hem Onc Mentor

Introduction: Response: Over 100,000 people in the U.S. are affected by sickle cell disease (SCD) which increases morbidityand mortality. People with SCD have a genetic blood disorder and frequently suffer from acute vaso- occlusivecrises (VOCs) causing severe painful episodes. Individuals with SCD most commonly seek pain management forsickle cell crisis (SCC) in the emergency department (ED) and are frequently admitted for continued therapy tocontrol pain. Impacted ED waiting rooms can result in long wait times to receive therapy despite the best triagepractices. In some cases patients leave without being seen. Within our facility we found that 10 patients with SCDwere responsible for 50% of admits for management of VOCs and 15 patients were responsible for 75% of EDutilization for SCC. The average time to first narcotic was 2:51 from ED triage. The current system does notprovide adequate access for care and could be more efficiently delivered in an outpatient setting. The aim of thisproject was to provide a treatment alternative for SCD and prompt access for pain management of VOCs whileimproving the patient experience. This also serves to decompress overburdened EDs and reduce hospitaladmissions.

Methods: Response: An outpatient infusion center model of care was developed to provide an alternative environment fortreatment to patients with SCD and SCC. Patients receive scheduled appointments for management of chronicissues and have the option to call in for management of their acute VOCs rather than waiting to be triaged for care.Services offered included short term pain management and IV hydration, exchange transfusion, blood productadministration and phlebotmychelation therapy. Hours of operation are from 8am to 8pm, weekdays. Datacollected included time to first narcotic, pain score, average visit time, and discharge status from the InfusionCenter. Success was measured by providing administration of narcotics within 1 hour of chair time, adequate paincontrol resulting in discharge home, and reduction in ED utilization and unnecessary hospitalization. A SCD nursenavigator was hired to provide clinical care in the infusion center and manage care.

Results:

Results: Response: 163 SCD patients were treated at the Cancer Center during the pilot study. The average time tonarcotic in the Infusion Room was 1:04 verses 2:51 in the ED, a 62.7% reduction. The average time to pain controlwas 6:33 with 93% of patients discharged home (3% transferred to ED and 4% transferred as direct admit forcontinued therapy). The most common services provided was pain management with IV hydration for SCC (63%),Desferal infusion (17%) and exchange transfusion (13%). There was a downward trend noted in ED utilization andhospitalization for the pilot group.

Discussion: Response: The Infusion Center model provides a quality experience for management of VOCs and a moreefficient use of healthcare resources. It is a preferred alternative for receiving care than going to the ED. Outcomesare promising to demonstrate a decline in ED utilization, hospitalization and unplanned readmission. More researchand analysis is needed to evaluate the cost benefit of the model.

Submitted Tracking Number: 263 Abstract Title: Response: Osteoporosis Overtreatment in the UC Davis Health System

Main Contact:First Name: Joshua Last Name: Fenton Email Address: [email protected] Degrees: MD, MPH Title: Associate Professor Main contact's role: Mentor



Anna Lee Amarnath MD, MPH Medical Consultant Learner

Peter Franks MD Professor Mentor

John Robbins MD, MSH Professor Mentor

Introduction: Response: The U.S. Preventive Services Task Force (USPSTF) recommends dual x-ray absorptiometry (DXA)screening for women aged >=65 years and for younger women at increased risk. However, for women to benefitfrom screening, clinicians must appropriately select women for drug treatment based on the presence of clinicallyimportant DXA abnormalities and patient risk. DXA reports at UCDHS routinely include T-scores for anatomicsites, such as the lateral lumbar spine, that the International Society for Clinical Densitometry (ISCD) does notrecommend for osteoporosis diagnosis. We hypothesized that UCDHS women are frequently prescribedosteoporosis drugs based on non-diagnostic DXA abnormalities.

Methods: Response: We performed a retrospective cohort study of electronic health records (EHR) and radiology records fortreatment naïve women aged 40-85 years receiving initial screening DXA within UCDHS from January 1, 2006through December 31, 2011. We classified women based on the presence of >=1 of six risk factors. We usednatural language processing to abstract T-scores from EHR radiology reports. For each site, we classified T-scoresas normal(T>-1.0), osteopenia (-2.5

Results: Response: Of 6,150 women who received initial DXA screening, 31.1% received new osteoporosis drug treatment.Overall, 14.2% of women had mainsite osteoporosis, 32.8% had non-mainsite osteoporosis, while the remainderhad no osteoporosis (either isolated osteopenia or normal T-scores). Most women with mainsite osteoporosis(73.5%) received new drug therapy, as did nearly half with non-mainsite osteoporosis (47.7%). Nevertheless,because non-mainsite osteoporosis or isolated osteopenia occurred commonly, women with non-mainsiteosteoporosis accounted for 50.3% of new prescriptions, while women without osteoporosis accounted for 15.8%.Of the 6,150 DXAs, 60.1% were performed on women aged 40-64 years without osteoporosis risk factors whomay not have been recommended for screening by the USPSTF. Of the 1,912 women who initiated new drugtreatment, 66.4% had DXAs either without osteoporosis or non-mainsite osteoporosis.

Discussion:

Discussion: Response: Within UCDHS, two-thirds of new osteoporosis drug prescriptions were potentially inappropriatebecause the osteoporosis diagnosis was based on DXA abnormalities considered non-diagnostic by internationalguidelines. Of these prescriptions, half were provided to younger women without risk factors who may not havemerited screening in the first place. Based on study findings, radiologists have ceased interpreting including laterallumbar T-scores on UCDHS DXA reports. Additional efforts are needed to ensure that screening is not frequentlyperformed on younger, lower-risk women.

Submitted Tracking Number: 265 Abstract Title: Response: PAIN MANAGEMENT BUNDLES IN THE EMERGENCY DEPARTMENT FOR OLDERPATIENTS WITH HIP FRACTURE

Main Contact:First Name: Katren Last Name: Tyler Email Address: [email protected] Degrees: MD Title: Associate Professor Main contact's role: Mentor



Dane Stevenson MD Geriatric Emergency Medicine Fellow Learner

Introduction: Response: Fragility hip fracture are common presentations to EDs and are associated with a high risk ofcomplications. Guidelines illustrate the value of multidisciplinary geriatric fracture programs for managing hipfractures. Implementing pain management bundles in the ED is a key part of geriatric fracture programs. Ourinstitution introduced a multidisciplinary geriatric fracture program (GFP) for fragility hip fractures in January2014 and we describe opioid dosing, administration of the fascia iliaca compartment block (FICB) anddevelopment of delirium in the first 154 patients admitted through the ED.

Methods: Response: Patients were prospectively enrolled in the GFP and included in the GFP database. Patients less than 65years of age, peri-prosthetic fractures, and patients whose fracture mechanism were not ground level falls areexcluded from the GFP and were never included in the database. Demographic data and clinical informationincluding MRN, name, sex, age and other parameters are collected into the database prospectively. The GFPdatabase includes the number of shifts delirium is identified by RNs using the Confusion AssessmentMethod–ICU. Analgesic doses for the first 24 hours were hand tabulated from the electronic medical record and24-hour morphine equivalence was calculated using a standard table.

Results: Response: From January 2014 to October 2015, 153 patients were enrolled in the GFP database. Of these, 75(49%, 95% CI 41-57%) patients received FICB in the ED. Of the 78 (51%) patients with hip fractures who did notreceive a FICB, 36 received less than two doses of opioids in the first 24 hours of their admission. After excludingpatients who received less than two doses of opioids in the initial 24 hours of their hospital stay, patients who didnot have an FICB in the ED had a median 24-hour ME dose of 16.3 mg (IQR 10.1-23.8) and 21/42 (50%, 95%CI34-66%) had delirium. Patients who had a FICB performed in the ED had a median 24-hour ME dose of 12.5mg(IQR 5.0–20.4) and 27/75 (36%, 95%CI 25-48%) had delirium.

Discussion: Response: A multimodal pain pathway introduced in the ED as part of a multidisciplinary hip fracture clinicalpathway reduces the opioid dose in the first 24 hours of the hospital stay, and may reduce the rate of deliriumduring hospitalization.

Poster Presentations

Submitted Tracking Number: 299 Abstract Title: Response: Acute heart failure admission from skilled nursing facilities versus community: an evaluation ofmortality risk and other clinical outcomes

Main Contact:First Name: Sukhi Last Name: Sidhu Email Address: [email protected] Degrees: Title: Pharmacy Intern Main contact's role: Learner



Sarah Bajorek Pharm.D. Pharmacist Mentor

Tiffany Pon Pharm.D. Pharmacist Mentor

Tiffany Tang Pharmacy Intern Learner

Christine Tran Pharmacy Intern Learner

Charisma Urbiztondo Pharmacy Intern Learner

Introduction: Response: Current studies on heart failure (HF) patients discharged to skilled nursing facilities (SNF) show a30-day readmission rate secondary to HF exacerbation of 27-43% as compared to other studies of 23% for patientsdischarged to the community, suggesting that patients may not be adequately managed at SNFs. The objective ofthis study is to assess whether patients admitted for acute decompensated HF (ADHF) from SNFs have a highermortality risk and worse clinical outcomes compared to those from the community.

Methods: Response: This was a single-center, retrospective chart review of patients aged >18 admitted for ADHF from SNF(intervention) or community (control). Patients with the following criteria were excluded: LVAD, incomplete data,prisoners, pregnant, cognitively impaired on treatment, and fluids entirely removed by hemodialysis. Primaryendpoint was mortality risk according to the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC)score that categorizes patients into six risk groups that represent increasing 3-year mortality rates (1:0-16, 2:17-20,3:21-24, 4:25- 28, 5:29-32, 6:33+). The intervention group was matched to the control group by age, sex, ejectionfraction (EF), and ethnicity. Secondary endpoints were clinical decompensation, length of hospital stay, 30-dayreadmission rate, and in-hospital mortality rate.

Results: Response: Of the 111 patients who met inclusion criteria, 64% (33/51) of SNF patients and 61% (32/53) ofcommunity patients were classified within the MAGGIC risk groups 3-5 (p=0.5), suggesting that majority ofpatients admitted for ADHF have a 3-year mortality risk of 30- 54%. Compared to patients from community, fewerSNF patients with reduced EF were on beta-blockers (BB) (68% vs 86%, p=0.15) and renin- angiotensinaldosterone (RAAS) inhibitors (23 vs 36%, p=0.32) prior to admission. Thirty-day readmission rate (20% vs 15%,p=0.48) and in-hospital mortality (16% vs 4%, p=0.03) were also higher in the SNF cohort. During hospitalization,SNF patients also required more loop diuretic therapy (p=0.02) and vasopressor utilization (13% vs 6%, p=0.2)than community patients. Average net intake/output was also higher in SNF patients (-7L vs -4.7L, p=0.26).

Discussion:

Discussion: Response: Although patients from the community were more likely to be on mortality-reducing medications(BB/RAAS inhibitors) PTA, three-year mortality rates between groups were similar. Despite not meeting statisticalsignificance, readmission rates, vasopressor use, and average net intake/output were higher in the SNF group,which may have clinical significance. Both in-hospital mortality and loop diuretic utilization were significantlyhigher in SNF patients; this further suggests SNF patients may be more acutely decompensated and require higherlevels of care. One possible reason for these results may be inappropriate management of SNF patients with sub-optimal medication regimens, which indicates potential need for educating local SNFs regarding appropriatemanagement of heart failure. Further study, however, with larger sample sizes is needed to see if a true statisticallysignificant difference in all clinical outcomes exists.

Submitted Tracking Number: 278 Abstract Title: Response: An Educational Program About Operating Room Fires Aimed at Effecting Behavior Change inAnesthesia Residents

Main Contact:First Name: Brian Last Name: Pitts Email Address: [email protected] Degrees: M.D., M.S. Title: Associate Professor, Anesthesiology and Pain Medicine Main contact's role: Mentor



AubreyYao M.D. Assistant Professor, Anesthesiology and Pain

Medicine Mentor

Introduction: Response: Operating room fires are rare events that have devastating medical, legal, and economic consequences.Although the etiologies and events leading to operating room fires is well described in the literature, inadequateanticipation and communication by the operative team continues to represent a significant contributor. At TheUniversity of California Davis Medical Center, the Surgical Time Out is an important pause that occurs in theimmediate preoperative period after the patient enters the operating room but before surgery begins. The goal ofthis pause is to eliminate wrong site and wrong person surgery, as well as to identify the patient care plan using ateam-based approach. Together, Nurses, anesthesiologists, surgeons, and the patient systematically review relevantconcerns before the start of surgery. We observed that in many instances where the risk of operating room fire washigher than normal (i.e. airway and ENT cases), team members did not always mention or discuss a plan tominimize the risk of fires. To improve awareness and increase communication about the risk of operating roomfires, we developed an inquiry-based educational intervention that used video-based learning and high fidelitysimulation.

Methods: Response: Because anesthesiologists play a pivotal role in the care and safety of the patient during surgery, wedeveloped an educational intervention for first-year anesthesia residents to not only deliver the knowledge requiredto minimize operating room fires, but also assess the application of that knowledge in a simulated clinical setting.Perceptions, knowledge, and prior experience was measured using survey questionnaires both before and after theintervention.

Results: Response: Both knowledge and confidence levels regarding the recognition and management of operating roomfires increased after the intervention (knowledge: 75% vs. 90%, N=8). The simulation was positively perceived byboth participants and observers ( rating 4.9 out of 5, N = 8). A surgical pause was performed; recognition andmanagement was achieved in less than 1 minutes. Reported barriers to real-life implementation: 1) productionpressure, 2) lack of knowledge, and 3) no cases with risk factors. At one month, 86% reported having mentionedthe risk of airway fires in the O.R. during the surgical pause compared to less than 2% before the intervention.

Discussion:

Discussion: Response: Educational interventions that increase the awareness of operating room fires have the potential toreduce patient morbidity and mortality. However, a gap exists between delivering an educational program andmeasuring its intended effect in clinical situations. The ultimate goal of effective instruction is to produce changethat can be translated into the real world. Achieving this goal remains a major challenge in medical education today.Simulation- based training combines medical knowledge with clinical practice in high acuity scenarios thatpromote experiential learning and critical thinking. Here we describe an educational approach that takes advantageof the unique capabilities of various learning environments to expand the learner’s awareness and skill in reducingthe risk of operating room fires.

Submitted Tracking Number: 309 Abstract Title: Response: Analysis and Educational Program To Reduce the Overuse of Neurodiagnostic Imaging in the Workupof Cerebrovascular Accidents (CVA)

Main Contact:First Name: Derek Last Name: Holder Email Address: [email protected] Degrees: MD MS Title: Resident Physician PGY4 Main contact's role: Learner



Mustafa Ansari MD Resident Physician PGY3 Learner

Glen Jickling MD Attending Mentor

Katherine Park MD Resident Physician PGY3 Learner

Dionne Swor DO Resident Physician PGY3 Learner

Introduction: Response: There is a perception of overuse of neurological imaging in the Neurology Department and theEmergency Departments in the workup of Cerebrovascular Accidents. It is not uncommon for patients to receivemultiple imaging studies with the same clinical questions regarding the etiology of the patient's symptoms. Thereare burdens placed on neuroradiology and nursing staff, as well as limited scanner time. There is also additionaladded anxiety for patients and exposure to anxiolytics and side effects associated with them during extra studies.These studies have significant cost as well as risks such as extra contrast exposure and increased time away fromnursing and physician staff, which can be dangerous, particularly in the immediate period after a stroke. Ourproject seeks to educate and implement strategic methods of reducing redundant neurological imaging studies.

Methods: Response: Our project has two phases. The first involves education and implementation of tools to help providersmake educated decisions for best practice in patient care. We have educated neurology and emergency departmentresidents on an accepted algorithm for workup in acute and chronic stroke, avoiding redundant studies. We alsoadjusted our department's order sets to avoid unnecessary "default" unnecessary studies. The second phase involvesanalysis of pre-implementation patterns and compares to post-project implementation rates of imaging. There arealso ongoing discussions to implement physician notifications (via EMR flags) to limit unnecessary studies that hadrecently been performed.

Results: Response: We have calculated the rate and number of imaging studies performed in the first day of a patient'sadmission from a group of patients collected from 2005-2015. There were an average of 5.24 studies per patient,which included CT Head, CT Angiography Head or Neck, MRI Brain, MR Angiography Brain or Neck, andCarotid Ultrasound. The education program recommends at most 3-4 studies per patient from the above list. Ouranalysis efforts are ongoing on a group of patients collected after education efforts were started in order tocompare pre and post- education imaging rates. Our team was able to collaborate with IT as well as neuroradiologyto discuss changes in order sets and the possibility of implementing EMR Flags in the future, to remind physiciansof all services of order redundancy (For instance, a reminder that CT Angiography with contrast is more sensitiveand specific than MR Angiography without contrast, and that ordering a MR Angiogram after a CT Angiogrammay be unnecessary).

Discussion: Response: Our analysis ofimaging rates is ongoing, as are efforts to continue and educate other services ofrecommended imaging modalities for the workup of acute and chronic stroke. We continue to evaluate the data ofpost-education rates of imaging orders as well as their patient value impact as well as ways of notifying orderingproviders of standard of care in neuro-imaging in real-time, including the use of EMR Flags, which will requireinter- departmental discussion and agreement. We are hopeful the current project will help solidify norms ofclinical practice and ensure patients high quality of care.

Submitted Tracking Number: 262 Abstract Title: Response: Antimicrobial Stewardship-Guided Protocol for Surgical Prophylaxis of Appendicitis in Children

Main Contact:First Name: Alexandra Last Name: Yonts Email Address: [email protected] Degrees: MD Title: Resident Physician (Pediatrics) Main contact's role: Learner



JamieAnderson MD Resident Physician (Surgery) Learner

Shinjiro Hirose MD Associate Professor, Pediatric Surgery Mentor

LindaShutzman MD Resident Physician (Surgery) Learner

Jean Wiedeman MD,PhD Associate Professor, Pediatric InfectiousDisease Mentor

Introduction: Response: Acute appendicitis is the most common pediatric surgical condition, occurring in 9-12/10,000 children.Most cases(50-75%)present as appendicitis without perforation (“uncomplicated”). Evidence and federal advisorycommittee guidelines suggest a single pre-operative administration of antibiotics,given within 1 hour of incision, isall that is required. The goal of this study is to educate providers regarding these guidelines and illustrate thatstandardization of local practices in compliance with said guidelines will maintain or improve local qualityoutcomes, without increasing negative events.

Methods: Response: This was an IRB approved retrospective cohort study. An EMR order set for surgical admissions wasdesigned and enacted in January 2015 and antibiotic dosing guidelines were disseminated and discussed in personwith Pediatric Surgery attendings/residents.Guidelines included limiting antibiotics to only pre-operative use anddictating which antibiotics should be used (Ceftriaxone and Metronidazole). EMR charts were identified by ICD9/10 codes. Additional inclusion criteria included “uncomplicated appendicitis” as defined by UC Davis Pediatricsurgeon and age 0-18 years. Historical cohort (N=96) included cases from 1/2013-12/2014. Interventional cohort(N=50) included cases from 1/2015-1/2016. Primary endpoints include surgical providers’compliance withguidelines, cost of antimicrobials (based on representative average wholesale prices), length of stay in hours andfrequency of surgical site infection (SSI). Secondary endpoints include rates of re-admission, post-discharge EDvisit, re-operation, fever, abscess, C. difficile infection or abdominal CT scan within 30 days of discharge. T-testswere used to compare pre/post variables via Excel.

Results: Response: Initial results show that the majority of providers (70%) were adherent to the guidelines following theeducational intervention (vs 10.4% in historical cohort,(p

Discussion:

Discussion: Response: The use of an EMR order set, as well as in person education about national guidelines for antimicrobialuse in pediatric uncomplicated appendicitis, leads to improved adherence to guidelines. When these guidelines arefollowed, less antibiotics are used and associated costs are decreased, and length of stay is shortened withoutincreasing any negative outcomes or complications of appendicitis. Next steps include continuing to educateproviders, in particular, new surgery residents, in regards to these guidelines and improve dissemination ofguidelines by adding them to the CRC website for reference.

Submitted Tracking Number: 301 Abstract Title: Response: Assessing the appropriateness of venous thromboembolism prophylaxis and clinical consequences ofover-prophylaxis

Main Contact:First Name: Calvin Last Name: Diep Email Address: [email protected] Degrees: Title: Pharmacy Intern Main contact's role: Learner



Hien Lu Pharmacy Intern Learner

Patricia Parker PharmD Pharmacist Mentor

Tiffany Pon PharmD Pharmacist Mentor

Introduction: Response: Implementation of the venous thromboembolism (VTE) risk assessment tool into the electronicmedical record (EMR) at UC Davis Medical Center (UCDMC) improved rates of VTE chemical prophylaxis;however, adverse effects of inappropriate chemical prophylaxis have not been evaluated. The American College ofChest Physicians recommends against chemical prophylaxis in patients with low VTE risk and patients withbleeding risks. The purpose of this study was to evaluate the effectiveness of the UCDMC VTE tool in promotingappropriate VTE prophylaxis and to assess consequences of over-prophylaxis.

Methods: Response: This was a single-center retrospective chart review from 06/01/2015-09/01/2015. This study includedpatients > 18 years who were hospitalized for greater than 48 hours. Patients on comfort care, receivingtherapeutic anticoagulation, or who were pregnant were excluded. Patients categorized as low, moderate, or highrisk for VTE were identified by the EMR VTE tool. Inappropriate prophylaxis was defined as the use of chemicalprophylaxis in the following populations: 1) low risk 2) moderate risk with exception(s) to chemical prophylaxis3) high risk with exception(s) to chemical prophylaxis. Exceptions to chemical prophylaxis were defined by theVTE tool and included known risk factors for bleeding. The primary endpoint was rate of VTE chemicalprophylaxis in the above populations. Secondary endpoints included in-hospital major and minor bleeding events.Descriptive statistics were used for analysis.

Results: Response: A total of 4,041 patient days were reviewed. Chemical prophylaxis was administered in 38%, 40% and21% of patient days in low risk, moderate risk with exceptions, and high risk with exceptions groups, respectively.The majority of low risk patients had no exceptions (88%). “Active bleeding” was the most common exception inmoderate risk patients (38%) while “thrombocytopenia” was most common in high risk patients (51%). Majorbleeding occurred at a rate of 0.27% (2/733). Both of these patients were categorized as moderate risk and had“active bleeding” exceptions. One of the two bleeding events was fatal, where the patient had two exceptions(“active bleeding” and “cirrhosis”).

Discussion:

Discussion: Response: This study suggests inappropriate utilization of VTE chemical prophylaxis in terms of over-prophylaxis at UCDMC as it was given in up to 40% of patients in these populations, potentially increasingbleeding risk. Compared to high risk patients, moderate risk patients were more likely to be inappropriatelyexposed to chemical prophylaxis and have an “active bleeding” exception, which potentially led to the observedbleeding events. Furthermore, the VTE tool creates the exception for “active bleeding” based only on changes inhemoglobin and hematocrit, which may have led to providers overlooking this exception. Bleeding events were notobserved in low risk patients likely because they were less likely to have any exceptions. Educating providers onhow to appropriately utilize the tool and potentially creating a more obvious alert for specific exceptions (e.g.“active bleeding”)may reduce the rate of inappropriate chemical prophylaxis administration and the associatedbleeding risks.

Submitted Tracking Number: 303 Abstract Title: Response: Beyond the code sheet: a novel instrument for evaluating code blue team performance

Main Contact:First Name: Samuel Last Name: Clarke Email Address: [email protected] Degrees: MD, MAS Title: Assistant Professor, Department of Emergency Medicine Main contact's role: Learner



Aaron Bair MD, MS Director, Center for Health andTechnology Mentor

ZoyaDerebenskiy BA, BS Quality and Safety Analyst Learner

Amy Doroy RN Nurse Manager, Medical IntensiveCare Unit Mentor

Kevin Floyd RN, BSN,CCRN Clinical Nurse Educator Mentor

Joleen Lonigan RN Nurse Manager, Patient CareResources Mentor

Introduction: Response: Documentation of in-hospital Code Blue cardiac/respiratory arrest emergencies supports real-time care,process improvement, and legal accountability. Currently, the “code sheet” serves as the primary documentation forwhat is often a chaotic and complex event. Vital aspects of leadership, organization, and team communication aregenerally not evident from the code sheet. In order to strengthen the capture of subtle features of Code Blue events,an interdisciplinary and interprofessional group from the recently reorganized Code Blue Committee developed anovel reporting instrument. Our objective was to document key leadership and communication behaviors of theCode Blue Team that may help or hinder resuscitation.

Methods: Response: The reporting instrument was developed over multiple iterations via group consensus. It contains itemsrelating to the clinical circumstances of the code, as well as items relating to leadership, organization, andcommunication during and after the code (based on a Likert 1-5 scale with 5 being the highest performance). Theinstrument also contains space for narrative comments to provide further detail. This instrument is filled out byspecifically trained members of the Code Blue Team (nurses from either the Medical Intensive Care Unit or RapidResponse Team). We used summary statistics and standard deviation (SD) for reporting our results.

Results: Response: We collected data from adult Code Blue events that occurred between July 1 and December 31, 2015.During this time there were 94 Code Blue calls. We received complete reporting instruments for 40 (43%) of theevents. These occurred in: ICU (n=16), Telemetry Unit (n=11), Med/Surg Unit (n=10), and non-inpatient unit(n=3) settings. Residents served as code leaders in 41% of codes (n = 16), and fellows in 33% (n = 13). For teamorganization, the mean score for appropriate distribution of labor (i.e. assigning roles such as chest compressions,airway management, medication administration) was 3.8 (SD 1.7), and for equipment positioning (e.g. defibrillatorvisible to team leader, adequate space for activity) was 3.8 (SD 1.2). For team leadership, the mean score for

clinical decision-making (establishment and execution of plan) was 3.9 (SD 1.3), and for team communication (e.g.use of closed-loop communication, sharing of plan with team) was 3.6 (SD 1.3). Debriefing was performed after75% of events (n = 30). Major themes from the narrative comments clustered around several factors: a)overcrowding, b) a need for more clearly defined roles within the team, c) difficulty with technical skills (e.g.central line placement), and d) barriers to performing effective debriefing after codes.

Discussion: Response: We believe that this reporting instrument is an important step towards a better understanding of thecomplex and dynamic nature of team interactions during Code Blue events. As we refine the reporting process, andfurther integrate the results into our quality assurance process, we anticipate that it will result in improvedoutcomes for our most vulnerable patients.

Submitted Tracking Number: 268 Abstract Title: Response: Central line blood stream infection reduction in Oncology patients using Chlorhexidine gluconatebathing.

Main Contact:First Name: Valerie Last Name: Sawhill Email Address: [email protected] Degrees: RN-BC, MSN Title: Clinical Nurse lll , Quality & Safety Champion Main contact's role: Mentor



Laurie Brunton RN Clinical nurse lll Learner

Nicole Mahr RN,MSN Clinical nurse lll Mentor

Wilson Yen RN Nurse Manager Davis 8 Mentor

Introduction: Response: Oncology patients are at risk for infections. Oncology patients need central venous access for thechemotherapy treatment. When there is a central line in place there is a risk that the bacteria from the skin canmigrate to the insertion site entering the blood stream causing a Central Line Blood Stream Infection (CLABSI).The NHSN benchmark for CLABSI is 2. Davis 8 CALBSI rate has been above the NHSN benchmark of 2 formore than 4 consecutive quarters Q1 2014-Q1 2015. The infections occur several days to weeks after insertionsuggesting that maintenance care should be considered. Most of the infections are caused by bacteria that normallygrows on the skin. The patients on Davis 8 either showered or were washed in bed with 2% CHG liquid soap. Thismethod of cleaning the skin has been found to be insufficient to remove bacteria from the skin and does notpenetrate the skin to provide a protective shield from bacteria. The goal of the project was to reduce the CLABSIrate to the NHSN benchmark by the end of 2015.

Methods: Response: The Nurse Manager, Clinical Nurse III (CNIII) group, the Infection Prevention nurse, and the Quality &Safety Nurse Champion met to analyze the problem. The decision was made to implement an intervention to reduceinfections. The Q&S Champion and CNIII nurses taught the nurses about the problem by reporting the infectionrate and cause of CLABSI. The nurses were instructed by video and demonstration on how to bathe patients withCHG wipes. The patients were educated on infection prevention and how to use the CHG wipes after showering.Signs describing how to use the CHG wipes were placed in each patient room to remind nurses and patients aboutthe use of the CHG wipes. Patient education on CHG bathing was placed in the Bone Marrow Transplant patienteducation binder. The Q&S Champion and IP nurse reported monthly to the CNIII group and staff the infectionsfor the month. The Q&S Champion asked the nurses if there were any barriers to CHG bathing and addressed theidentified barriers.The Q&S Champion continued to encourage the nurses and patients to use the wipes. The CNIIInurses audited the charts for nurse documentation of CHG bathing. They also coached nurses on CHG bathing anddocumentation. We measured our infection rate using the Infection Prevention data of hospital acquired infections.The monthly infection report was reviewed in daily huddles with staff and posted in the nursing unit.

Results: Response: The CLABSI rate was decreased to reach the benchmark in Q2 and Q3 of 2015. The project decreasedthe number of CLABS by having patients use the CHG wipes. This project showed that when nurses involvepatients in their care there are good outcomes.

Discussion: Response: The project showed the patients risk of infection reduces with daily bathing with the CHG wipes. Thenext step for D8 is for the nurses to pay close attention the integrity of the central line dressings.

Submitted Tracking Number: 307 Abstract Title: Response: Collaborative care for achieving a cure in patients with chronic Hepatitis C infection

Main Contact:First Name: Patricia Last Name: Poole Email Address: [email protected] Degrees: PharmD Title: Pharmacist Specialist Main contact's role: Mentor



Jessica Gomez PharmD Staff Pharmacist II Learner

Kathleen Haight Pharm.D. Staff Pharmacist II Mentor

Thomas Harper CPhT Pharmacy Technician III Mentor

RebeccaHluhanich PharmD Staff Pharmacist II Mentor

Vinh Nguyen Pharm.D. PGY-2 Ambulatory Care ResidentPharmacist Learner

Introduction: Response: Approximately 4 million people in the United States are estimated to be infected with hepatitis C. Overtime, chronic Hepatitis C can cause serious health problems including liver failure, and is the leading cause of livercancer and liver transplantation. Following the long-awaited FDA approval of direct acting antiviral medications totreat chronic Hepatitis C in December 2013, there was insufficient capacity within UC Davis specialty clinics toprovide treatment to all interested patients. Additionally, there was insufficient expertise within the specialty clinicsto navigate the complicated authorization process, mitigate drug interactions and adherence barriers, and coordinatecare among providers. The addition of clinical pharmacists and clinical pharmacy technicians to the existingspecialty clinic staff was mobilized to bridge this gap in access and quality.

Methods: Response: Clinical pharmacist staff were imbedded into hepatology and infectious disease specialty clinics fromJanuary 2014 to December 2015 to co-manage patients with Hepatitis C (HCV) under a collaborative practiceagreement. The pharmacists participated in HCV regimen selection, patient education, lab ordering andmonitoring, side effect management, adherence support, care coordination and documentation of patient outcomes.Clinical pharmacy technicians supported the prior authorization, patient assistance, medication delivery andadherence support functions. Resident pharmacists were layered with experienced clinicians to extend care andmeet the academic learning mission. The patient experience was analyzed by stage of disease, treatmentprogression, prescription payment assistance, and clinical outcome of achieving a cure. Patient and providersatisfaction was assessed by written surveys.

Results: Response: Over the 24 month period of the project, over 900 patients with HCV were referred to the clinicalpharmacist co-management panel. Of 488 patients who completed the full course of treatment and surveillance,92% achieved a cure. The pharmacy team continues to monitor approximately 500 patients who are in some stageof pre- treatment work up, active treatment monitoring, or post-treatment surveillance. The pharmacy technicianssecured financial assistance for patients’ prescription treatment in excess of $3 million dollars in the second year ofthe program. Patient satisfaction scores each quarter rated the pharmacy staff and UC Davis Specialty pharmacy

favorably, with 93% strongly agreeing that staff were compassionate, friendly and helpful, and 98% rating the UCDavis Specialty pharmacy as 9 or 10 with a score of 10 as the "best possible" during the most recent quarter. UCDavis medical providers also rated the clinical pharmacy team efforts favorably.

Discussion: Response: The integration of clinical pharmacists and pharmacy technicians into UC Davis specialty clinicsexpanded access to Hepatitis C specialty care through clinical and payor interventions. Cure rates for chronichepatitis C infection are impressive at 92%, including a high proportion of difficult-to-treat patients. Patient andprovider satisfaction remain high, endorsing the high quality of care provided by the clinical pharmacy team. Theintegration of resident pharmacists as learners yields a high quality opportunity for future practitioners to gainspecialized clinical expertise. As the model is also self-sustaining through prescription revenues, expansion toother specialty clinics continues with a similar model.

Submitted Tracking Number: 256 Abstract Title: Response: Creating a Culture of Safety through a Geriatric Hip Fracture Interprofessional Team

Main Contact:First Name: Philip Last Name: Wolinsky Email Address: [email protected] Degrees: MD Title: Professor, Orthopedic Surgery Main contact's role: Mentor



Calvin Hirsch MD Professor, General Internal Medicine Mentor

Christina Slee MPH Director, Quality and Safety Learner

Katren Tyler MD Associate Professor, Emergency Medicine Mentor

Introduction: Response: In 2013, the UC Davis Medical Center (UCDMC) created a co-managed model of care for geriatric hipfracture patients involving orthopedic surgery (OS) and internal medicine (IM). The program developed a focus onpatient safety through three strategies: 1) developing standardized geriatric-friendly order sets, 2) cohorting ofpatients on the orthopedics service, and 3) using weekly interprofessional huddles to identify patient safetyconcerns and escalate them to the UCDMC Patient Safety Events Committee.

Methods: Response: Standardization in care was established with EMR-generated order sets for the emergency department(ED) admission, fascia iliac compartment block (FICB) administration in the ED, the inpatient admission, andpost-op care. Cohorting was used to sort patients to the service most skilled at managing them (orthopedics vsmedicine) based on comorbidities and potential complications. Lastly, a weekly interprofessional huddle was usedto identify system-level patient safety concerns requiring institutional review by the Patient Safety EventsCommittee (PSEC).

Results: Response: Between January 1, 2014, and November 30, 2015, 189 patients were enrolled in the GFP. Between2014 and 2015, 24.7% more hip fracture patients received IM consults (p < .05), and uptake of the FICB order setin the ED increased by 18.8% (p = NS). In the cohorted population, length of stay and incident delirium remainedunchanged between 2014 and 2015. Three patient safety events were brought to PSEC and escalated tointerprofessional teams who established or reinforced nursing-resident-attending communication guidelines,designed training to improve management of high-risk medications, and expanded the GFP pathway tonon-geriatric patients at high risk for complications.

Discussion: Response: The complexity of GFP patients required a multi-pronged approach to patient safety. The order setshave succeeded in directing medical staff to best practices, including alternatives to opioid use such as the FICB.Medically unstable patients are routinely assigned to medicine for pre-op optimization, allowing 50% of patients tobe cohorted on the orthopedic service. PSEC has increased the visibility of medical co-management challengesacross the institution and highlighted the value of interprofessional participation in patient safety. Specific areas ofimprovement include improving inter-service transfers for patients who do not need critical care, expandingco-management to other at-risk patients (ie, end-stage renal disease patients on dialysis), and breaking down silos

between services. One future goal of the collaborative care model is to consolidate GFP admissions to medicine toa non-academic service with a small number of rotating attending providers in order to optimizemedicine-orthopedic cooperation through greater familiarity with the GFP.

Submitted Tracking Number: 297 Abstract Title: Response: Decreasing Fluoroscopy Time for Percutaneous Coronary Intervention

Main Contact:First Name: Brad Last Name: Stauber Email Address: [email protected] Degrees: DO Title: Fellow, Cardiovascular Medicine Main contact's role: Learner



Wendy Foster BS Project Manager Mentor

Garrett Wong MD Assistant Clinical Professor Mentor

Introduction: Response: Continued advances in interventional cardiology have led to an ever growing number of patients eachyear undergoing procedures with fluoroscopy. While patients benefit from these necessary diagnostic andinterventional studies, the price paid is exposure to ionizing radiation and its side effects. As a quality measure, thecardiac catheterization laboratory at UC Davis reports data to the National Cardiovascular Data Registry (NCDR).We have known that compared to hospitals in the United States, our average fluoroscopy time required to performpercutaneous coronary intervention (PCI) is approximately double the national average. Although we aim to deliversafe and quality healthcare, there is always room in improve our standards. Decreasing fluoroscopy minutes duringPCI is one such area that can be improved. The aim of this project has been to decrease the mean fluoroscopy timeto perform these interventions of the 2014-2015 academic year.

Methods: Response: All PCI procedures over the course of the third quarter of 2014 until the second quarter of 2015 werereported to the NCDR including data regarding fluoroscopy time (minutes) and history of coronary artery bypassgrafting (CABG). Several interventions were employed at the beginning of Q3 2014. Firstly, individual operatorswere informed of their averages on a quarterly basis. Additional efforts were put in place including a push to usefluoroscopy images when possible instead of cineradiography (which increases radiation dose and time), and strongconsideration of whether a right heart catheterization needed to be performed in addition to the left heartcatheterization + PCI (which also increases fluoroscopy time). Finally, trainees were given the opportunity to honetheir techniques in a simulation lab to help improve skills while fluoroscopy is being used.

Results: Response: Mean fluoroscopy time for all-comers from 18.6 minutes in the third quarter of 2014 to 16.6 minutes bythe second quarter of 2015 (11% decrease). When accounting for history of CABG, an improvement in fluoroscopytime was when looking at patients with and without a history of CABG.

Discussion: Response: On a per capita basis in the United States exposure to radiation has more than doubled since the 1980’s.Risks from have been well described in the literature for decades, including (but not limited to) tissue injury,cancer, and reproductive effects. As radiation exposure increases, risks also increase. This can affect not onlypatients but all persons in the laboratory, including physicians, nurses, and technicians. With steps in place toactively decrease fluoroscopy time, we saw a 11% decrease in mean time over the period of one year.Improvements can be attributed to several aspects of the intervention. Radiation awareness with culture aimed atdecreasing fluoroscopy time seemed to make a difference. Furthermore, as with any training institution, less

decreasing fluoroscopy time seemed to make a difference. Furthermore, as with any training institution, lessexperienced trainees can improve skills in a simulation lab to help minimize time under ionizing radiation. Withour averages still above national average, next steps will include continued use of simulation lab, review offluoroscopy time after each case, and continued awareness with aim for decreased ionizing radiation exposurewhile maintaining high quality studies.

Submitted Tracking Number: 311 Abstract Title: Response: Decreasing Postoperative Pulmonary Complications after Spine Surgery

Main Contact:First Name: Adam Last Name: Wegner Email Address: [email protected] Degrees: M.D., Ph.D. Title: PGY-3 Resident, Orthopaedic Surgery Main contact's role: Learner



YasharJavidan M.D. Assistant Profession, Department of Orthopaedic

Surgery Mentor

EricKlineberg M.D. Co-Director of the Spine Center, Associate

Professor, Department of Orthopaedic Surgery Mentor

RolandoRoberto M.D. Chief of Spine Service, Executive Vice Chair,

Professor of Orthopaedic Surgery Mentor

Introduction: Response: Spine surgery inflicts a significant physiological challenge onto the patient, necessitating prolongedICU stays for postoperative management and monitoring, and limitingmobility due to pain and activity restrictions.Early mobilization and respiratory care are paramount to recovery after spine surgery in order to decrease the riskof pulmonary postoperative complications (PPC’s) such as pneumonia, pulmonary embolism, and prolongedintubation, all of which contribute to increased overall morbidity and prolonged ICU and total hospital lengths ofstay. These complications tax the healthcare system’s limited financial and physical resources and negatively affectthe patient experience. The UC Davis Spine Center has identified a higher than expected rate of postoperativepulmonary complications (PPCs) after spine surgery, according to NSQIP data. By improving postoperativepulmonary care, we hypothesize that we can decrease the risk of PPC's after spine surgery.

Methods: Response: A new spine postoperative order set will be constructed to implement consensus treatment protocols tomaximize pulmonary care through improved orthotic production and use, early physical therapy, early respiratorytherapy, and DVT prophylaxis. Implementation will require cooperation between multiple departments involved inthe multidisciplinary care of postoperative spine patients. We will use NSQIP PPC data as our primary outcome, aswell as secondary measures such as time to first mobilization, time to receive orthotic, rate of DVT prophylaxis,and time to respiratory.

Results: Response: It is expected that the number of PPCs will decrease with improved pulmonary care, and that patientswill receive their orthotics faster, receive optimal pulmonary care through respiratory therapy, mobilize earlier, andreceive DVT prophylaxis at a higher rate than before implementation of a new spine postoperative order set. It isalso expected that training of residents and staff on these new procedures will result in improved communicationand care coordination.

Discussion:

Discussion: Response: We hypothesize that early mobilization and improved pulmonary care will decrease the rate of PPCs. Itis expected that certain aspects of these new protocols may elucidate new systemic barriers to optimal care ofpostoperative spine patients that we will address through fine-tuning of the order set or systemic policy changes todecrease postoperative complications, improve the patient experience, and decrease costs.

Submitted Tracking Number: 264 Abstract Title: Response: Early Quality Benefits to Participation in The American College of Surgeons' Optimal Surgical Care ofthe Child Pilot Project

Main Contact:First Name: Suzyn Last Name: Daniel Email Address: [email protected] Degrees: BSN, MBA, RN, CNOR Title: Pediatric NSQIP Administrative Nurse Main contact's role: Learner



DianaFarmer

MD, FACS,FRCS

Chair Department of Surgery, UC DavisChildren's Hospital Mentor

ShinjiroHirose MD Chief, Division of Pediatric General,

Thoracic and Fetal Surgery Mentor

GregMaynard MD Clinical Professor of Medicine, and Chief

Quality Officer Mentor

KarenSemkiw

BSN, MPA,RN Children's Program Manager Mentor

ChristinaSlee

BSJ, BA,MPH Director, Quality and Safety Mentor

Introduction: Response: UC Davis Children’s Hospital became a pilot site for the ACSs’ Level 1 Children’s Surgery Center.The program’s intent optimizes principles and resource standards for quality-improvement, safety processes, datacollection and process verification. Participation initiated substantial changes, resulting early quality benefits underthe direction of the newly formed Children’s Surgery Performance Improvement and Patient Safety (CSPIP) incollaboration with the Quality Departments prior to receiving our first risk- adjusted report.

Methods: Response: The CSPIP formed, meeting monthly reviewing surgical program performance and safety eventsintra-operatively, within 48 hours, to 30 days post-operatively guiding ACS program requirements. Pediatricphysician chairs redefined credentialing/privileges, formally engaging in peer review, event assessment, analysis,education/improvement recommendations. A program nurse manager was hired attending to data and projectmanagement. The hired Surgical Case Reviewer consulted with IT for data automation to improve abstractionefficiency. Hospital-wide quality projects in collaboration with the CSPIP provided real-time data furtherenhancing early benefits.

Results: Response: Early quality benefits initiated enhanced efficiency: data automation and decreased need for follow-upphone calls; safety: pediatric surgeon credentialing/privileging designation, adverse event analysis resultingequipment, medication & practice changes and increased daily & on-call pediatric specialized care; andperformance: “Case Status” added to OR HUDDLE, and formation of additional pediatric-transition unit increasingopen-bed efficiency in the ED.

Discussion: Response: Participation in the pilot ACS initiated a multifaceted approach guided by the multidisciplinary CSPIP.In monitoring our pediatric surgical program, early benefits initiated improvement in efficiency, patient safety andperformance.

Submitted Tracking Number: 273 Abstract Title: Response: Enhanced Recovery Protocols Reduce LOS in Elective Colorectal Surgery Patients: An ACS NSQIPProject

Main Contact:First Name: Kimberly Last Name: Brink Email Address: [email protected] Degrees: RN, BSN Title: Surgical Case Reviewer, NSQIP Main contact's role: Mentor



ChristineCocanour

MD, FACS,FCCM

Professor of Surgery, NSQIP SurgeonChampion Mentor

James Holcroft MD Professor of Surgery, Former NSQIPSurgeon Champion Mentor

Vijay Khatri MBChB, FACS,MBA Professor, NSQIP Director Mentor

Anne Marder RN, BSN Surgical Case Reviewer, NSQIP Mentor

Introduction: Response: The goal of the Enhanced Recovery Program is to improve patient outcomes, increase hospitalefficiency and value, and decrease provider variability in the care of the colorectal surgical population bydecreasing surgical stress, length of stay, and complication rates. This program is intended to accelerate recoverywhile still successfully meeting discharge criteria. Using NSQIP data, the average length of stay in 2013 for aroutine elective colectomy patient at UCDMC was 6.02 days, and for a routine elective proctectomy patient, 9.45days.

Methods: Response: The Enhanced Recovery Program is a multimodal, patient focused approach to rehabilitation in thepost-operative colorectal patient. This paradigm has focused elements in the patient's journey through surgery,including pre-operative, intra-operative, and post-operative care processes. Targeted interventions include patienteducation, pre-operative fluid intake and nutrition status, use od multi-modal approaches to pain control,maintaining intra- operative fluid balances, and early mobilization and nutrition post- operatively. Length of stayand post-operative occurrences are evaluated using NSQIP abstracted data.

Results: Response: The Enhanced Recovery Program was initiated in mid-2014 targeting elective colorectal patients thatmet NSQIP inclusion criteria. With the above protocols initiated, the average length of stay was reduced to 5.37days in colectomy patients, and 5.53 days for proctectomy patients. In addition, there was a reduction in morbidityevents in this population placing UCDMC in the top 10% of participating hospitals for urinary tract infections andsurgical site infections.

Discussion: Response: Although the case volume for these 3 years is small, the reduction in length of stay and overallmorbidity for this population of patients is notable. It is expected that this trend will continue and these bestpractices will be implemented in other surgical departments.

Submitted Tracking Number: 279 Abstract Title: Response: Evaluating cancellations of surgeries that occurred on the day of or one day before intended operationdate at the Children’s Surgery Center of UC Davis Medical Center

Main Contact:First Name: Joseph Last Name: Baek Email Address: [email protected] Degrees: M.D. Title: Anesthesiology Resident Physician (PGY-3) Main contact's role: Learner



Tzu-Ang Li Undergraduatestudent Undergraduate student Learner

NiroopRavula M.D. Assistant Clinical Professor of

Pediatric Anesthesiology Mentor

Introduction: Response: The cancellation of scheduled surgeries pose numerous problems including potential harm to patients,patient dissatisfaction, and a waste of scarce resources. These problems are especially magnified when thesurgeries are cancelled on the day of or one day before the surgery. We have looked at reasons for cancellationsand preventable causes at the Children’s Surgery Center (CSC) at UC Davis Medical Center (UCDMC).

Methods: Response: We looked all the surgery cancellations that occurred in a ten-month period from 1/1/2015 to10/30/2015 at CSC. The data was collected by the UCDMC Perioperative Performance, Safety, & QualityImprovement Team. We then singled out cancellations that occurred on the day of or one day before the plannedoperation date. From those, we focused our study on the canceled cases that could have been prevented. We dividedthe data into four categories by reasons: 1) surgical, 2) medical, 3) anesthesia-related, 4) patient-related. From thesurgery category, we deemed the cancellation preventable if the reasons were either “surgery previouslyperformed” or “patient reevaluated, surgery not needed.” From the medical category, the cases were preventable ifthe provider wanted “more evaluation needed” before surgery. From the patient- related category, cancellationswere selected as preventable for the following reasons: not-NPO, insurance reasons, no longer wants surgery,unable to reschedule, or other miscellaneous reasons. There was no preventable cancelled cases from theanesthesia category.

Results: Response: In the 10-month period from 1/1/2015 to 10/30/1015 at the CSC, there was a total of 3073 casesscheduled and 305 cancelled cases. 123 of those cancellations were on the same day or one day before the plannedoperation date. We will call these cancellations “near-day cancellations.” Out of 123, 55 of them were deemedpreventable. 56.4% (31 cases) of the near-day preventable cancellations were due to surgical reasons; two mainreasons being “surgery previously performed” and “surgery not needed.” Patient-related reasons were the secondmost common near-day preventable cancellations (38.2%). There was a variety of patient-related reasons, but thetwo most common ones are insurance and “patient no longer wants surgery” categories.

Discussion:

Discussion: Response: Nearly 20% of all the cancelled cases were deemed preventable. Many were cancelled because thesurgery was either not needed or already performed, and of insurance and consent issues. Per UCDMCperioperative services, the contribution margin of each cancelled cases was roughly about $6000; that is roughly$360,000 in preventable loss of revenue for the hospital. Many could have been prevented if patients were sent tothe preoperative assessment clinic to be medically optimized. These added steps will improve patient satisfactionscore, reduce unnecessary cost to the hospital, and decrease burden to patients’ families.

Submitted Tracking Number: 277 Abstract Title: Response: Evaluation of appropriate venous thromboembolism (VTE) prophylaxis in hospitalized pregnantwomen undergoing cesarean section.

Main Contact:First Name: Natalie Last Name: Wessel Email Address: [email protected] Degrees: DO, MPH Title: Resident Physician, PGY3 Main contact's role: Learner



Vincent Cagonot PharmD candidate Learner

RonnieDelmonte PharmD candidate Learner

Laurie Finta MD, FACOG Medical Director of Maternity Services Mentor

Tiffany Pon PharmD,BCPS

Assistant Professor of ClinicalPharmacy Mentor

Denise Roach PharmD Clinical Services Supervisor Mentor

Introduction: Response: Venous thromboembolism (VTE) is a leading cause of maternal mortality. Studies have shownpregnant women have a 4-5 fold increase in VTE risk compared to women who are not pregnant and hospitalizedpregnant women undergoing c-section are at an even higher risk. Consensus regarding appropriate chemical VTEprophylaxis during pregnancy is lacking. Three organizations currently provide different recommendations: theAmerican Congress of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians andGynaecologists (RCOG), and the American College of Chest Physicians (ACCP). In 2013, ACOG District IIpiloted the Safe Motherhood Initiative (SMI) to reduce maternal mortality. The SMI combines elements from theseguidelines to create new recommendations for prophylaxis, where patients undergoing c-section who haveadditional risk factors for VTE qualify for chemical prophylaxis. University of California, Davis Medical Center(UCDMC) currently has no VTE prophylaxis protocol for the OB population. The purpose of this study is toevaluate chemical VTE prophylaxis practice for women undergoing c-section at UCDMC and compare it to theSMI recommendations, with the hypothesis that current practice at UCDMC is insufficient.

Methods: Response: This was a single-center retrospective chart review of pregnant women undergoing c- section from05/01/13-09/01/15. The study included pregnant women aged 18 and older undergoing c-section who met criteriafor chemical VTE prophylaxis according to the SMI. Exclusion criteria included treatment with anticoagulationprior to admission. Primary endpoints were rate of mechanical or chemical prophylaxis order placement andchemical VTE prophylaxis administration. Secondary endpoints were incidence of VTE within 6 weeks afterc-section and VTE-associated mortality.

Results:

Results: Response: A total of 626 charts were reviewed. The rate of mechanical prophylaxis was 94.5% (580/614).Chemical prophylaxis was ordered in 4.6% (28/614) of patients and in those patients 98.1% (262/267) of dosesordered were administered. The incidence of 6-week post-partum VTE was 0.81% (5/614). There were zero casesof VTE-associated mortality.

Discussion: Response: Recommendations for chemical VTE prophylaxis in pregnant women are based only on observationalevidence and therefore remain controversial due to lacking consensus. However, the results of this study suggestfailure to utilize any guideline or protocol for chemical prophylaxis in the OB population at UCDMC may beproblematic. Only 4.6% of patients who met criteria for chemical prophylaxis according to the SMI actuallyreceived it. And, despite high compliance to mechanical prophylaxis (94.5%), 0.81% patients did develop VTEwithin 6 weeks of c-section; this is 2-4-fold higher than nationally reported rates of 0.2-0.4%. It is unclear howmany women would need to receive chemical prophylaxis to prevent one VTE associated maternal death.Nonetheless, VTE remains a major cause of maternal mortality on a population level, and women at increased riskneed to be identified. At UCDMC, one strategy to improve rates of chemical prophylaxis would be to include theOB population into the existing EMR-based VTE risk-assessment tool.

Submitted Tracking Number: 325 Abstract Title: Response: Exploring Staff Perceptions of A Newly Implemented Endotracheal Tube Assist Device in the MICU

Main Contact:First Name: Andrea Last Name: Rosato Email Address: [email protected] Degrees: RN Title: MS Student Main contact's role: Learner



Beverly Schacherbauer RN MS Student Learner

Carel Troutman RN MS Student Learner

Introduction: Response: An increased number of lip/facial pressure ulcers were observed in intubated patients in the MedicalIntensive Care Unit (MICU), which were attributed to standard tape securing protocols. This prompted review ofevidence based practice of ETT stabilization, changes in policy and the trial of the Anchor Fast Endotracheal TubeAssist Device (ETAD) beginning November 17, 2015. Prior to the trial, the Airway Management Protocol wasrevised to allow for either taping or ETAD based on nursing discretion. Data were collected at 45 days postimplementation by the MICU leadership and evidenced potential issues with the ETAD. This included devicefailures, minor skin breakdown, inconsistent practice and documentation patterns, and confusion about deviceindications within the interdisciplinary team. The project aims is to understand the staff’s perceptions of the ETADafter the initial trial period via Survey Monkey. Information obtained from this project will help guide and informfuture staff education and potentially clarify protocols specific to the utilization of the device.

Methods: Response: Based on the results of the 45-day post implementation data, a survey was created to explore thepotential barriers to implementation in the MICU. The survey consisted of eighteen questions that focused on fourspecific domains: benefits of the ETAD, decision making on ETAD appropriateness, training and knowledgesurrounding the ETAD, and confidence in utilization of the ETAD using a combination of Likert and open-endedanswers. Demographic information on the survey participants will be collected including gender, years of ICUexperience, and shift worked. The survey was reviewed by the MICU Nurse Manager and three subject matterexperts for content validity. The survey will be sent to all MICU nursing staff via work email. The data will becollected, analyzed, and presented to the Nurse Manager with recommendations for the next area of focus.

Results: Response: Prior to ETAD implementation, two full thickness lip/facial ulcers were associated with standard ETTtaping protocols. At 45-day post implementation of ETAD, full thickness ulcers were not present, although therewas a stage 1 ulcer and 3 skin tears reported. Preliminary survey data shows 43% of nurses disagree that the deviceprevents pressure sores.

Discussion:

Discussion: Response: Nurse perception’s of the ETAD’s effectiveness are inconsistent with pressure ulcer data indicating aneed for further staff education in the next PDSA cycle. The unit could consider providing rates of pressure ulcerfindings to align nursing perceptions to the outcome data. Additional findings will be used to determine how bestthe MICU Leadership team can promote the safe and effective use of the ETAD, address staff concerns anduncertainty, and provide supplemental education.

Submitted Tracking Number: 260 Abstract Title: Response: Implementation of integrated hematopathological services: to improve patient care and reduce cost.

Main Contact:First Name: Ananya Last Name: Datta Mitra Email Address: [email protected] Degrees: MD Title: PGY-1 Main contact's role: Learner



Saba Ali MD PGY-3 Learner

Dennis Dwyre MD Faculty Mentor

Jeffery Gregg MD Faculty Mentor

Hooman Rashidi MD Faculty Mentor

Adam Stelling MD PGY-4 Learner

Introduction: Response: Clinical Problem : Effective management of patients with hematologic malignancies depends uponprompt and precise diagnosis. Arriving at a differential diagnosis can often be challenging due to overlappingclinical manifestations in several malignant and non-malignant conditions. Planning appropriate treatmentaccording to disease stage and patient prognosis requires the integration of a spectrum of diagnostic tests includingclinical analysis, peripheral smear evaluation and trephine bone marrow (BM) biopsies which undergo multi-stagetesting for determining histologic subtype, molecular and immnophenotypical profiles, degree of maturation orpoint of maturation arrest. The cumulative interpretation of these results is the fundamental basis for providingethically reliable diagnoses and high quality patient care. Diagnostic delay as well as the potential for repeatedbone marrow biopsies due to specimen inadequacy or poor quality can be tormenting and take a tremendous toll onthe quality of life for both patients and their families. As clinicians, we responsibly guide and support the patientsand their families throughout the diagnostic period, anxiously waiting for the final diagnosis which will ultimatelydrive therapy. Although pathology results are not the only important aspect of a diagnostic workup, for patients itoften does answer one of the most important questions of all: “Do I have cancer?” Irrespective of the answer, theanguish of the wait is no less arduous. And sadly, if the answer is “yes,” then this is just the start of an extensivelong journey involving treatment options and prognostic measures. We are in the process of implementing somechanges in the BM biopsies which not only has markedly decreased turn-around time (TAT) but also has allowedmolecular studies in the clot section.

Methods: Response: Project Description: We propose developing and implementing diagnostic interventions in terms ofimprovement in the quality of BM sampling within the next 6- 8 months, with constant follow-up, monitoring andamendment in the sampling techniques, and technician work flow for a total duration of 18 months. It is a newaspect of an existing project involving the coordinated effort of Hematopathology division in the Department ofPathology and Laboratory Medicine and the Hematology-Oncology division of the department of InternalMedicine.

Results:

Results: Response: Metrics: Patient data including hematological diagnosis, demographics, clinical parameters, andmanagement, will be collected through utilization of the EPIC/LIS. Clinical outcomes will include time todiagnosis, time to initiation of anticancer therapy, total hospitalization, length of stay in Hematology-Oncologyservice, number of repeat biopsies and estimated cost savings. Time to diagnosis will be defined as the time ofcollection of BM sample to the date of the first BM biopsy result.

Discussion: Response: We will compare patients with hematological malignancy who received BM results with and withoutthe rapid decalcification technique every 6 month interval starting from July 1st 2013 till June 30th 2016.

Submitted Tracking Number: 310 Abstract Title: Response: Implementing AUA Guidelines for Office Cystoscopy

Main Contact:First Name: Robert Last Name: Lurvey Email Address: [email protected] Degrees: M.D. Title: Resident Main contact's role: Learner



Roger Low M.D. Professor Mentor

Introduction: Response: Antibiotic overuse presents a risk of adverse event on both the individual and community level.Previously, it was standard policy in our department to provide all patients undergoing cystourethroscopy withperi-procedural antibiotics. This practice did not appear consistent with the American Urological Association(AUA) guidelines on antibiotic prophylaxis. Our goal was to review the antibiotic guidelines with the departmentand to quantitate the decrease in antibiotic use.

Methods: Response: The AUA guidelines were reviewed with clinic staff, all residents, and pertinent faculty through e-mailand discussion at our weekly case conference in June of 2015. Signs listing the AUA guidelines were also postedin the two cystoscopy suites. In addition, as part of a separate change in billing practices, physicians were asked toplace an order in EMR if antibiotics were given. Residents were also asked to separately document in theirprocedure notes if antibiotics were provided and a reason why. Previously, antibiotics were given as part ofstandard operating procedure without an EMR order. Between June 10, 2015 and October 7, 2015, nursing staffkept a log of cystoscopies performed in a single cystoscopy sweet and whether the patient received antibiotics.Separate chart review was performed by a single resident of all cases logged where antibiotics were provided toidentify if they were provided within guidelines.

Results: Response: A total of 200 cystoscopies were logged. 77 patients (39%) received peri-procedural antibiotics. Onchart review, the majority of patients received antibiotics due to advanced age or manipulation. One patientreceived antibiotics due to patient request. Six patients had no identifiable reason for receiving antibiotics and threereceived antibiotics in the log despite EMR documentation to the contrary. Overall, it appears 5% of patientsreceived antibiotics contrary to guidelines.

Discussion: Response: By implementing and reinforcing the AUA guidelines for antibiotic prophylaxis, we decreased ourantibiotic use by over 60%. Over-antibiotic use was seen in only 5% of our patients. Prior studies by Herr et alfound less than 4% rate of symptomatic bacteriuria after cystoscopy without antibiotics. Further studies will needto better define the exception guidelines as laid out by the AUA.

Submitted Tracking Number: 321 Abstract Title: Response: Improving Breast Cancer Screening Rates in the Primary Care Clinics

Main Contact:First Name: vaihere Last Name: sagues Email Address: [email protected] Degrees: Title: Operations Analyst Main contact's role: Learner



HEALTH MANAGEMENT ANDEDUCATION CARECOORDINATION

N/A Learner

PCN/HBC LEADERSHIP TEAMS

CLINIC MEDICALDIRECTORS;ASSISTANTDIRECTORS

Mentor

DEPARTMENT OFRADIOLOGY N/A Learner

PCN/HBC PRIMAR CARECLINICS PRACTICEMANAGERS; PHYSICIANS,AND

CLINICAL SUPPORTSTAFF Learner

IT REPORT AND REGISTRYTEAMS ANALYSTS Learner

Introduction: Response: The aim was to integrate a team-based care model to improve clinical quality measures across allprimary care clinics. We started with a focus on the breast cancer screening measure, using evidence-basedguidelines and national benchmarks.

Methods: Response: We redesigned MA/LVN workflow to engage patients at point-of-care. Our first priority was building astrong collaborative effort with the Department of Radiology. Having access to schedule into radiology templatesallowed our care teams to increase the scheduling rate at check-out and overall patient satisfaction. We developedtraining resources for Clinical Support Staff to learn how to review a patient’s chart (HM, Surgical History, Media,and Imaging), pend a mammography screening order, schedule from the order at point-of-care, and documentusing overrides if mammography screening was done at an external facility. To help MA/LVNs identify eligiblepatients, we developed weekly reports that look ahead of the schedule and look back for missed opportunities,including whether the order was placed, if a modifier/override was added, or an appointment was made. Anothermethod was leveraging technology to help us with patient outreach, such as MyChart messages and using anautomated call system, called "EmmiPrevents." To keep this effort at the forefront, data is shared at monthlymeetings for the entire care team. Incentives were also utilized to build up friendly competition between clinics.We rewarded clinics the “Most Improved” and “Highest Performer” on a quarterly basis with pizza luncheons or acatered breakfast. The CDC provides patient-friendly flyers that were ordered to raise awareness in all of theclinics. To continue our momentum and further engrain workflows, we developed a refresher training presentationat the 1-year anniversary in November 2015. We presented it to the ‘Back-Office Lead’ meeting and they used the

at the 1-year anniversary in November 2015. We presented it to the ‘Back-Office Lead’ meeting and they used thePowerPoint presentation as a template at their designated Clinic site.

Results: Response: As a result of continuous focus since November 2014, the combined PCN and HBC Primary Carecollaborative has improved from 61.4% (November 2014) to 66.1% (December 2015) in the mammographyscreening rate measure.

Discussion: Response: As the healthcare industry moves toward value-based care, the care team model is an integral part ofour long-term success with clinical quality measures and clinical quality improvement projects. This projectengaged all staff levels in the QI process and reinforced a common purpose. Next steps include the utilization ofthis team-based model and a similar implementation approach for new clinical quality measures.

Submitted Tracking Number: 304 Abstract Title: Response: Improving Patient and Visitor Hand Hygiene: A Missed Opportunity for Infection Prevention

Main Contact:First Name: Andrew Last Name: Liman Email Address: [email protected] Degrees: BA Title: Medical Student II Main contact's role: Learner



Ulfat Shaikh MD Director for Healthcare Quality Mentor

JeanWiedeman MD Pediatrics Infectious Diseases Attending

Physician Mentor

Introduction: Response: Healthcare systems regularly enforce employee hand hygiene as a key component of infectionprevention. However, there is less information on the importance of patient/visitor hand hygiene and whether ornot they are compliant with current policies. The purpose of this pilot study was to measure patient and visitorknowledge, perceptions, and self-reported behaviours around hand hygiene, and implement an intervention toimprove these measures.

Methods: Response: A pilot study was conducted on the Pediatric ward of the University of California, Davis MedicalCenter. English-speaking families of patients over the age of 3 were asked to complete a survey. One adult fromeach family was given a pre-survey. Patients over the age of 7 were also given a pre-survey, although they werenot asked to self-report behaviour. The next day, participants were given a post-survey to assess for change. Toassess for response bias, the first two weeks of the study consisted only of surveys with no intervention (baselinegroup). Subsequently, the intervention was added between the pre/post surveys where patients and their familieswere invited to the playroom for an interactive and educational hand hygiene activity (intervention group).Within-group changes were compared between groups.

Results: Response: 235 surveys were completed representing 130 unique families, but only 39 families remained longenough to participate in both pre/post surveys, with 8 of these families also participating in the activity. 10 patientsparticipated long enough to complete both surveys, with 5 of them also participating in the activity. Whencomparing the family intervention group (N=8) to the family baseline group (N=31): knowledge of minimum handwashing time increased from 25% to 75% (baseline group decreased from 32% to 26%); reported hand washingincreased from an average of 3.5 points to an average of 4.0 points, out of 4 possible points with 1 point awardedfor each situation in which hand washing was reported (baseline group increased from 3.6 to 3.8); perception thatinfectious agents are found on the hands increased from an average of 8.9 points to an average of 9.8 points, on a10-point scale (baseline group increased from 8.9 to 9.0); perception that infections acquired at a hospital can leadto serious illness increased from an average of 9.4 points to an average of 10.0 points, on a 10-point scale (baselinegroup decreased from 9.6 to 9.5). When comparing the patient intervention group (N=5) to the patient baselinegroup (N=10): perception that infectious agents are found on the hands increased from an average of 7.4 points toan average of 8.8 points, on a 10-point scale (baseline group decreased from 7.8 to 7.3).

Discussion:

Discussion: Response: This pilot project supports scaling up the study to collect a larger sample. The work facilitates morediscussion on patient and visitor hand hygiene, a novel approach to infection control.

Submitted Tracking Number: 251 Abstract Title: Response: Improving the Documentation of Complications to Support Accurate Reporting of AHRQ PatientSafety Indicators

Main Contact:First Name: Tessie Last Name: Kaithathara Email Address: [email protected] Degrees: RN, MSN Title: Quality and Safety Administrative Nurse Main contact's role: Mentor



JenniferErickson

RN, MSN,MBA

Quality and Safety AdministrativeNurse Mentor

Bobbi Henk RN, MSN,CPHQ

Quality and Safety AdministrativeNurse Mentor

CaleneRoseman RN, MSN Quality and Safety Administrative

Nurse Mentor

Johanna Sanders RN, BSN Quality and Safety AdministrativeNurse Mentor

Greg Woolf RN, MS Quality and Safety AdministrativeNurse Mentor

Introduction: Response: Introduction: The Patient Safety Indicators (PSIs) were developed by the Agency for HealthcareResearch and Quality (AHRQ) to provide information on potential in-hospital complications and adverse eventsfollowing surgeries, procedures, and childbirth. Each PSI has its own set of technical specifications and ismonitored displayed by The University HealthSystem Consortium (UHC) in a risk adjusted format with a peercomparison ranking. The pre-intervention (2011) UCDMC PSI overall composite rate per 1000 exceeded the UHCcomparison group with a rate of 5.03 vs 4.61 for the UHC comparison group. The pediatric patient safety indicators(PDI) also significantly exceeded the UHC comparison group with a composite rate of 9.87 vs the UHCcomparison group rate of 6.54.

Methods: Response: Methods: The approach implemented included three main modes of intervention: 1) Automated triggerreports were developed to search the Electronic Medical Record for PSI related documentation. These reports werereviewed, and if determined a possible valid PSI existed, the documenting provider was contacted to verify the PSIand review related documentation strategies. 2) After coding, but prior to Health Information Management (HIM)billing a case with a potential PSI, the case was emailed to the Q&S nurses for review and validation. If a potentialvalid PSI was determined the documenting provider was contacted to verify the PSI and discuss appropriatedocumentation. 3) Medical staff departments and nursing leaders were educated, via group presentations, regardingappropriate PSI related documentation. PSIs were also reviewed with nursing unit staff in weekly quality unitrounds. Due to the complexity of most of the PSIs, this education was specific to each identified PSI. In addition,process improvement and root cause analyses were utilized with select medical staff departments.

Results:

Results: Response: Results: For select adult patient safety indicators there was a significant overall improvement of 63%.However, due to a decrease in case volume, PSI 17, 18 and 19 decreased in performance despite the number ofreportable cases being reduced or remaining unchanged. For select pediatric patient safety indicators there was alsoa significant overall improvement of 35%. Children’s hospital physician and nursing leadership were very engagedin the PDI review process and are largely responsible for the significant improvement.

Discussion: Response: Discussion: Implementing a multi-modal improvement process was effective in reducing the number ofreported PSI/PDI cases and improving the accuracy of documentation related to procedure and patient care relatedcomplications. Improvement in these select PSIs was a significant contributing factor in UCDMC UHC Scorecardmoving from 2 stars in 2012 to 4 stars in 2014. This movement was related to the scorecard safety domainindicator, which showed a 52.8% improvement. This improvement in the PSIs raised the safety domain rankingfrom 93 in 2012 to 9 in 2014.

Submitted Tracking Number: 323 Abstract Title: Response: Improving Timely Inpatient Lab Results and Minimizing Order Cancellations on an AcademicMedical/Surgical Ward

Main Contact:First Name: Kanal Last Name: Singh Email Address: [email protected] Degrees: M.D. Title: Chief Resident of Quality and Patient Safety Main contact's role: Mentor



Introduction: Response: Timely and clear communication of lab is a necessity to facilitate effective patient care in an inpatientsetting. Even a small, teaching facility such as the VA Hospital in Mather, CA is 45 Medical/Surgical beds, ~80%of which are occupied/day) is no exception to this. A problem was identified several years earlier: morning labsresults were late, resulting in delays in patient care and hospital discharges. Labs at this institution are collected byphlebotomists (preferred methods) at two specified times/day, or otherwise by a nurse (if workload allows). TheMedicine service and laboratory collaborated to develop a new quality standard targeting all routine morning labs(e.g. BMP) result by 8 AM. This strategy, did improve the efficiency of lab staff in processing and resultingmorning labs. However, to ,maintain this cutoff time an unofficial policy was adopted by staff that if a test couldnot be obtained or resulted in time, it would be cancelled (without notification of primary team or nursing staff)with the implication that the provider could reorder if needed. This resulted in frustration among the inpatientmedical service, and potentially delayed patient care/flow. Due to this, we developed a subsequent QI projectattempting to minimize lab test cancellations (goal of at least 25% reduction) and improve communication betweenlab and medical staff.

Methods: Response: Using the VA QI model (VA-TAMMCS) we observed and analyzed the process of inpatient labcollection by the phlebotomy service. We noticed multiple reasons for lab cancellations, such as patient refusal,hard sticks, and last minute lab orders (“add-ons”) that significantly increased the workload of the phlebotomists.We implemented use of a “missed lab” card which the phlebotomist would deliver to the patient’s nurse,communicating inability to collect a sample and the reason behind it. We hypothesized if notified an RN couldobtain the necessary blood sample before 8AM, avoiding any cancellations.

Results: Response: Two months of data collection (November –December 2015) showed the majority of lab cancellationswere due to “add-ons” (109, and 112 respectively), which is mainly due to provider error (e.g. lab orders not placedthe evening prior by the residents/interns). Additionally, “missed lab” cards now identified the reasoning behindthe inability to obtain the labs in the first place. However, despite some nurses attempting to obtain samples whenphlebotomy could not, the project did not result in any decrease in the overall number of cancelled labs.

Discussion:

Discussion: Response: Interestingly, we see that the attempts at quality improvement (such as time cutoffs for labs) can havepotential downsides—particularly when a a metric is targeted (e.g. 8AM lab result time) at the expense of clinicalcare. Additionally, while out QI project did not result in its desired effect, it did allow us to understand thereasoning behind lab cancellations in more detail. Future direction of this project will include resident educationabout "add-on" labs, and we will consider re-evaluating the need for a morning cutoff time for lab results.

Submitted Tracking Number: 315 Abstract Title: Response: In & Out on Photopheresis: Does vascular access choice improve procedural efficiency and patientsafety?

Main Contact:First Name: Grace Last Name: Monis Email Address: [email protected] Degrees: MD, PhD Title: Transfusion Medicine Fellow Main contact's role: Learner



SarahBarnhard MD Assistant Clinical Professor, Pathology and

Laboratory Medicine Mentor

Introduction: Response: Per the American Society for Apheresis Guidelines (2013), extracorporeal photopheresis (ECP) is “atherapeutic procedure in which buffy coat...is treated extracorporeally with a photoactive compound and exposed toultraviolet A light and subsequently reinfused to the patient.” Our apheresis service uses the CELLEXPhotopheresis System manufactured by Therakos (Raritan NJ). From 2013 to 2015 our ECP procedures grew by43% (160 to 282 per year) while our clinic capacity remained the same. Therefore, we continue to seekopportunities to improve our workflow efficiency. In December 2015, two of our ECP patients had repeatinstrument alarms during their procedures necessitating treatment times nearing 3 hours. This reduced bed andnurse availability. We investigated the cause and established previously unpublished safe procedural run timeranges for the various vascular access types compatible with ECP. We also identified novel trends in procedure runtimes between vascular access devices, an important consideration when recommending vascular access for a newpatient.

Methods: Response: Per Therakos bulletin CLX #09, “post-reinfusion hemolysis…may occur as a result of excessive heat inthe centrifuge chamber. Factors include duration of treatment, length of system downtime between treatments, andambient room temperature.” Optimization of venous access to allow collection and return rates > 15 ml/min is theonly specification noted. We searched PubMed for published ECP adverse events and safe procedure run timereference ranges, but no literature was available. We performed a retrospective cohort analysis of 68 proceduresperformed across 19 patients in 2015. Thirty two (32) procedures were performed using double-lumen vortex ports(DL-VP), 13 double lumen tunneled apheresis catheters (DL- TAC), 10 single lumen vortex ports (SL-VP), and 13procedures with peripheral IV's (PIV). No adverse events were reported. Total run time was recorded. Procedureswere stratified by vascular access type. Reference ranges were established by the mean +/- 1 standard deviation.Means were compared using the two-sample student’s T- test.

Results: Response: The mean procedure run times were: DL-VP 104 +/- 10 mins, DL-TAC 102 +/- 12 mins, SL-VP 142+/- 10 mins, PIV 143 +/- 14 mins. A comparison of the means revealed no statistical significance between DL-VPand DL-TAC (p=0.6835) or SL-VP and PIV (p=0.7827). However, DL- VP and DL-TAC independently comparedwith SL-VP and PIV mean run times were statistically significant (p

Discussion:

Discussion: Response: We will use these data to recommend DL-VP or DL-TAC access on all eligible new patients referredfor ECP. In addition, our proposed reference ranges for each vascular access type will ensure that physicians areimmediately consulted when patients fall outside the procedure run times so we can help trouble shoot the issueand ensure ongoing patient safety. Our established reference ranges will be incorporated into departmental policiesand procedures in the near future.

Submitted Tracking Number: 257 Abstract Title: Response: Increasing Awareness and Advance Directive Completion Rates in the Primary Care Setting

Main Contact:First Name: Ashley Last Name: Clark Email Address: [email protected] Degrees: BS Title: Medical Student Main contact's role: Learner



Brian Swanson M.D Adult Medicine Physician Mentor

Introduction: Response: The PSDA of 1991 first brought attention to the importance of advance directives. Since theimplementation of the act little has been done to educate, encourage and implement this initiative highlighting theneed for efforts focused on improving interventions to increase completion rates. The purpose of this project is totest a model to increase AD completion rates, and thus providing more complete patient centered care. The aim is toimprove completion rates by 25% over the three-month implementation period.

Methods: Response: To improve completion rates in the primary care setting records will be reviewed of patients 65 andolder that have a physical or follow up scheduled during the 3-month implementation period. If the patient has anAD, it will be noted. If the patient does not, their chart will be flagged for education. Educational information and aletter explaining the intent will be sent out to patients a week prior to their scheduled appointment. A discussion,10-15 minutes in length, will take place between the patient and the practitioner. If the patient is prepared, he/shewill be assisted in completing the AD form. If the patient declines, a note will be made for follow-up. The “study”portion of the project is the calculation of the compliance rates before and after implementation of the project todetermine the effectiveness of the education provided.

Results: Response: Tentative data: Patients 65 and older received educational information at their appointment everyTuesday in the implementation period. Unfortunately, most appointments are scheduled only a few days prior, notproviding enough time to mail information. Additionally, the time burden on the provider limited the intervention.Fifteen patients opted to complete their form, which was a total increase of 25%. End-of life issues are not easytopic to discuss for multiple reasons, particularly due to the time constraint in a primary care setting. Patients werealso quick to say that their family members knew what they would want. A lot of education was focused on thesemisconceptions. Due to the scheduling pattern of the patient panel forms were not mailed in advance. If the patientwas appropriate the discussion was attempted if the patient was prepared, but this did not allow for multimodalintervention.

Discussion: Response: The goal of a 25% increase in AD completion rates was met and patients were satisfied with theeducation provided. Patients were willing to complete their ADs, but they needed time to discuss the informationwith family. Having a process in place for the primary care provider was an important step in maintaining thisimportant issue at the forefront of providers minds. Whether it is monthly or annually, their needs to be anintervention with the patient population that can benefit most. It is the provider’s responsibility to initiate thesediscussions and to update forms as needed. Utilizing the students to continue the AD discussions will benefit the

patients, the practice, as well as the student because it will help develop skills in discussing end-of-life issues.

Submitted Tracking Number: 258 Abstract Title: Response: Increasing Colorectal Cancer Screening Rates at CommuniCare, Davis

Main Contact:First Name: Anastasia Last Name: Warde Email Address: [email protected] Degrees: Medical Student (MS3) Title: Project Co-coordinator Main contact's role: Learner



Betsy Meux MD Attending Physician Mentor

Yolanda Mora Clinic Manager Mentor

Sonia Moreno Patient Services Representative Mentor

Introduction: Response: Colorectal cancer (CRC) is the second most common cause of cancer death in the U.S. (1). Globally, itis the third most common cancer among women and second most common among men, with an average lifetimerisk of 5%. Ninety-percent of colorectal cancers occur in patients older than 50 years (1). Because CRC tends todevelop slowly, and in a predictable manner, it is highly preventable through regular screening, which is able todetect asymptomatic, early stage disease (4). However, in the U.S., screening rates remain below national goals (1).Screening is recommended for everyone over age 50, but only 65.1 % of U.S. adults between 50-75 years werescreened in 2012 (1). The USPSTF's Grade A recommendation for CRC screening says that average risk,non-symptomatic patients should begin screening at age 50 and continue until age 75 (2). Accepted screeningmodalities include either fecal occult blood testing (FOBT), fecal immunochemical test (FIT), flexiblesigmoidoscopy, or colonoscopy (2). Our screening rate of eligible patients at CommuniCare, Davis was 30% at theinitiation of this project. Our goal was to increase the screening rate for CRC in eligible patients from the rate of30% at time of initiation of the project, to 58%. Our short-term goal was to determine the method of outreach thatmost increased compliance with CRC screening through FIT testing in men and women age 50-75 years old whoare patients at CommuniCare Davis, and have not had a colonoscopy in the past 10 years or fecal immunochemicaltest or fecal occult blood test in the past 1 year. We selected FIT testing because it is a relatively simple,non-invasive test for occult blood in stool yet highly effective.

Methods: Response: Our primary intervention was increasing directed outreach to patients eligible for and in need of CRCscreening. We identified three methods of outreach to patients in need of CRC screening: (1) 10 cold calls topatients who need FIT test according to our registry to encourage the patient to come in to complete the screening(2) Identify 10 patients during our “huddle” at beginning of the day who need FIT test and discuss/offer FIT testduring their appointment (3) Mail 10 FIT tests to patients identified as needing FIT testing for them to return bymail. We recorded the number of FIT tests completed/returned for each method as a way to predict the mosteffective mode of outreach to guide future efforts.

Results: Response: Thus far, the greatest response has been with speaking to patients when they are already coming in foran appointment. Our data collection is still underway and we are planning subsequent PDSA cycles with largercohorts after this first round is completed.

Discussion: Response: Data collection still underway. Will be completed in the next month.

Submitted Tracking Number: 247 Abstract Title: Response: Indwelling Urinary Catheter Removal in Relationship to Post-Operative Urinary Retention: Timing isEverything

Main Contact:First Name: Tina Last Name: DiPierro Email Address: [email protected] Degrees: RN, MSN, NE-BC Title: Nurse Manager Main contact's role: Mentor



Charlie Dharmasukrit RN, MS, CMSRN Clinical Nurse Learner

Introduction: Response: Aggressive measures to prevent CAUTI (catheter-associated urinary tract infections) encouraged theOrthopedic Surgeons to order very early removal of the indwelling catheters placed during surgery, often at 0600on post-operative day (POD) 1. It appeared to nursing staff on the orthopedic unit that this was leading to anincrease in the occurrence of postoperative urinary retention requiring one or more intermittent catheterizations andoften the necessity to discharge patients home with an indwelling catheter in place for follow-up with a Urologistpost discharge. Nurses worked with physicians to develop a protocol for removal of the indwelling catheter onpost-operative day 2 between 0000 and 0400. This protocol was implemented March 2012. The researchersobtained Institutional Review Board approval to perform a retrospective chart-review study to determine if thenumber of intermittent catheter and/or indwelling catheter reinsertions significantly decreased as a result of thenew protocol.

Methods: Response: The protocol called for nursing staff to remove the Foley catheter between 0000 and 0400 in themorning of POD 2 and was applied to patients on the orthopedic joint, spine, and trauma services. A total of n=243patient charts were retrospectively reviewed. This sample included n=105 total knee and hip replacement patientspre-implementation of protocol who were admitted November 2011 through February 2012, in addition to n=137total knee and hip replacement patients post-implementation of protocol who were admitted November 2012through February 2013.

Results: Response: Statistical Analysis was conducted using the statistical software environment R, version 3.2.0.Adjusting for age and surgery type, women who had their Foley catheter removed prior to POD 2 0000- 0400 hadodds of intermittent catheterization 3.9 times higher than women who had their Foley catheter removed during theprotocol-specified time window (p=0.022). Adjusting for time of Foley catheter removal, gender, and surgery type,older patients had significantly higher odds of intermittent catheterization, with an estimated 5% increase in oddsfor each additional year of age (p=0.032) and had significantly higher odds of indwelling catheter reinsertion, withan estimated 16% increase in odds for each additional year of age (p

Discussion:

Discussion: Response: The data did not show any significant difference between implementation of the protocol and theincidence of post-operative urinary retention as measured by the number of intermittent catheters and indwellingcatheter reinsertion. However, removal of the indwelling catheter within the time-frame as dictated by the protocoldid show a significant reduction in all catheter reinsertions within the female population. This study did not accountfor history of post-operative urinary retention, underlying medical conditions, and medications administered thatare known precursors to urinary retention (i.e. narcotics). Post-operative urinary retention may result in patientdiscomfort, increased length of stay, and increased incidence of all catheterizations. The usage of a protocol toremove indwelling catheters in the early hours of POD 2 has the potential to reduce the incidence of postoperativeurinary retention.

Submitted Tracking Number: 324 Abstract Title: Response: Meaningful Office Visit for Outpatient Oncology: Ensuring Patient- Centered Care

Main Contact:First Name: Joy Last Name: Morgan Email Address: [email protected] Degrees: R.N., O.C.N. Title: MS Student Main contact's role: Learner



Melissa Soderlund R.N., O.C.N. MS Student Learner

Introduction: Response: Introduction: A recent Institute of Medicine report outlined a conceptual framework with key domainsessential for a high-quality cancer care delivery system. Goals of the recommendations ensure coordinated,comprehensive patient-centered care and patient engagement through shared decision-making. Chemotherapyordering is a complex process that requires a structured error-avoidance plan. In an outpatient community cancercenter, oncology nurses voiced frustration with increasing volume of post-clinic visit care coordination due to labresults not being available at the time of the clinic visit. The nursing team was dissatisfied with the time spentreconciling lab results with chemotherapy orders and obtaining order revisions based on preset parameters.Additionally, patients were denied an opportunity to discuss the lab results and their plan of care during the officevisit, which increased the amount of nurse post-visit care coordination. The aim of this project is to improve thecurrent clinic visit process by utilizing a multidisciplinary team to ensure patient-centered care. Goal: Decrease thenumber of chemotherapy orders written prior to MD review of lab results to 25% by March 2016.

Methods: Response: Methods: A multidisciplinary team developed a detailed process map to identify challenges, causes, andpossible solutions to improve the process. A retrospective chemotherapy order and pharmacy order revision auditwas completed. Patients were surveyed as to preference of lab draw prior to- or same day of clinic visit and thenan audit was conducted along after implementing the process change.

Results: Response: Results: The process map revealed the complexity of the patient visit in relation to whether or not thelab result was available at the appointment and when chemotherapy orders were written. However, physiciansbelieved patients would prefer not to make an additional visit for a lab test. The chemotherapy order/lab auditrevealed that chemotherapy orders were written (n=45) 62% of the time without the lab result available for patientand physician review. Pharmacy audit: (n=68) 60% of order clarifications related to lab result timing. Patientsurvey: 95% (n=86) preferred to have labs test prior to appointment so the results could be discussed. Based onthese findings, a process change was implemented successfully for one physician; subsequently the change wasadopted for all physician visits.

Discussion:

Discussion: Response: Discussion: This project suggests patients want to participate in their care and treatment planning duringclinic visits, consistent with patient-centered care. By initiating pre-clinic visit lab testing, chemotherapy orderswritten before lab review decreased from 62% to 24%. Physician review of lab results prior to writingchemotherapy orders reduced the number of order clarifications and decreased the amount of post-clinic visit carecoordination. Future goals should consider the date and time of the lab compared to the date and time of the officevisit as well as patient satisfaction with inclusion in treatment decisions.

Submitted Tracking Number: 249 Abstract Title: Response: Medical necessity of routine admission of children to the Intensive Care Unit with mild traumatic braininjury

Main Contact:First Name: Jared Last Name: Ament Email Address: [email protected] Degrees: MD, MPH Title: Resident Main contact's role: Learner



Joseph Galante MD Trauma Surgery Faculty Mentor

Krista Keachie MD Resident Learner

Daniel Nishijima MD Emergency Medicine Faculty Mentor

Patrick Tertulien BS Student Learner

Marike Zwienenberg MD Neurosurgery Faculty Mentor

Introduction: Response: Approximately 475,000 children are treated for traumatic brain injury (TBI) in the USA each year; mostare classified as mild TBI (Glasgow Coma Scale [GCS] score 13-15). Patients with a “positive” head CT, definedas either intracranial hemorrhage or skull fracture, irrespective of severity, are often transferred to tertiary carecenters for Intensive Care Unit (ICU) monitoring. This practice creates significant burden on the healthcare system.The purpose of this investigation was to derive a clinical decision rule (CDR) that maximizes safety and resourceallocation.

Methods: Response: We retrospectively reviewed mild TBI patients ≤16 years old presenting to a Level 1 trauma centerfrom 2008-2013. Data were abstracted from institutional TBI and trauma registries. Independent covariatesincluded, age, GCS score, pupillary response, CT characteristics, and injury severity score. A composite outcomemeasure, ICU-level-care, was defined as cardiopulmonary instability, transfusion, length of stay >2 days,intubation, placement of intracranial pressure monitor or other invasive monitoring, and/or need for surgicalintervention. Stepwise logistic regression defined significant predictors for model inclusion with p

Results: Response: A total of 290 patients with mild TBI were included in the analysis; 63 (21.7%) had ICU-level-care.The CDR consisted of 5 final predictor variables: admission GCS2, non-isolated head injury, and midline shift>5mm on CT. The decision rule identified 53 of 63 patients requiring ICU-level care (sensitivity 84.1%; 95% CI75.1%-93.2%) and 102 of 227 patients who did not require ICU-level care (specificity 44.9%; 95% CI38.5%-51.4%).

Discussion: Response: We derived a clinical tool that defines a subset of pediatric patients with mild TBI at low risk forICU-level-care. Although prospective evaluation is needed, the potential for improved resource allocation issignificant. An additional goal is to conduct a cost-utility analysis comparing the clinical decision rule with currentpractices.

Submitted Tracking Number: 300 Abstract Title: Response: Minimizing Wrong Site, Wrong Patient, Wrong Procedure Incidences By Improving Pre- ProcedureDocumentation Compliance

Main Contact:First Name: Benjamin Last Name: Keller Email Address: [email protected] Degrees: MD Title: Surgical Research Fellow Main contact's role: Mentor



James Becker MD Surgical Research Fellow Learner

Diana Farmer MD Professor & Chair; Pediatric Surgery Mentor

Laura Goodman MD Surgical Research Fellow Learner

Kathe McDonald GME Representative Mentor

Lori Teach GME Representative Mentor

Introduction: Response: Wrong site, wrong patient, and wrong procedure events are infrequent but persistent in surgical care,and can be devastating for the patient and provider. While a significant amount of effort has been placed intopreventing these events from occurring in the operating room, the same level of attention has not been placed onpreventing wrong site, wrong patient and wrong procedure events in the clinic and during bedside procedures. Withthe changing landscape in health care and a new focus placed on these "never events" by the National QualityForum and the Joint Commission, it is imperative to implement new strategies to prevent these events. The purposeof this project is to improve pre-procedure documentation compliance and decrease the occurrence of these“never-events” at UCDMC by improving bedside and clinic workflow.

Methods: Response: This project is being implemented in two phases. The first phase ensured that the data reports generatedby Health Information Management (HIM) for pre-procedure documentation compliance were accurate andmeaningful, and that the electronic medical record (EMR) navigator for pre-procedure documentation was intuitiveand easy to use for clinicians. To do this, resident representatives from each clinical department were queried for alist of their most common bedside and clinic procedures. These lists were then used to build accuratepre-procedure documentation compliance reports. To improve the EMR procedure navigator, changes were draftedand executed with the help of HIM. The second and current phase of the project is focused on documentationcompliance education. This phase consists of department-specific education at grand rounds and point of carereminders in the clinical environment.

Results: Response: After developing department-specific lists for common bedside and clinic procedures, thepre-procedure documentation compliance summary was run by HIM. This initial report showed that correctperformance and documentation of a pre-procedure time-out, was 36% for bedside procedures and 15% forclinic-based procedures. Some specialties and clinics did not document any pre-procedure time-outs. With poorcompliance confirmed, specialty-specific presentations have been created to educate clinicians about thecompliance issues with pre-procedure documentation, and to educate providers about using the EMR navigator. Inaddition, point-of-care reminders, including education sheets to be placed on equipment carts and in UCDMC

custom procedure packs, have been created. Currently this education phase is underway and pre-proceduredocumentation compliance reports will be tracked to measure improvement.

Discussion: Response: While pre-procedure documentation compliance cannot be directly tied to a reduction in wrong site,wrong patient, wrong procedure incidences given their rarity, each reminder to the patient care team may preventan event from occurring. Our initial work on this project demonstrates that pre-procedure documentationcompliance for bedside and clinic procedures at UCDMC is poor. With the multiple approaches included in phasetwo of this project, we hope to improve compliance to over 80% in the next academic year.

Submitted Tracking Number: 313 Abstract Title: Response: Out of Rhythm – Is Telemetry Always the Answer?

Main Contact:First Name: Karnjit Last Name: Johl Email Address: [email protected] Degrees: M.D. Title: Associate Internal Medicine Program Director Main contact's role: Mentor



Chhavi Bajaj M.D. Internal Medicine Resident PGY 3 Learner

Hershan Johl M.D. Associate Clinical Professor Mentor

Maha Sami M.D. Internal Medicine Resident PGY 2 Learner

Jacqueline Stocking R.N., M.B.A. Quality and Safety Mentor

Tianyi Wang M.D. Internal Medicine Resident PGY 3 Learner

Introduction: Response: Cardiac monitoring is often used for patients admitted to the hospital. The American Board of InternalMedicine Foundation, through its Choosing Wisely Campaign, and the Society for Hospital Medicine, through itsChoosing Wisely Recommendations, have identified the need for appropriate telemetry use including for those whohave dangerous arrhythmias or who are at risk of sudden cardiac death. Excess telemetry usage without indicationscan increase healthcare costs and can result in inappropriate distribution of limited resource. For example, giventhe limited availability of telemetry beds, patients who need telemetry often will have to wait in the emergencyroom for a prolonged period of time delaying their care and admission to the hospital for appropriate managementand treatment.

Methods: Response: We will use a descriptive cross-sectional study design to compare the prevalence of inappropriatetelemetry admission orders before and after a Choosing Wisely quality improvement intervention.. Patientsadmitted to telemetry will be identified by an automated electronic health record report. Each medical record willbe analyzed by two physicians and the rationale for the telemetry order categorized into three classes: AHA I(definite indication), AHA II (potential indication) and AHA III (not indicated) and comparing the prevalence ofeach category between groups. In cases of disagreement between the two physicians, a third independent physicianwill review the data to arrive to a consensus. The intervention will include education and the addition of a dropdown menu embedded into the internal medicine admission order set which will require selection of an AHA classthat justifies the need for telemetry.

Results: Response: Preliminary pre-intervention data revealed that a significant proportion of patients on cardiac telemetrywere categorized as AHA class III indication. Through this intervention, we aim to reduce inappropriate (AHAclass III) telemetry orders by 50%. The post-intervention data collection and analysis is currently in process andresults will be presented at the symposium.

Discussion:

Discussion: Response: Patients admitted to cardiac telemetry without a clear AHA indication (class III) experience an increasedEmergency Department length of stay and contribute to decreased availability of inpatient beds, both of whichnegatively impact throughput. It is important to not only ensure patients receive the appropriate level of care, butalso to practice cost conscious care and appropriate allocation of resources. We hypothesize that placing simplerestrictions on the use of telemetry can have a positive impact on healthcare and improve patient safety and care inthe hospital without compromising other aspects of patient care and provider satisfaction.

Submitted Tracking Number: 286 Abstract Title: Response: Patient Centered Recovery Program: A Step Beyond the Street Sheet

Main Contact:First Name: Aimee Last Name: Moulin Email Address: [email protected] Degrees: MD Title: Assistant Professor Main contact's role: Mentor



Debra Kahn MD Associate Professor Mentor

Introduction: Response: Nationally ED visits for substance abuse are increasing.1, In 2011 about 2.5 million ED visits resultedfrom medical emergencies involving drug misuse or abuse.1, The UCD Emergency Department is no different.Last year approximately1,700 patients were seen for primary substance use disorders. Many other ED patientshave a co-occurring substance use disorder that complicates their medical and psychiatric treatment. . Very few ofthese patients receive treatment for, their substance use. disorder in the ED. Our aim with the Patient-CenteredRecovery program (which is adapted from a UC San Diego, and funded by the University Office of the President).is to encourage healthcare providers to screen for substance use disorders, refer to our in-house substance abusecounselor for a brief intervention, and provide linkages to community substance abuse treatment programs. It is ourhope that this program will increase the likelihood of patients entering specialized treatment for substance abuse,and decrease the medical, psychiatric, and social complications of substance use disorders.

Methods: Response: Our primary target population is patients with co-occurring mental health and substance abusedisorders, however all patients with primary substance abuse disorders presenting to the UCD Emergency Roomare eligible. Psychiatry Faculty and Residents, Emergency Medicine Faculty and Residents, and ED SocialWorkers identify patients with a substance abuse disorder who will likely be discharged from the UC Davis ED.Our program runs M-F 8a to 5p. Patients are evaluated by the UCD Certified Alcohol and Drug Councilor usingthe SBRIT model, (Screening Brief Intervention and Referral to Treatment). For patients with an interest intreatment every effort is made to connect the patient with local treatment programs, and in some cases thesepatients can be transferred directly from the ED to residential substance abuse treatment.

Results: Response: Since the beginning of the program we have identified 135 patient with substance use disorders. Manyof our patients had multiple prior ED visits, 19 had 5 or more ED visits in the 6 months prior to our interventionfor substance abuse. One patient had 30 visits to the ED in the 6 months prior, and has not returned in theintervening 2 ½ months. A vast majority of our patients had a form of government insurance, 78% Medi-Cal, 11%Medicare, 7% Private Insurance, 1% VA, and 2% were un-insured. Thirty patients or 22% reported that they werecurrently homeless. Of the patients seen by the CADC, a majority 60% were interested in treatment and referred toa recovery program.

Discussion:

Discussion: Response: Many patients presenting to the UCD ED with substance use disorders are receptive to intervention andtreatment. Patients are interested in treatment referrals. Wehave more patients ready to begin treatment programsthan available programs. We hope to partner with community substance treatment programs to increase treatmentoptions for our ED patients. We expect to show that patients consulting with our substance abuse specialist andreceiving an SBIRT intervention with personalized referrals will have improved outcomes in terms of recurrentmedical and/or psychiatric emergencies.

Submitted Tracking Number: 276 Abstract Title: Response: Patient-level Factors Associated with Quality of Care Delivered to Children Treated in PediatricEmergency Departments

Main Contact:First Name: Parul Last Name: Dayal Email Address: [email protected] Degrees: MS Title: Graduate student Main contact's role: Learner



NathanKuppermann

MD,MPH

Professor, Emergency Medicine andPediatrics Mentor

James Marcin MD,MPH Professor, Department of Pediatrics Mentor

Patrick Romano MD,MPH

Professor of General Medicine andPediatrics Mentor

Introduction: Response: While children comprise 27% of all emergency department (ED) visits in the U.S., many EDs are notfully prepared or capable of caring for children. As a result, the quality of care (QOC) provided to children in theED can vary greatly. It is important to identify factors associated with this QOC to direct interventions towardsimproving QOC and addressing disparities. In this study, we examined the association of various patient-levelfactors and QOC delivered to children in the ED, and hypothesized that certain factors would be associated withhigher QOC.

Methods: Response: We abstracted data from 600 records of pediatric patients (

Results: Response: In univariable analyses, higher average QOC scores were significantly associated with male sex(30.8±2.0 vs. 30.4±2.3), non-Hispanic white race (31.0±2.1 vs. Hispanic: 30.5± 2,0, Non- Hispanic black:30.2±2.3), private insurance (31.1±2.1 vs. Public: 30.4±2.1, Uninsured: 29.9±2.5) and triage level (Emergent:30.8±1.9, Urgent: 30.6±2.2, Non-urgent: 29.8±2.6). Chief complaint categories were significantly associated withQOC scores. The chief complaint categories of trauma and asthma/wheezing had higher QOC scores (trauma:31.2±2.3, asthma/wheezing: 30.9±1.8) compared to gastroenteritis (30.5±2.0), abdominal pain (29.6±2.0),seizures/other neurological issues (30.2±2.3) and upper respiratory symptoms (30.2±2.3). In the multivariableanalysis, chief complaint categories were significantly associated with QOC; specifically fever (aBeta= -0.65, 95%CI: -1.24, -0.06) and upper respiratory symptoms (aBeta= -0.68, 95% CI: -1.30, -0.07). Female gender was alsoassociated with lower QOC scores (aBeta= -0.31, 95% CI: -0.62, 0.005, p=0.05).

Discussion: Response: Clinical factors were associated with the QOC delivered to pediatric patients receiving care in a diversesample of children’s hospital EDs. The differences in QOC were primarily attributable to the child’s chiefcomplaint category. Further research is needed understand what differences in processes of care ultimately impactthe QOC delivered to children in the ED with certain chief complaints compared to others.

Submitted Tracking Number: 288 Abstract Title: Response: PREANESTHETIC FASTING: A SOURCE OF DISATISFACTION AMONG INPATIENTPEDIATRIC PATIENTS AND THEIR FAMILIES

Main Contact:First Name: Danielle Last Name: Birmingham Email Address: [email protected] Degrees: M.D. Title: Pediatric Anesthesia Fellow Main contact's role: Learner



Niroop Ravula M.D. Assistant Clinical Professor Mentor

Linda Valdez Asst III Perioperative Services Mentor

Introduction: Response: Preanesthetic fasting guidelines are designed to minimize the risk of pulmonary aspiration for anypatient undergoing anesthesia. The current NPO policy at UC Davis Medical Center indicates a minimum fastingperiod of 2 hours for clear liquids, 4 hours for breast milk, 6 hours for infant formula or a light meal, and 8 hoursfor nonhuman milk or a regular meal including meat and fatty foods. Despite these guidelines, inpatients arefrequently kept NPO for well beyond 8 hours. Prolonged fasting, particularly in the pediatric population, can havedetrimental consequences including significant dehydration, hemodynamic instability under anesthesia, difficultyobtaining IV access, poor glycemic control, child irritability and overall patient and family dissatisfaction. Thisproblem is often frequently encountered among inpatients scheduled for add-on surgeries or procedures. Thepurpose of this study was to evaluate the fasting time for pediatric inpatients scheduled for MRI and CT scan and toidentify areas of potential improvement.

Methods: Response: We performed a single center retrospective review of all pediatric inpatients age 18 years or youngerwho underwent radiographic imaging between March 2015 and October 2015. Data was provided by perioperativeservices including: type of procedure, date of procedure, patient age, time at which patient was made NPO andtime at which anesthesia was performed. Only patients who had undergone an MRI or CT scan withoutintervention were included. Patients who underwent drain placement, line placement, nuclear medicine proceduresor IR procedures were excluded. The provided time points were used to determine fasting time. Data was furtheranalyzed based on patient age and procedure.

Results: Response: A total of 75 patients met inclusion criteria ranging in age from 10 weeks to 17 years old. 50.7% ofthese patients underwent an MRI of the brain. Among all patients, the average fasting period was approximately10 hours 45 minutes with a minimum time of 2 hours 35 minutes and a maximum time of 20 hours 51 minutes.Average fasting times did not significantly differ among age groups: 9 hours 47 minutes for ages 0-2, 12 hours 7minutes for ages 3-5, 11 hours 53 minutes for ages 6-10, 12 hours 8 minutes for ages 11-15, and 10 hours 21minutes for ages >15.

Discussion:

Discussion: Response: Prolonged fasting is a frequent occurrence despite institutional and national guidelines. Our dataindicates that at a single tertiary care center the average pediatric inpatient scheduled for an MRI or CT scan withanesthesia is kept without food for more than 2 hours beyond the recommended 8 hour fasting period and withoutclear liquids for more than 8 hours beyond the recommended 2 hour fasting period. Although our results arelimited in scope and do not account for all pediatric patients scheduled for anesthesia, they highlight a significantproblem. One of our primary initiatives to address this issue will be to educate pediatric nursing and house staff oncurrent NPO guidelines. Additional steps will be taken to better facilitate communication and scheduling betweenanesthesia, radiology and the pediatric service.

Submitted Tracking Number: 312 Abstract Title: Response: Research, Education, and Community Health in the San Joaquin Valley (REACH SJV): ImprovingMedical Education and Healthcare Delivery

Main Contact:First Name: Chelsea Last Name: Gong Email Address: [email protected] Degrees: Title: Medical Student Main contact's role: Learner



Tonya Fancher M.D., M.P.H. Project Advisor Mentor

Emanuel Jaramillo Medical Student Learner

Angel Mendoza Medical Student Learner

Frederick Meyers M.D., M.A.C.P Project Advisor Mentor

Lilia Sanchez Medical Student Learner

Introduction: Response: REACH SJV is a student-driven team-based project in Fresno, CA established to improve quality ofhealthcare delivery by understanding the physician deficit in the SJV and bridging gaps in medical education. Theprogram aims to increase the number of physicians with Valley ties through collaboration with an establishedpipeline program and retain UCSF-Fresno trained physicians in the SJV by identifying key motivators of practicelocation. Furthermore, we recognize the time constraints of our education limit the necessary community exposurevital to increasing our cultural awareness. By supplementing our clinical skills with community immersion, weshift our focus to patient- centered care to improve quality of healthcare delivery.

Methods: Response: Our four-week program has four components: mentorship, research, community immersion, andpreceptorships. Utilizing teams, each component was led by two students, with all students participating.Mentorship provided workshops and individualized support to Fresno State undergraduates, assessed by medicalschool application and matriculation rates. Research anonymously surveyed residents to identify motivators thatpredicted their place of practice, hypothesizing that personal motivators are more likely to retain residents in theSJV. Community immersion occurred through platforms of dialogue with local communities: Sikh, Hmong,Oaxacan, and farmworkers of Corcoran. Preceptorships enhanced clinical skills measured with self-assessmentsurveys.

Results: Response: Mentorship: Longitudinal assessment needed. 17 undergraduates participated; two applied and receivedadmission offers. Research: Five personal motivators had statistical significance. Serving specific patientpopulations (p=0.01, OR=15.74) and primary care specialization (p=0.02, OR=16.02) were positive predictors forretaining residents, while teaching opportunities (p=0.01, OR=0.09), environmental impacts on lifestyle (p=0.02,OR=0.05), and debt over $200,000 (p=0.01, OR=0.07) were negative predictors. Community Immersion:Qualitatively, we found community immersion increased our awareness of different cultures, such as learningabout the connection between Hmong families and shamanism. Preceptorships: Three areas showed significantimprovement: increased comfort in performing pediatric physical exams, assessing appropriate work-ups, and casepresentations.

Discussion: Response: REACH SJV was developed to understand physician shortages and increase quality of medicaleducation to improve healthcare delivery. Research and mentorship provided avenues to address physicianshortages. Mentorship proved beneficial to underrepresented students. Given their likelihood to return and servetheir intended population, we should focus recruitment efforts on SJV students through mentorship. Havingidentified personal motivators as predictors for future practice location, we also hope to influence residencyrecruitment towards graduates who wish to serve the SJV. Preceptorships and community immersion addressed thegaps in our education. Along with improved clinical skills through patient encounters, dialogue with differentcommunities enhanced our communication across cultural backgrounds. SJV preceptorships provided insight intopopulation-specific health issues not otherwise understood in preclinical years. REACH SJV is a team-basedapproach that enhanced leadership, and as leaders, we can improve quality of medical education and healthcaredelivery by adding cultural humility to our technical skills and helping recruit the future physicians of the SJV.Future directions include identifying better assessment methods and funding.

Submitted Tracking Number: 296 Abstract Title: Response: Shortening Family & Community Medicine Resident Response Times to EMR Inbasket Phone Calls.”

Main Contact:First Name: Brent Last Name: Hanson Email Address: [email protected] Degrees: MD Title: Resident Physician, Project Coordinator. Main contact's role: Learner



Thomas Balsbaugh MD Director of PCMH Mentor

Kay Nelsen MD Program Director Mentor

Upal Sarker MD Resident Physician, Project Coordinator. Learner

Introduction: Response: The advent of electronic medical records (EMR) has shifted significant portions of patient care tovirtual spaces such as physician inbaskets. This work represents a significant time requirement and source of stressfor Family and Community Medicine (FCM) residents. Our large patient panels and roles as primary care providerscreate a large volume of tasks that must be done through EMR. How we approach these tasks affects the efficiencyof our clinic, the quality of patient care, and patient experience. Our current culture and workload prevent residentsfrom responding to phone calls within an appropriate time frame. Our goal is to address 90% of inbasket phonecalls within 24 hours, with zero responses taking greater than 72 hours.

Methods: Response: Project Coordinators worked with EMR technicians to quantify the volume of inbasket tasks and lengthof time residents currently take to address them. Individual data over the previous 6 months was gathered andprovided to residents. As part of quality improvement curriculum, FCM residents participated in Values StreamImprovement (VSI) training during monthly didactic sessions. During these sessions, residents mapped inbasketprocesses and identified challenges. Subsequently, each resident categorized the reasons remaining tasks had notbeen addressed. We identified the most common challenges, brainstormed solutions, and plotted them on animpact- feasibility matrix. The solutions with the highest impact and lowest effort were selected forimplementation.

Results: Response: EMR reports from July to December 2015 show FCM residents receive over 300 inbasket tasks onaverage each month. 65% of phone calls are addressed within 24 hours, with an average response time of 2.1 days.In addition, 19% of calls are unaddressed at 72 hours. The five most common challenges are: 1) needing to sign aform in person, 2) needing to call a patient back, 3) task addressed, encounter not yet closed, 4) using the task as areminder, 5) needing to review the chart. Solutions include clinic staff using dot phrases for documenting incomingphone calls and faxes, determining the scope of tasks that can be delegated to clinic staff, and formalizingexpectations for resident response times.

Discussion:

Discussion: Response: Our clinic has a high volume of inbasket tasks. Our current response times to phone calls are better thanpreviously expected, however, not at goal. Many of the challenges that lengthen response times are related to thevaried methods different residents use to address tasks. Clarifying and formalizing processes quickly became thetheme of our solutions. Next steps include creating dot phrases to be used by staff, and discussing delegation oftasks with our Patient Centered Medical Home Committee comprised of faculty, residents and clinic management.

Submitted Tracking Number: 259 Abstract Title: Response: Surgical Resident Shift Length Does Not Impact Types of Errors Made

Main Contact:First Name: Jamie Last Name: Anderson Email Address: [email protected] Degrees: MD MPH Title: Surgical Resident Main contact's role: Learner



Joseph Galante MD Program Director, General Surgery Residency Mentor

Laura Goodman MD Surgical Resident Learner

Guy Jensen MD Surgical Resident Learner

Introduction: Response: In 2010, resident duty hours were restricted in an attempt to improve patient safety and residenteducation. An underlying assumption is that longer work hours result in increased complications due to fatigue.However, the restrictions have also increased hand-offs, and some worry this may unintentionally cause anincreased risk to patient safety. We hypothesize that longer work-hour shifts by first year surgery residents(“interns”) do not increase incidence of adverse events due to fatigue, nor does it change the types of errorsperformed. To test this hypothesis, we performed a retrospective review of all complications reported to ourMorbidity and Mortality (M&M) committee, comparing types of errors made during a year when first-year surgicalresidents were restricted to 16-hour shifts to the following year, in which shift length was unrestricted, andfirst-year residents regularly worked 24-hour shifts.

Methods: Response: All surgical mortality and morbidity (M&M) submissions at a university hospital surgery departmentfrom July 1, 2013-June 30, 2015 were reviewed. During 2013-14, standard 2010 duty hours were in place. In2014-15, duty hour restrictions at this institution were relaxed with no restrictions on length of shift. Root causesof adverse events were compared between academic years. 16 root causes were categorized as technical, judgment,cognitive, or team failure (including miscommunication, fatigue).

Results: Response: 383 adverse events, including 54 deaths, were analyzed. There was no difference in errors resulting inmortality between years (p=0.479). There was fairly equal distribution of errors due to technical (195, 26.1%),judgment (196, 26.2%), cognitive (229, 30.7%) errors. Team failure accounted for 127 errors (17.0%). The onlysub-category that was marginally statistically significant was communication among the surgery team, in which agreater percentage of errors were committed in 2014-15 (13.1% vs. 7.1%, p=0.050). Overall, manual technicalerrors (44.1%) and delay in diagnosis (40.0%) were the two errors most often committed. Only 14.3% of caseswere urgent or emergent, and only 5.8% of cases were performed at night. There was no difference in proportionof errors performed urgently/emergently or at night between years. Patients with a complication had an average of2.5 errors (SD 1.6). Approximately one-third of cases (129, 33.7%) had only one error; these were most commonlyfrom technical errors (52, 40.3%).

Discussion:

Discussion: Response: When duty hours were less restrictive, there was a slight increase in the proportion of errors due to poorcommunication, but no other differences in types of errors made. The surgical morbidity and mortality conferenceshould place greater emphasis on identifying root causes of errors to identify areas of improvement. Policiesdetermining duty hours should also be guided by optimizing resident education.

Submitted Tracking Number: 272 Abstract Title: Response: Taking Huddle to the Next Level to Improve Continuity and Outcomes

Main Contact:First Name: Esther Last Name: Vazquez Email Address: [email protected] Degrees: RN, BSN Title: CNIII Main contact's role: Learner



Debra Burgess RN, BSN, HCA Quality Nurse Mentor

Karley Kinsey RN, BSN CNIII Learner

Introduction: Response: Coordination of cancer care is complex, involving multiple sites for entry. Head and neck oncologypatients require multidisciplinary management involving a surgeon, an oncologist, radiation therapy,psychiatrists/social workers, nursing and nutritional support. Patients treated with combined modality treatment(CMT) are also at high risk for developing complications leading to the need for urgent hydration and treatmentbreaks. Complex treatment plans necessitates optimal communication between Cancer Center staff in the clinics,Infusion Room and Radiation Oncology to facilitate treatment as care. The purpose of this project is to improve thecontinuity of care, clinical outcomes and interdepartmental communication at the Cancer Center for CMT patientsand other high risk cancer patients transitions to outpatient therapy and along the care continuum.

Methods: Response: A nurse-led interdepartmental huddle process aimed at improving patient outcomes and communicationbetween departments was developed. Huddle sessions included nurses/nurse navigator, case manager, socialworker, dietitian, and other clinical staff as needed. CMT and other patients at high risk for developingcomplications were the priority. This typically included head and neck, GYN, colorectal cancers and patientslacking family and/or socioeconomic support systems. Frequently, these patients needed help to coordinateappointments, and extra support to prevent weight loss, dehydration, anxiety and pain. Once referred for huddlepatients were re-assessed weekly to navigate care and ensure the huddle process was beneficial. This process led tothe development of a “risk-based” acuity tool to objectively evaluate high-risk patients.

Results: Response: Metrics for improvement included staff surveys to evaluate the huddle process; need for urgenthydration during treatment; and number of unplanned therapy breaks. After huddle issues with issues withinterdepartmental communication decreased to 10% leading to higher staff satisfaction. The need for urgent IVhydration during radiation and CMT decreased to 6%, which is a 56% drop compared to the pre-huddle baseline.We estimate there was a 10% decrease in complication related treatment breaks.

Discussion: Response: The interdepartmental huddle process lead to improved staff communication and the ability to worktogether as a team. High risk oncology patients benefitted through more coordinated care improving outcomes andthe patient's healthcare experience. More studies are needed to evaluate specific treatment complications tocontinue to improve patient care.

Submitted Tracking Number: 305 Abstract Title: Response: Technological Tools in the Fight Against Clostridium Difficile

Main Contact:First Name: Catherine Last Name: Adamson Email Address: [email protected] Degrees: RN Title: PCS Quality and Safety RN Main contact's role: Learner



Sean Fraser RN RN analyst Learner

Stacy Hevener RN Manager, PCS Quality and Safety Learner

Mary Manaloto RN PCS Quality and Safety RN Learner

Christopher Polage MD Grant Director: Stop C. difficile Project Learner

Introduction: Response: We needed to bridge RN nurse workflow and EMR tool utilization. To make this QI project a success,bedside RNs needed to integrate new workflows into their routines. Two of the new tasks that RNs were havingtrouble remembering to perform were to complete a C difficile risk assessment upon admission, and to perform a Cdiicile surveillance swab test at the time of discharge. We aimed to gather staff input in order to identify the barriersto completing these tasks, and then create EMR tools, reminders, and alerts to real-time prompt nurses to completethese tasks. This was a multidisciplinary effort involving nursing, IT, the RN analyst, and the project medicaldirector. Project Timeline March 12, 2014 - June 24, 2015

Methods: Response: After meeting with frontline staff to identify barriers and elicit suggestions/input, our group created twotools. The first, in order to remind the nurse to complete the admission risk assessment, was a best practice alert,implemented August 21, 2014. The second, in order to remind the nurse to perform the swab test just beforedischarge, was a two-part EMR reminder that was NOT an alert. This was a "soft stop" as requested by thesupervising Nursing Director so as to not delay the discharge process. Implementation:July 30, 2014.

Results: Response: We found that compliance with admission assessment completion rose from 75-85% to a sustained90-98%. We found that compliance with performing the surveillance test at discharge rose from 45-60% to asustained 75-85%. Data are still being collected to ensure sustainability.

Discussion: Response: We found that hospital-wide best practice alerts (judiciously applied to avoid alert fatigue)andnonintrusive EMR reminder systems are effective at prompting appropriate workflow performance, especially asthe staff learn and internalize the new behavior. Daily compliance reports, shared regularly with staff, encourageand celebrate the desired behavior.

Submitted Tracking Number: 319 Abstract Title: Response: The Cost-Effectiveness of a Hospitalist Service for Safely Triaging Admissions from the EmergencyDepartment”

Main Contact:First Name: Kanal Last Name: Singh Email Address: [email protected] Degrees: M.D. Title: Chief Resident of Quality and Patient Safety Main contact's role: Mentor



Raja Jagadeesan M.D., M.P.H. Chief of Hospital Medicine Mentor

Introduction: Response: The hospitalist field has grown immensely since its foundation over 20 years ago, with an everexpanding role--a role which is especially interesting given the changes in medical insurance and hospitalreimbursement, such as Medicare’s ACO system. When examining capitated healthcare organizations (such as theVA), lessons learned will become more applicable in the broader healthcare field, especially as Medicareincentivizes systems to self-aggregate into ACOs to cut down costs. There have been many studies on the costeffectiveness of hospitalist groups, often with conflicting conclusions. We sought to conduct a study on the role ofcost effectiveness of triaging by our hospitalist group here at VA Mather (a 45 bed hospital in Northern California,with an average patient stay of 3.6 days). Our hospitalist group is composed of six full time physicians who workon a seven on and seven off traditional model. Hospitalist triage ED admissions for appropriateness ofhospitalization, and as reflected in the analysis below, this can lead to cost savings while preserving patient safety.

Methods: Response: We analyzed manually reported data over one year period (2015) from 4 out of 6 hospitalists, notingnumber of hospitalist consultations by the ER, and subsequent number of discharges per disc discretion of thehospitalist. We conducted subgroup analysis looking representation to the ER or readmission in 30 days, ormortality (at 30 or 90 days).

Results: Response: We reviewed data from 1,104 hospitalist consultations/evaluations of which 128 patients slated foradmission were discharged from ED (11.6%) after hospitalist consultation. 30 of represented to ours/other EDwithin 30 days; 13 were admitted at VA Mather or other hospitals within 30 days. Two out of the 128 patientspassed away within 90 days but both were readmitted within 30 days post discharge. This means 10.4% of patientsare successfully discharged home without readmission at 30 days. Assuming that on average patients dischargedfrom ED after hospitalist consultation would have normally required a 1.5-2 day total stay, and hospital admissionsto generally cost $3000-$3500 per diem, we estimate that our hospitalist group saved between $517,000 to$805,000. If we extrapolate this data to the number of patients evaluated in ED for admission by our hospitalistgroup over the course of the year (~ 2,200 to 2,500 patients on average) we have an estimated cost savingsbetween 1,030,500 to 1,820,000.

Discussion:

Discussion: Response: Hospitalist groups emerged as a subgroup in IM out of the necessity for dedicated inpatient physiciansin an increasingly complicated medical system. Studies have repeatedly shown that dedicated inpatient physicianscan lead to significant cost savings to healthcare organizations, in particular ACOs. Our data support this sameconclusion. Further study into developing effective means of outpatient follow up after ED discharge can alsoimprove on this current model by improving patient safety.

Submitted Tracking Number: 280 Abstract Title: Response: The Feasibility of Developing and Implementing In Situ Simulated Trauma Codes

Main Contact:First Name: Matthew Last Name: Kiefer Email Address: [email protected] Degrees: MD Title: Simulation Fellow and Clinical Instructor Main contact's role: Learner



MunaAljahany MBBS Simulation Fellow Learner

Aaron Bair MD, MS Professor, Medical Director of CHT andCVC, Associate Dean CME Mentor

JosephGalante MD, MAS Professor, Chair of Department of Surgery Mentor

Ian Julie MD, MAS Assistant Professor, Co-Director SimulationFellowship Mentor

ChristineWilliams

RN, MS,CNS Trauma Program Manager Mentor

Introduction: Response: Additional team members: Allison Shuken, RN, MS; Anthony Carden, MD; Bonnie McCracken, MSN,RN, NP-C, NEA-C; Edgardo Salcedo, MD; Erik Laurin, MD; Jennifer Mattice, RN, MSN; Kellie Brendle, RN,MS, CNS; Ryan Bales, RN, BSN; William Hammontree, RN, BSN In early 2014, a multidisciplinary team fromthe UC Davis Departments of Surgery and Emergency Medicine began a process of simulation-based trainings toimprove the management of traumatically injured patients. Cases were constructed based on actual cases whereerrors or delays in care were identified by the quality improvement (QI) process.

Methods: Response: Three cases were developed as follows: (i) a victim of motor vehicle collision requiring application ofpelvic binder to prevent deterioration from hemorrhage related to an unstable pelvic fracture; (ii) a constructionworker presenting after fall with open femur fracture requiring application of tourniquet to prevent exsanguination;(iii) an elderly man “found down” with intra- abdominal bleeding and hypothermia requiring rapid rewarming,diagnostic ultrasound, and rapid blood transfusion. Twice a month on a rotating basis, these simulated cases wererun in the trauma bay of the emergency department. High-fidelity mannequins were utilized, programed andsupported by CVC staff. On-call residents, nurse practitioners, nurses and technical staff responded in real-timethrough the trauma activation system (i.e. 922 critical trauma activation). After the case was run to completion, astructured debrief was performed by nursing, trauma and emergency medicine educators. The debriefing focusedon team leadership, technical trauma resuscitation skills, and communication. Additionally, a summary of theeducational highlights, along with recorded video, was sent via UCD email to participants to highlight key learningpoints.

Results:

Results: Response: Over the course of 16 months of the intervention most Trauma Program nurse practitioners and surgicalresidents in the UC Davis Department of Surgery have participated in one or more of the simulated traumascenarios. Staff and space constraints challenged initial implementation, however concerted efforts by aninter-professional group emphasized to staff the importance of training under such real life conditions. Thus far,members of the training team have noticed improvements in the use of personal protective equipment, teamleadership, closed-loop communication, and technical skills as performed by trainees and staff over the 16 monthsof the intervention. Changes implemented as a result of these trainings have included a demarcation (i.e. red line)in the trauma bay for crowd control, structured delineation of team member positioning relative to the patient, andadditional nurse training on the use of the Level One blood infuser.

Discussion: Response: Our plans are to further evaluate various key time intervals related to care, appropriateness ofdocumentation in the EMR, use of tranexamic acid and blood products, and resident leadership skills. Our16-month experience with simulated in situ trauma codes proves the feasibility of designing and implementing aneducational intervention that is closely integrated into the QI process.

Integrating Quality Symposium Abstract Evaluation Form

Abstract #: 284 Abstract Title: Enhancing the practice of Nursing through Teach-Back communication- Pilot Program

Scale:Poor = 0 Fair = 1 Good = 2 Excellent = 3 N/A

Score for this evaluation: __________________

Recommend (circle one): Rejection Poster (55 to 60 max)

Podium (13 max)

Criteria:

1. Background/introduction a. Is the project/program innovative or unique? b. Is the rationale logical, sound and supported by the information presented?

2. Methodology a. Are the interventions/methods/practices appropriate? b. Is the data analysis method clearly specified?

3. Results a. Do the results clearly present the outcome of the project/program?

4. Conclusions/Recommendations a. Do the conclusions flow logically from the results?

5. Overall quality of the abstract a. Is the abstract well-written, clear and flows well?

6. Contribution a. Does the project/program contribute new and useful information addressing a timely and significant quality problem?

7. Congruence with Integrating Quality (IQ) goals a. Does the project/program appropriately involve learners?

Notes:

Submitted Tracking Number: 284 Abstract Title: Response: Enhancing the practice of Nursing through Teach-Back communication- Pilot Program

Main Contact:First Name: Megan Last Name: Heather Email Address: [email protected] Degrees: MSN Title: CN IV Main contact's role: Learner



Diana Pearson MSN CN IV Mentor

Introduction: Response: The program was a quality improvement program designed with the main goal of improving patienteducation techniques. It was developed with the knowledge that nurses are providing a high level of care for theirpatients, however were being scored low in nursing communications specific to listening, explaining/teaching andcourtesy as evidence by hospitals HCAHPS scores. Frequent readmissions due to inconsistent care andcommunication are also a major issue. This impacts the entire health system by overcrowding, misuse of healthresources, and negative patient/ family outcomes. The pilot program began May 2015 and is scheduled to continuefor one year. It has been structured for Davis 14 nurses. Specific Aims: Create a consistent model for patient/familyeducation. Provide pilot RN’s enhanced communication training. Improve patient outcomes and satisfaction withcare Improve HCAHPS scores

Methods: Response: Piloted a health literacy/teach-back model that combines Unity Point Health’s “Always UseTeach-back” program and The National Patient Safety Foundation’s “Ask Me 3” tool. The program was piloted onDavis 14 focusing on the following key program pieces: Unit based-3 hr. ‘Teach-back Communication Intensive’class for RN’s, ongoing RN de-briefing, focused population specific patient education materials and handouts, andEMR DOT phrase for documentation. Class offered role plays for nurses to practice communication tools withpatients/ families. Nurses were observed pre and post class providing nursing education. There is a nursecommunication leader available to proactively support nurses on the unit. Students were provided a evaluationform pre and post class that was completed by each student. HCAHPS scores evaluated.

Results: Response: Evaluations show that after the communication intensive, nurses feel they have a higher level ofconfidence using the teach-back technique, providing education to patients/families with low health literacy levels,and expressing empathy and compassion compared to before completing class. Nursing communication HCAHPSon Davis 14 have increased an average of 9.5% since program start. We learned that ongoing follow up isnecessary for the RN’s to create consistency in using the teach-back technique. We discovered that nurses felt theywere doing teach- back prior to the class. They discovered that they had not been using teach-back after all. Theprocess of how nurses educated their patients/ families changed based on the teach-back technique. Nursessupported the program and are embracing the teach-back technique on a daily basis.

Discussion:

Discussion: Response: The Teach-Back Communication Pilot Program is becoming well integrated into Davis 14. The nurseson D14 continue to improve their communication techniques with providing patient education. The improvedconfidence and skill level of the nurses as well as the increased HCAHPS scores show the positive outcomes thatthis program has created. In conclusion this pilot project has been extremely successful in improving nursingcommunication,and empowered patients to be better prepared to care for themselves after discharge. Ongoingefforts for this program will include designing and implementing a teach-back communication program that is bothinterdisciplinary and system wide.

Submitted Tracking Number: 253 Abstract Title: Response: The use of a body diagram to improve quality of care in dermatology: Interim study results

Main Contact:First Name: Jillian Last Name: Millsop Email Address: [email protected] Degrees: M.D., M.S. Title: Dermatology Resident Main contact's role: Learner



LarissaLarsen M.D. Assistant Professor, Department of

Dermatology Mentor

RajaSivamani

M.D., M.S.,C.A.T.

Assistant Clinical Professor, Departmentof Dermatology Mentor

Introduction: Response: In dermatology, many conditions require the use of topical medications. Often, patients are prescribedmore than one type of topical medication and must remember the treatment instructions provided at their clinicvisit. The conventional method in clinical practice is to educate the patient verbally during the clinic visit and/orprovide written instructions for applying the topical medications. In clinical practice, however, we have found thatit can be difficult for patients to recall these instructions which may lead to poor outcomes, poor compliance, anddecreased patient satisfaction. One method to improve quality of care to patients is to provide a visual tool such asa body diagram for patients to recall instructions for medication use. In our study, we aim to evaluate the impact ofthe body diagram for topical medication use on the quality of care received by the patient. We assess the comfortlevel of patients in applying topical medications to the appropriate body part and for the instructed amount of timeand the ability to recall instructions in applying topical medications in patients receiving the body diagramcompared to patients who do not receive the body diagram. We present the interim results of our study.

Methods: Response: We plan to recruit 42 adult subjects from the UC Davis Dermatology clinic. Subjects are randomized toa group that will either receive a body diagram at their clinic visit or that will not receive a body diagram. Eachsubject will complete an initial survey at the time of their clinic visit and a post survey 1 month later. Both theinitial survey and the 1 month post survey include 8 questions assessing the patient’s perceived quality of careduring the visit and comfort level of applying the prescribed topical medications to the appropriate body part, forthe instructed amount of time, and perceived ability they can recall instructions for topical medication use.

Results: Response: Twenty-one subjects have been recruited thus far. The quality of care perceived by patients whoreceived the body diagram and those who did not receive the body diagram was similar and both groups respondedpositively to questions regarding quality of care, with the exception of one subject who did not receive the bodydiagram and reported negative responses. For comfort level in applying topical medications for the appropriateamount of time and ability to recall the amount of time to apply medications, minor differences were found:subjects who had not received a body diagram did not all respond positively to these questions in contrast tosubjects who had received a body diagram. Subjects responded less positively about their quality of care, comfortlevel for applying topical medications, and perceived ability to recall instructions in the 1 month post survey ascompared to the initial survey.

Discussion: Response: Thus far, the results demonstrate that we may need to enhance our ability to improve perceivedlong-term quality of care to our dermatology patients. The use of a body diagram may be the first step toimproving care.

Submitted Tracking Number: 283 Abstract Title: Response: Ventilator Associated Pneumonia (VAP) in the PICU: Reducing Rates through a Five Part PreventionBundle

Main Contact:First Name: Cheryl Last Name: McBeth Email Address: [email protected] Degrees: RN,BSN,MS, CCRN Title: UC Davis Children's Hospital Nurse Educator Main contact's role: Mentor



Eunice Butler RN,MSN Clinical Nurse Learner

Amy Powne RN,MSN,CNS,CCRN PICU/PCICU Nurse Educator Mentor

Introduction: Response: Ventilator Associated Pneumonia (VAP) is a leading cause of hospital acquired infections whichpotentiates increased morbidity and mortality rates in the pediatric patient population. In 2010 the PICU VAP rateshovered at four times the benchmark rate (1.8) of the National Healthcare Safety Network (NHSN). Due to thestaggering rate (7.86) an interdisciplinary team dedicated to preventing VAP was developed to address barriers ofVAP prevention care and create an evidenced-based bundle. The overarching goal of this committee was toimprove the quality of care provided to ventilated patients and reduce the incidence of VAP in the PICU.

Methods: Response: Utilizing the Lean SIX Sigma and DMAIC methodology, the committee developed clearly definedgoals: improve the quality of care delivered and lower the VAP rate to below the NHSN benchmark. Through anevidenced based approach, a VAP prevention bundle was developed and implemented. Multidisciplinary educationwas conducted over a five-month period through one-on-one teaching, in-services, posters, and bedside signs.Compliance of bundle elements was monitored by bedside audits completed by the VAP team.

Results: Response: While the 2011 VAP rate remained above the NHSN benchmark, the number of VAPs in the PICUcontinued to steadily decline from 15 to 7. In June 2012, less than two years post bundle implementation the VAPrate fell below the NHSN benchmark (1.2) to1.16. Five years after implementing the PICU VAP PreventionBundle, the rate continues to be low, with a 2015 rate of 0.41 showing a consistent improvement of outcomes. Asour educational goals were met, we began to see a change in the culture of workflow with regard to VAP andoverall unit and patient safety.

Discussion: Response: Despite moving to a new unit in November 2011 (increasing bed capacity by 30%) and the addition ofmore than 60 bedside nurses in the last three years, the PICU VAP rate remains below the NHSN benchmarkdemonstrating a sustained culture change. The committee continues to re-assess the progress and educational needsto maintain these low VAP rates. Importantly, the committee continues to educate staff with the latestresearch-based evidence and strives to build on the momentum of a unit culture steeped in an environment ofsafety.

podium presentations - uc davis health · 2016-03-03 · introduction: response: standardized...

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