Internal Medicine Abstracts - PowerPoint Presentation

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Internal Medicine Abstracts

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Necessity is the Mother of Implementation: Patient Satisfaction with Telemedicine for Palliative Care During the COVID-19 Pandemic

Adrienne Baksh MD

,

Aira

Martin, Soraira Pacheco DO

Results:Primary:  Patients were asked: “If you had to choose over 1 year (12 appointments), how many in-person and telemedicine appointments would you want for palliative care?”  74% of patients preferred to conduct half or more of their appointments via telemedicine. Secondary:  Responses related to logistics of attending appointments (such as time spent, personal and family work leave, etc.) indicated that telemedicine visits resulted in decreased burden for patients, compared to in-person visits.  

Conclusions:Patient satisfaction was favorable toward the incorporation of telemedicine into palliative follow-up care. Patients reported decreased time burden with telemedicine for palliative medicine appointments.No patients surveyed reported disatisfaction with telemedicine for palliative clinic visits. More information is needed from patients who did not participate in telemedicine appointments to identify which patients are most appropriate for this medium.  

Methods:We administered a multiple choice, phone survey to patients who were seen in a local county hospital and a large academic medical center.  Questions assessed patient satisfaction, barriers to care, and technological readiness. The survey was administered to patients who participated in virtual palliative medicine appointments, during the COVID-19 pandemic.  Preliminary descriptive statistics of 26 patients are presented.

Overview/Problem Statement:Offering telemedicine for palliative symptom management can help to relieve some of the logistical burdens of in-person follow-up care.Before resources are invested into technological developments and healthcare advocacy to expand telemedicine coverage for palliative care, it is important to assess patients’ attitudes toward using this medium.  Telemedicine expansion during the COVID-19 pandemic offers an opportunity to obtain patient feedback. 

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Figures: 

Necessity is the Mother of Implementation: Patient Satisfaction with Telemedicine for Palliative Care During the COVID-19 Pandemic

Adrienne Baksh MD

,

Aira

Martin, Soraira Pacheco DO

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The Impact of Admission Source on Cardiac Catherization Length of Stay at Memorial Hermann Heart & Vascular Institute

Hanna, A.H

, Honan, K. A.,

Fossas

-Espinosa, J., Box, N.,

Thanikachalam, S.,

Amatullah, A., Kim, J. W., Chen, J. W., Anderson, H. V. Results:This sub-group analysis of DRG 286 compared patients who were sent from clinic versus those who came through the ED and showed a statistically significant difference in the proportion of days spent in the hospital before their procedure. Using a t-test, we found that patients admitted from clinic spent less time prior to their procedure than those who were admitted from the ED (Figure 2). Importantly, we also found that the total number of days spent in the hospital did not differ between the two groups (Figure 3).

Conclusions:Patients who are sent from clinic have faster time to procedure than those who were admitted from the ED. One possible conclusion is that ED admissions often have severe conditions that require more workup time than patients admitted from clinic. Additional in-depth root cause analyses of this data would be fruitful. Methods:135 patient charts came from 3 DRG codes of interest. A sub-group analysis using t-test statistics was used to interrogate admission source versus the number of pre-procedure days out of a patient’s total length of stay.

Length of Stay Index: LOS-i= [Observed LOS] / [Expected LOS]NOTE: All patient charts and their data were collected from The Heart and Vascular Institute (HVI) at Memorial Hermann Hospital, Texas Medical Center DRG code 286: Circulatory disorders except AMI, with cardiac catheterization with major complication or comorbidity (MCC)

Overview/Problem Statement:Healthcare systems worldwide are struggling with length-of-stay (LOS) and LOS-index issues. [1,2]. Our hospital’s cardiac catheterization lab observed LOS/LOS-i were higher-than-expected and

up-trending over the past decade. Furthermore, 3 of the top 4 DRG codes with the highest LOS-indices were codes involving cardiac catheterization procedures (Figure 1). We analyzed variables including source of admission, to find those parameters associated with an increased LOS/LOS-

i

.

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Figure 1: Overall trends of LOS observed vs expected (MH-TMC versus other tertiary care centers)

Figures 2: Statistically significant difference is proportion of hospital stay spent prior to cardiac catherization for DRG 286. Patients sent from clinic hard a short proportion of time to procedure than did patients who presented to the ED (P value = 0.045).

Figure 3: The total number of days spent in the hospital was equal for both patient groups (P value = 0.30).

The Impact of Admission Source on Cardiac Catherization Length of Stay at Memorial Hermann Heart & Vascular Institute

Hanna, A.H, Honan, K. A.,

Fossas-Espinosa, J., Box, N., Thanikachalam, S., Amatullah, A., Kim, J. W., Chen, J. W., Anderson, H. V.

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Characteristics of Patients Receiving Home-Administered Continuous Parenteral Antibiotics via a Disposable Elastomeric Pump at Two County Hospitals in Houston, Texas

Sam Karimaghaei

, Aishwarya Rao, Juliet

Chijioke

, Kristin Constance, Natalie Finch, Masayuki

Nigo

Results:We identified 481 OPAT patients during the study period. A total of 91 received intravenous antibiotics via eCIP, with two initiating therapy outpatient. 83 patients (93.4%) achieved a cure from infection. A total of 1925 days of IV antibiotic therapy was administered outpatient, with a median duration of 12 days. 21 patients (23.1%) presented to the ED during IV therapy. Only one case of 30-day hospital readmission due to complications of IV therapy Antibiotic side effects: Nafcillin: Acute kidney injury (1 patient), leukopenia (1 patient), edema of legs and abdomen (1 patient), transaminitis (1 patient); Piperacillin/Tazobactam: AKI (1 patient); Cefazolin: elevated LFTs (1 patient)

Patient characteristics and outcomes are summarized in the tables and figures. Conclusions:This project revealed that patients who received IV antibiotics via eCIP had a high cure rate with a relatively low incidence of side effects and 30-day hospital readmission. ED visits during therapy were relatively high, which indicates the necessity of close patient monitoring via the OPAT program.

eCIP potentially avoided a significant number of hospital or long-term care facility stays and likely contributed to the early disposition of patients. Methods:

We retrospectively analyzed patients discharged from HarrisHealth System hospitals from 12/2018 to 02/2021 who received IV antibiotics with the eCIP at home. We extracted various patient characteristics and outcomes related to OPAT.Overview/Problem Statement:

Outpatient parenteral antibiotic therapy (OPAT) is an option for patients who require parenteral antimicrobials but are otherwise stable and no longer require hospitalization. The OPAT programs in

HarrisHealth

system have implemented a disposable elastomeric continuous infusion pump (

eCIP

,

SMARTeZ

®) for intravenous (IV) antibiotics since December 2018. The

eCIPs

require only one exchange a day and optimize pharmacokinetics of the antibiotics. This quality improvement project described the clinical characteristics of patients who received home-administered antibiotics via

eCIP

.

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Figures:

Figure 1. Distribution of Infections Among Patients

Figure 2. Distribution of Infections Among Patients by Pathogen

Figure 3. Frequency of Bacteremia Among Patients

Figure 4. Distribution of Administered IV Antibiotics

Table 1. Characteristics of eCIP

PatientsTable 2. Outcomes of eCIP PatientsCharacteristics of Patients Receiving Home-Administered Continuous Parenteral Antibiotics via a Disposable Elastomeric Pump at Two County Hospitals in Houston, TexasSam Karimaghaei, Aishwarya Rao, Juliet Chijioke, Kristin Constance, Natalie Finch, Masayuki Nigo

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Coordinating Care in Oncologic Emergencies: A Quality Improvement Project

Frances

Cervoni

-Curet,

Arthi

Sridhar, Wei Yang, Binoy

Yohannan, Julie Rowe, Jessica Jones, Neha Maithel, Adan Rios, Anneliese GonzalezResults:The ongoing data collection process has started to capture the diagnosis-to-treatment time for each of the emergencies, and a pre-intervention survey assessed the familiarity of nursing staff with handling them. We hypothesize that at the end of our intervention we will see a decreased time of diagnosis-to-treatment as well as improved familiarity level of the nurses based on a post-intervention survey, which be distributed six months from go-live. Conclusions:APL, hyperleukocytosis, HLH, and

ifosfamide-induced neurotoxicity are oncologic emergencies associated with high morbidity and mortality. Our group has implemented systemic changes that include improved documentation and education to improve the care of patients with these diagnoses. Methods:Our group identified the four emergency situations listed above as critical areas of need. For each emergency, we dissected the process of its recognition and current management. We created process maps outlining the ideal flow of events to reduce morbidity and mortality associated with treatment delays to serve as a reference for oncology nurses and pharmacists. An interactive nursing education module was created, targeting high-yield areas to improve the efficiency of handling these emergencies, such as explanation of the diagnosis, urgency of care, treatment, navigating physician-nurse communication, and post-treatment monitoring.Background:Beyond the well-described oncologic emergencies such as tumor lysis syndrome (TLS), febrile neutropenia, and hypercalcemia of malignancy, several other diagnoses should be managed with equal swiftness and care.

(1) Acute Promyelocytic Leukemia (APL) is a curable disease; however, the 30-day mortality continues to be as high as 20%, which is hypothesized to be due to delays in early treatment with all trans-retinoic acid (ATRA)1. (2) Hyperleukocytosis is a common occurrence in acute and chronic leukemias and contributes to the development of leukostasis

, TLS, or disseminated intravascular coagulation2. (3) Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome that has a rate mortality around 40%; it has gained more recognition recently, yet the diagnosis still requires a high degree of suspicion and prompt treatment with the HLH-94 protocol3-4.

(4)

Ifosfamide

, a commonly used chemotherapy in solid and hematologic malignancies, is known to cause toxic encephalopathy, which requires prompt recognition, administration of methylene blue, and possible secondary prophylaxis for future use

5

. Our QI project aims to improve the care of patients with these four diagnoses.

References:

1. Xu, Fang

MSa,b

et al, Analysis of early death in newly diagnosed APL patients, Medicine: December 2017 - Volume 96 - Issue 51 - p e9324

2. Ruggiero A et al

doi

: 10.1007/s11864-015-0387-8. PMID: 26820286.

3. Paul La

Rosée

et al Recommendations for the management of hemophagocytic

lymphohistiocytosis

in adults.

Blood

2019

4. Ramos-Casals et al Adult

haemophagocytic

syndrome. Lancet. 2014;383:1503–16.

5.

Ajithkumar

T et al.

Ifosfamide

encephalopathy. Clin Oncol (R Coll

Radiol

). 2007

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Figures (if any):

Coordinating Care in Oncologic Emergencies: A Quality Improvement Project

Frances

Cervoni

-Curet,

Arthi

Sridhar, Wei Yang, Binoy Yohannan, Julie Rowe, Jessica Jones, Neha Maithel, Adan Rios, Anneliese Gonzalez

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Developing a Diagnosis and Treatment Algorithm for Primary Immune Thrombocytopenia (ITP)

Mohammad Alsheikh-Kassim,

Iqtidar Hanif

, Eunise Chen, Matthew Ward, Jeffrey Chen, Sameeksha Bhama

Results:

The overall average score of the pre-intervention survey was 58.3% compared to the post-intervention survey average score of 69.1%. Participants showed a greater improvement in the treatment section of the survey (46% in the pre-test vs 62.4% in the post-test) compared to the diagnostic section of the survey (70.6% in the pre-test vs 75.8% in the post-test).

Conclusions:Provider knowledge of both treatment and diagnosis of ITP was found to be increased after administration of the instructional session, with a greater improvement noted in tested knowledge of ITP treatment options. Methods:

We distributed a pre-intervention survey to assess physician baseline knowledge on ITP. We then conducted an instructional session to Internal Medicine physicians covering the diagnosis and treatment of ITP in accordance with 2019 ASH guidelines. Areas addressed included a diagnostic algorithm, when to admit patients with ITP, treatment options, and platelet transfusion goals for various scenarios. Upon completion of the lecture, a post-intervention survey was distributed to assess knowledge, and resident teams were provided ITP diagnosis and treatment algorithms.Overview/Problem Statement:Immune Thrombocytopenia (ITP) is characterized by autoantibodies against platelets typically presenting with minor cutaneous bleeding (petechiae, purpura, and epistaxis), but on occasion, severe bleeding (gastrointestinal and intracranial hemorrhage). ITP is a diagnosis of exclusion and treatment recommendations depend on severity of symptoms. The objective of the project is to streamline and outline the diagnostic algorithm for physicians to aid in earlier diagnosis and appropriate management of ITP.

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Protocolizing the diagnosis of COVID-19-associated Pulmonary Aspergillosis (CAPA)

Dr. Andres Hughes, Dr. Jon Henderson, Dr. Serena

Zadoo

, Dr. Mohammed

Karimjee

, Dr. Matthew Dallo, Dr. Muhammad Khan, Jennifer Cortes,

Dr. Jeffrey Chen, Dr. Brandy McKelvy, Dr. Luis OstroskyResults:2 CAPA cases occurred pre-protocol (Jan 2020 - Feb 2021) and 1 CAPA case post-intervention (March - April 2021) [Fig 1A]. Diagnosis criteria included imaging, positive culture and serum GM >0.5. Outcomes for all 3 cases were death. Time to initiate diagnosis pre-protocol decreased from 12.5 days (n=2) to 4 days post-protocol (n=1). Number of galactomannan ordered was also tracked; testing increased starting July 2020, peaked in Jan 2021, then decreasing since then [Fig 1B].

Conclusions:Despite suspicion that the covid pandemic has increased the incidence of CAPA, CAPA cases remained low in our MICU. Number of galactomannan tests ordered may actually reflect the trajectory of the covid pandemic rather than physician ordering habits. Time to Aspergillus diagnosis and treatment has decreased since initiation of our screening protocol, though limited by low power of study. Methods:Our algorithm, diagnosis, and treatment is modeled by the ECMM/ISHAM consensus criteria. The protocol was incorporated in Memorial-Hermann TMC MICU starting March 2021.

Overview/Problem Statement:COVID-19-associated Pulmonary Aspergillosis (CAPA) patients suffer a high mortality rate. A recent study showed a 67-77% mortality amongst CAPA patients, many deceased within 2 weeks of diagnosis [1]. Bartoletti et. al proposed CAPA criteria which may lead to earlier diagnosis: pulmonary infiltrates on imaging with at least 1 of following: serum galactomannan (GM) >0.5, BAL GM >1.0, or positive aspergillus culture [2]. Due to the rapid mortality of CAPA, we aim to incorporate an algorithm based on CAPA criteria to increase galactomannan testing to decrease the time to initiate treatment.

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Figure 1A

. # of Covid Associated Pulmonary Aspergillus (CAPA) Cases in MICU per Month

Figure 1B

. # of Galactomannan Ordered in MICU by Month

Protocolizing the diagnosis of COVID-19-associated Pulmonary Aspergillosis (CAPA)

Dr. Andres Hughes, Dr. Jon Henderson, Dr. Serena

Zadoo, Dr. Mohammed Karimjee

, Dr. Matthew Dallo, Dr. Muhammad Khan, Jennifer Cortes, Dr. Jeffrey Chen, Dr. Brandy McKelvy, Dr. Luis Ostrosky

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Barriers to advance care planning with patients in LBJ house call program

Dana Giza

,

Arvindselvan

Mohanselvan,

Soraia Pacheco, Jessica Lee Cristina MurdockResults:Out of all responders, 66.7% were familiar with ACP, 62.5% felt comfortable talking about death and 37.5% were waiting for patients to initiate ACP discussions. The most common barriers to ACP were: low health literacy (50%), spiritual/religious values (50%), cultural values (50%), superstitious beliefs (62.5%), lack of awareness of prognosis (62.5%). Approximatively 62.5% of the providers believed that inability to speak the primary language of the patient interferes with delivery of ACP. Post-intervention survey, 70% of the participants considered that the IHI model and the practice activity were helpful and that they felt more confident in addressing barriers related to ACP.

Conclusions:Communication skills training is important for house call providers to increase confidence in holding conversations with patients and promote patient autonomy at end of life. Educating house call providers at LBJ on barriers of ACP improved their communications skills and confidence in discussing about ACP. Methods:We conducted a qualitive initiative to raise awareness about barriers to ACP in the LBJ house call program. First, six nurse practitioners and three physicians were asked to complete a pre-intervention survey to identify possible barriers associated with ACP. Based on the survey results, an educational intervention was developed. The IHI (Institute for Healthcare Improvement) Conversation Ready was proposed as a model for delivering ACP when barriers might be encountered. Participants had the opportunity to use the model in a practice activity. Lastly, we asked the participants to complete a post-intervention survey to assess for the effectiveness of the educational intervention.

Overview/Problem Statement:Advance care planning (ACP) protects patient’s autonomy and respects preferences at the end of life. One model of delivering ACP does not fit all and there are multiple barriers that can impact ACP. We sought to investigate from the providers’ perspective which are the possible barriers impacting ACP in the LBJ house call program.

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The Impact of Patient Sex on Cardiac Catherization Length of Stay at Memorial Hermann’s Heart & Vascular Institute

Box, N.R.

, Honan, K.A., Hanna A.B.,

Amatullah

A., Fossa-Espinosa J.E., Kim J.W.,

Thanikachalam

S., Chen J.W., Anderson, H.V. Results:When taken as a whole, females had a statistically significant longer LOS (p=0.021) but not LOS-I (p= 0.054), but when broken down none of the DRG codes had significant differences between males and females for LOS/LOS-I (all p values > 0.10). For acute MI patients, there was no difference between the sexes for LOS/LOS-i (p=0.446/0.221). When acute MI (STEMI and NSTEMI) was removed females still had a significantly higher LOS (p= 0.019) but again LOS-i was similar (p= 0.069).

Conclusions:Interestingly LOS is statistically elevated in several comparisons LOS-i is not statistically different in those same comparisons. This might reflect that while women are staying longer, this is being anticipated as well. Also interesting is that no one DRG was driving the difference as when evaluated individually they had no significant differences. We also theorized that acute MIs could be driving the LOS/LOS-i down by decreasing pre-procedure days, however when removed the difference between the sexes was still present. Further investigation into the cause of the increased LOS in females would be useful.

Methods:135 patient charts came from 3 DRG codes of interest. Data was divided into male and female groups and tested as a whole group, by DRG, and with indications for catheterization (acute MI vs. others). T-tests were used to determine significant differences.Overview/Problem Statement:

Healthcare systems are in a continual dynamic with the length-of-stay (LOS) and LOS-index enigma[1,2]. Our cardiac catheterization lab observed LOS/LOS-i were higher than-expected and up-trending over the past decade. Codes involving cardiac catheterizations were 3 of the DRG codes with highest LOS-i (Figure 1). We evaluated if a patient’s sex affected their LOS/LOS-i.

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Figures:

Figure 1

[1]:

Ko SQ, Strom JB, Shen C, Yeh RW. Mortality, Length of Stay, and Cost of Weekend Admissions. J Hosp Med. 2018 Jul 1;13(7):476-481.

doi

: 10.12788/jhm.2906.

Epub 2018 Jan 25. PMID: 29370319.[2]: Seto

AH, Shroff A, Abu-Fadel M, Blankenship JC, Boudoulas KD, Cigarroa JE, Dehmer GJ, Feldman DN, Kolansky DM, Lata K, Swaminathan RV, Rao SV. Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv. 2018 Oct 1;92(4):717-731. doi: 10.1002/ccd.27637.

Epub 2018 Apr 24. PMID: 29691963.DRG code 246: Percutaneous cardiovascular procedures with drug-eluting stent with major complication or comorbidity (MCC) or 4+ vessels or stents - market size, prevalence, incidence, quality outcomes, top hospitals & physicians

DRG code 247: Percutaneous cardiovascular procedures with drug-eluting stent without major complication or comorbidity (MCC) - market size, prevalence, incidence, quality outcomes, top hospitals & physiciansDRG code 286: Circulatory disorders except AMI, with cardiac catheterization with major complication or comorbidity (MCC)P = 0.019

The Impact of Patient Sex on Cardiac Catherization Length of Stay at Memorial Hermann’s Heart & Vascular Institute

Box, N.R.

, Honan, K.A., Hanna A.B.,

Amatullah

A., Fossa-Espinosa J.E., Kim J.W.,

Thanikachalam

S., Chen J.W., Anderson, H.V.

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Improving Physician Confidence in Diagnosing and Treating TTP/HUS with an Order Set

Simbiat

Olayiwola

,

Saumil Datar

, Zoe Alaniz, Andrew Zarker, Jeffrey Chen, Arthi Sridhar, Modupe Idowu Results:Pooled survey data from before and after the conference demonstrated a statistically significant (p < 0.005 in all categories) increase in all parameters of interest including level of comfort in dealing with thrombotic microangiopathies, initiating appropriate workup, and understanding treatment options in facilities with and without plasma exchange. In addition, on a scale of 1-5 representing “not at all likely” to “extremely likely,” participants averaged a value of 4.07 demonstrating their likelihood of using an orderset to help guide standardization of approach to TMA in the hospital.

Conclusions:Education in the management of thrombotic microangiopathies can help standardize the approach and prompt treatment of this medical emergency. In addition, providers are very receptive towards the implementation of a standardized order set.Methods:An orderset was created to assist with timely diagnosis and treatment of TTP/HUS. An educational conference was prepared around this orderset and was presented to a group of Internal Medicine physicians. A survey was performed prior to and after delivery of the educational conference to help determine future utility and likelihood of adoption of an orderset once available.

Overview/Problem Statement:Thrombotic microangiopathies, such as TTP and HUS, are rare hematologic diseases that can present with nonspecific symptoms, leading to delayed diagnosis and poor patient outcomes. However, with prompt treatment, outcomes are significantly improved. There is currently no integrative orderset available at MHH-TMC for rapid diagnosis of TTP/HUS, so our QI initiative aims to implement an

orderset at MHH-TMC to improve efficiency in diagnosing and treating TTP/HUS. 15

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Figures:

Improving Physician Confidence in Diagnosing and Treating TTP/HUS with an Order Set

Simbiat

Olayiwola

,

Saumil Datar, Zoe Alaniz, Andrew Zarker, Jeffrey Chen, Arthi Sridhar, Modupe Idowu

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Identifying Risk Factors For Hypoglycemia in Insulin Patients In the Inpatient Setting

Laurent Ehrlich, Cullen Grable, Iqtidar Hanif, Aneel Henry,

Vi Pham

, Christopher Skalomenos, Charles Wanna, Shane Wing, Victor Wong, Michelle Narat, Mohammed Hamdi, Jeffrey Chen, Philip Orlander

Results:

Of the 117 hypoglycemic events, 197 risk factors were identified. The top three causes were renal dysfunction (47%), intensive glycemic control (46%), and decreased PO intake (32%), followed by other factors shown in Figure 1.

Conclusions:

Multiple risk factors often place patients at risk for inpatient hypoglycemia. The most common factors found in our data analysis were renal dysfunction, intensive glycemic control and decreased po intake. Improper titration of insulin by physicians when these risk factors are identified contribute to inpatient hypoglycemia. Based on the top causes identified through this project, the Endocrine department has launched a series of educational tools for physicians to use when managing insulin in the inpatient setting.

Methods:At Memorial Hermann Hospital, an inpatient hypoglycemia dashboard was implemented to detect blood glucose levels <60. From 10/1/2020 to 11/30/2020, there were 117 hypoglycemic events involving 56 hospitalized patients on insulin which were reviewed in this project. Each patient chart was analyzed to see which of the following factors may have placed a role: renal dysfunction, NPO for procedure, decreased PO intake, artificial nutrition, intensive glycemic control, treatment of hyperkalemia, and uncertain cause.Overview/Problem Statement:

Hypoglycemia is associated with increased morbidity and mortality among hospitalized patients. In a large retrospective study of 31,970 patients, 10.5% of hospitalized patients had at least one hypoglycemic event. We sought to define the most common causes of hypoglycemia in insulin patients to develop an educational campaign aimed at physicians.16

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Figure 1: Risk Factors for Hypoglycemia

Identifying Risk Factors For Hypoglycemia in Insulin Patients In the Inpatient Setting

Laurent Ehrlich, Cullen Grable, Iqtidar Hanif, Aneel Henry,

Vi Pham

, Christopher Skalomenos, Charles Wanna, Shane Wing, Victor Wong, Michelle Narat, Mohammed Hamdi, Jeffrey Chen, Philip Orlander

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Bad to the Bone: Improving Osteoporosis Screening in the Outpatient Setting

Monica Cheng, MD

,

Wasay

Mohajir, DO, Sarwar Khan, MD, Ramanjit

Kaur, MD, Brian Lam, MD, Robby Wesley, DO, Aysha Chaudhri, MD, MS, Nahid Rianon, MD, DrPhResults:Before the intervention there were 5.2% missed DEXA scans. After the intervention there were 3.1% missed scans. We performed a Pearson’s chi-square test to evaluate the significance of these results. The intervention did not improve screening significantly, 2(1,N=227), p=0.65.

Conclusions:With our data, we found that calculating FRAX score didn’t significantly decrease missed screenings as many patients were already appropriately screened - a comment on the success of the original healthcare maintenance checklist. During the pandemic, fewer maintenance encounters occurred particularly for at-risk, elderly patients. Due to limitations of the screening tool, further consideration of demographics and comorbidities may additionally characterize risk factors needing increased screening. Implementing this template at UTPB could further evaluate its utilityMethods:A retrospective chart review of female patients ages of 50-90 at LBJ Outpatient Medicine Clinic from November 2019 - January 2020 was used as baseline of osteoporosis screening occurrence in comparison with encounters in September - November 2020 that used an updated template reflective of current USPSTF guidelines. Percentage of appropriate screening was compared between time frames to determine effectiveness of intervention in decreasing missed osteoporosis screening.

Overview:USPSTF recommendations (updated in 2018 to reflect fracture risk assessment) regarding osteoporosis are provided for outpatient practice to improve care and prevent poor outcomes like preventable osteoporotic fractures that create stress from a patient to public health level. We aim to decrease missed osteoporosis screening in internal medicine clinics through resident awareness in compliance with current recommendations of practice.

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Evaluating physician confidence in identifying and treating acute

vaso

-occlusive crises in

patients with sickle cell disease

Ijele

Adimora

, Akshitha Yarrabothula, Jordan Thomas, Shelby Irwin, Jeffrey Chen, Arthi Sridhar, Modupe IdowuResults

Our intervention:Increased provider knowledge of the electronic medical record (EMR) order set, Increased comfort in inpatient continuation of outpatient SCD medicationsIncreased comfort with multimodal pain regimens in acute VOC. Improved provider confidence in diagnosing and managing acute chest syndrome. All results were statistically significant with a p-value of <0.01.  Conclusions

Designing and advertising a standardized protocol for inpatient management of acute VOC improved provider confidence in acute management of SCD patients. Methods Revised the existing SCD inpatient protocol

Educated providers on the management of acute VOC and acute chest syndrome in SCD during an academic noon conference. Provider comfort in each aspect of the protocol was assessed both pre and post intervention through Qualtrics survey. For statistical analysis, a chi-square test of good fit was used to analyze survey responses. Overview/Problem Statement

Despite existing guidelines regarding pain management in sickle cell disease (SCD), there remains variability in the treatment of acute vaso

-occlusive crises (VOC) in SCD.

The primary objective of this study was to educate providers about inpatient management of acute VOC and acute chest syndrome. 

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Figure 1.

Pre-intervention

Post-intervention

P

-value

How comfortable are you continuing inpatient sickle cell medications? 

n=34

n=37Not comfortable8 (23.5%)0 (0%)

< 0.001Somewhat comfortable21 (61.8%)26 (70.3%)

Very comfortable5 (14.7%)11 (29.7%)

How comfortable are you continuing home pain medications? 

n=33

n=36

Not comfortable

8 (24.2%)

0 (0%)

< 0.001

Somewhat comfortable

17 (51.5%)

18 (50%)

Very comfortable

8 (24.2%)

18 (50%)

How comfortable are you beginning a multimodal pain regimen for acute VOC inpatient? 

n=34

n=37

Not comfortable

15 (44.1%)

3 (8.1%)

< 0.001

Somewhat comfortable

14 (41.2%)

22 (59.5%)

Very comfortable

5 (14.7%)

12 (32.4%)

How comfortable are you diagnosing acute chest syndrome? 

n=32

n=37

Not comfortable

11 (34.4%)

1 (2.7%)

< 0.001

Somewhat comfortable

17 (53.1%)

21 (56.8%)

Very comfortable

4 (12.5%)

15 (40.5%)

How comfortable are you managing acute chest syndrome? 

n=34

n=36

Not comfortable

18 (52.9%)

1 (2.7%)

< 0.001

Somewhat comfortable

14 (41.2%)

21 (56.8%)

Very comfortable

2 (5.9%)

15 (40.5%)

Selected Results of Provider Confidence Survey

Evaluating physician confidence in identifying and treating acute

vaso

-occlusive crises in

patients with sickle cell disease

Ijele

Adimora

,

Akshitha

Yarrabothula

, Jordan Thomas, Shelby Irwin, Jeffrey Chen,

Arthi

Sridhar, Modupe Idowu

Slide23

Utilization of Ova and Parasite at Lyndon Baines Johnson Hospital

Raju S

, Garrison K, Omo-

Ogboi

A,

Aisenberg G.

Results:226 (92%) samples for O&P were recorded, out of 245 ordered These were 53% male with a median age of 49±15 yearsMost samples were collected on the day of the order (0±4 days) and reported 3±4 days after the orderOnly 5 (2%) of the O&P samples were positiveNone had eosinophilia or travel history, 3 had HIV infection, 3 had diarrhea. One had negative stool antigen test. Antibody tests were not requested among these pts.The remainder 221 (98%) O&P samples were negative,

Diarrhea was reported in 60%, chronic in nature in 25%. 16 of these had eosinophilia, 5 had travel history, and 91 with HIVOf 87 cases where stool antigen tests were ordered, 3 were positive. Of 15 cases where serum antibody tests were ordered, 4 were positiveConclusions:The overall yield of O&P was low, therefore we were unable to find predictors of positivity. The yield of stool antigen and serum antibody tests were also low, though were ordered infrequently.This may be impacted by low prevalence of GI parasitic infections in Houston and also by clinical settings in which O&P was orderedAdditionally we do not know how stool antigen and serum antibody tests performed among those in whom O&P was not requested

Methods:This study retrospectively assessed results of O&P requested at LBJ Hospital from Jan 1 to Dec 31, 2020. We also documented age, gender, endemic area travel, chronicity of diarrhea, eosinophilia, stool parasitic antigen, blood parasitic antibody.

Overview/Problem Statement:Ova and parasite (O&P) stool studies are often used to evaluate for GI parasitic infections, however newer antigen and antibody-based testing have become standard of care. Current guidelines still include O&P tests in the assessment of patients with chronic diarrhea but fail to offer a more rational, evidence-based approach to its use.

We believe that the use of O&P in our hospital is not guided by a probabilistic approach, and often leads to negative results that seldom change management.

We aim to determine the circumstances under which O&P was positive at LBJH and if our suspicion is correct, to make recommendations to our clinicians to prioritize the correct study in the correct clinical setting.

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Results:

Eighteen of 35 hospitalists responded. Across all skills, mean ratings were: importance 4.7±0.5, confidence3.5±0.2, and frequency 3.4±0.6. Table shows highest/lowest rated skills.

Conclusions:

Our institutional needs assessment revealed a mismatch in how important hospitalists rated specific geriatric skills, how confident they were performing them, and how often they used them. Mean importance rating across skills was more than 1 Likert point higher than confidence and frequency ratings, suggesting an opportunity to enhance geriatric clinical competence. Hence, we designed a 13-session, flipped classroom Geriatric Acute Care Certificate Training Program for hospitalists to meet this need.

Methods:

We anonymously surveyed hospitalists at a large academic tertiary referral hospital to assess institutional needs using an adapted survey from the University of Chicago CHAMP course. On a 5-point Likert scale, hospitalists rated the importance of performing 23 different geriatric assessment & management skills (1=not important;5=extremely important), their confidence performing them (1=very low;5=very high), and frequency of use (1=never;5=always). We conducted descriptive analyses.

Overview/Problem Statement:

Older adults are at high risk of hospital-related complications, and acute care geriatricians are needed. However, there is a national shortage of geriatricians, and hospitalists fill this need. Though the Society of Hospital Medicine considers geriatric care a core competency, many hospitalists have no prior training. 22Mismatch in hospitalists’ rating of importance of geriatric skills and confidence and frequency performing themJantea R, Onyema E, Kwak M, Xavier A, Flores R,

Biebighauser J, Pennington L, Dyer C

Slide25

 

Importance (Mean±SD)

Confidence (Mean±SD)

Frequency (Mean±SD)

Highest rated

Assess risk & prevent delirium (4.9

±0.4)

Reduce polypharmacy (4.9

±0.3)Determine appropriateness of urinary catheter (4.9±0.4)Appropriate use of criteria to treat UTI (4.9±0.3)Screen for & manage constipation (4.9±0.3)

Mobilize patients (4.9±0.4)Document advance directives (4.9±0.4)Assess capacity (4.9±0.4)Give bad news (4.9±0.4)Discuss hospice (4.9±0.4)Develop safe & effective discharge plan (4.9±0.4)

Determine appropriateness of urinary catheter (4.2

±0.8

)

Appropriate use of criteria to treat UTI (4.2

±0.5

)

Assess capacity (4.0

±0.6

)

 

Determine appropriateness of urinary catheter (4.1

±0.8

)

Appropriate use of criteria to treat UTI (4.2

±0.7

)

Screen for & manage constipation (4.3

±0.7

)

 

Lowest rated

Complete skin exam (4.0

±1.0

)

Screen for depression (4.4

±0.7

)

Assess Cognition (4.5

±0.6

)

Identify fall risk factors (4.5

±0.7

)

Diagnose frailty (2.5

±0.9

)

Complete skin exam (2.7

±0.9

)

Screen for depression (2.9

±0.9

)

Assess pain in dementia (2.9

±0.9

)

Complete skin exam (2.2

±0.9

)

Diagnose frailty (2.3

±1.1

)

Screen for depression (2.3

±0.7

)

Mismatch in hospitalists’ rating of importance of geriatric skills and confidence and frequency performing them

Jantea

R

, Onyema E, Kwak M, Xavier A, Flores R,

Biebighauser

J, Pennington L, Dyer C

Slide26

Improving Oral Chemotherapy Compliance and Documentation in the Oncology Clinic at LBJ Hospital

Lindsey Farmer

, Natalie Chen,

Quinne

Sember, Sophia Lee, Rohit Goswamy, Robert Hester,

Raamis Khwaja, Christina Haddad, Akshar Dash, Daniel Nguyen, Hilary MaResults:

41 patients over 5 months were identified. 63% were non-English speakers. 49% had breast cancer, 39% GI cancers, and 12% other cancers. 68% were on capecitabine, 29% on palbociclib, and 3% on sorafenib. 12% of clinic visits correctly incorporated the dot phrase. In the post-intervention survey, 73% of providers felt that documentation of oral chemotherapy compliance is important. 70% of respondents cited failure to remember as the primary reason for lack of use of the dot phrase. Conclusions:Despite providers viewing documentation of oral toxicities and compliance as important, a low uptake of the dot phrase was observed. The main barrier was incorporation of the dot phrase into routine workflow. Future efforts to increase uptake will focus on automated reminders and regular assessments.

Reference: Mulkerin, D., Bergsbaken, J., Fischer, J., Mulkerin, M., Bohler, A., &

Mably, M. (2016, October). Multidisciplinary optimization of ORAL Chemotherapy delivery at the University of wisconsin CARBONE Cancer Center. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5063187/

Methods:

A set of standardized questions designed to assess the above were generated in the form of auto-populated electronic medical record phrases (dot phrase). Physicians were reminded to incorporate those questions in documentation during clinic visits. Chart reviews were performed to assess usage frequencies of the dot phrase. A post-intervention survey was delivered to providers to assess barriers to consistent documentation. 

Overview/Problem Statement:

The safe delivery of oral chemotherapy is challenging due to difficulties in timely assessment of toxicities and patient adherence

1

. Baseline chart review at Lyndon B. Johnson’s Oncology Clinic revealed inconsistent documentation of oral chemotherapy toxicities and adherence. Our team conducted the present quality improvement project to improve documentation of toxicity assessment, patient education and adherence with the chemotherapeutic agents sorafenib, capecitabine, and

palbociclib

by 25% by December 2020. 

 

23

Slide27

Figure 1: LBJ Oral Chemotherapy Dot Phrase

Is this patient new to the therapy? {

SLYes

/No with start date:25550}

Which oral chemotherapy? {chemotype:25552}

Dosing and schedule of chemotherapy addressed? 

{YES/NO/N/A}Chemotherapy calendar provided to the patient?{YES/NO/N/A}Patient education on possible adverse effect given? {YES/NO/N/A}Patient education on when and how to contact clinic given? {YES/NO/N/A}Missed dose addressed? {YES/NO/N/A}

Adverse effect experienced by patient? {YES/NO/N/A}Barriers to medication adherence assessed and addressed? {YES/NO/N/A}Figure 2: Use of “.LBJORALCHEMO” Dot Phrase Figure 3: Post Survey Data

73%Feel documentation or oral chemo compliance is important54%Use template to write notes every time

63%Update template each time prior to clinic64%Fellows were contact by UT resident to remind of incorporating dotphrase into clinic note100%Fellows aware of oral chemo QI project

70%

Forgot to use dotphrase to document oral chemo compliance as main barrier to its use

82%

Fellows are likely to use oral chemo calendar as educational tool in the future

Improving Oral Chemotherapy Compliance and Documentation in the Oncology Clinic at LBJ Hospital

Lindsey Farmer

, Natalie Chen,

Quinne

Sember

, Sophia Lee, Rohit Goswamy, Robert Hester,

Raamis

Khwaja

, Christina Haddad,

Akshar

Dash, Daniel Nguyen, Hilary Ma

Slide28

Results:

F

rom 54 residents from 18 facilities

Mean Age: 85.7 years

Gender: Female (70%), Male (29.6%)

When pre and post quarantine weights were compared, greater than 41% of the residents in the study had at least 5% weight loss and 20% incurred 10% or more weight loss.

Conclusions:In this small study, significant weight loss occurred for a large percentage of the residents and inconsistent or absent weight documentation occurred. Weight charts were used incorrectly, facilities lacked alerts to contact providers, and in some cases no weights were recorded. Phase II will determine if there is any correlation between dementia, depression and other variables with abnormal weight loss in these residents. Further studies are needed to quantify the impact of quarantine on resident weight and the need to consistently monitor patients for weight loss during these periods. Using our findings, we will develop a nutrition guideline for the local ALF facilities and the National Center for Assisted Living to reduce risk of weight loss during any future isolation and quarantine events.

Methods:This was a retrospective chart review involving UTPhysician Center for Healthy Aging house call patients from 18 ALFs in the Houston area. Pre-Covid-19 weights from January, March and April were compared to weights from July and August of 2020. Nine cases were discarded due to missing or inconsistent weights. Other variables included age, gender, initial BMI, dementia or depression diagnosis, dependence in self-feed, and medications. Descriptive statistics and paired sample T test were used. This study was approved for Quality Improvement by UTHealth. Overview/Problem Statement:Assisted living facility (ALF) residents are at greater risk of declining health and death from the COVID-19 pandemic due to advanced age, frailty and underlying chronic conditions. ALF residents can suffer from the consequences of the methods employed to reduce viral transmission in these facilities. These include mandatory room quarantine. Instead of eating together in a dining room, most residents were eating alone in their rooms. Room quarantine can lead to loneliness, decline in appetite, less feeding assistance, and potentially harmful changes in weight. National ALF guidelines for weight monitoring during quarantine are lacking. If quarantine results in abnormal or clinically significant weight loss of 5% or more in one month or 10% or more in 6 months, as defined by Medicare, it can result in increased morbidity and mortality. Facilities could take necessary steps to reduce the risk. We hypothesized that a substantial proportion of residents will experience clinically significant weight loss during quarantine and that weight loss will be more likely among patients with dementia.

Paired Sample T-TestCompare before and after quarantine weights

Sig .001Compare pre-Covd 19 BMI to % of weight changeSig <.001

24

The Effect of Quarantine on Body Weight in Residents of Assisted Living Facilities

Maureen S Beck, Faith D.

Atai

, &

Shuyan

Bi

Slide29

A Training Curriculum for Assessing Adult Capacity and Mistreatment

Julia Hiner, MD

; Jason Burnett, PhD; Cristina Murdock, MD; John Halphen, MD, JD

Results:

Improvement was also shown in all subgroup questions including knowledge of mistreatment, capacity, examination documents, and Forensic Assessment Center Network processes.

Please see Table 1 and Figure 1 for additional results.Conclusion:

Preliminary data suggests improvement in Geriatric Medicine fellows’ knowledge following participation in the newly improved virtual Older Adult Mistreatment rotation, now featuring a comprehensive educational curriculum. The goal in educating fellows on these topics is to ideally prevent harm, but at minimum identify current harm so timely protective measures can be taken for at-risk older adults by appropriate organizations.Limitations: The value of experiential learning gained through observing and participating in virtual capacity assessments cannot be excluded as a potential contributing explanation for improvement in fellows’ questionnaire scores. No comparative data exists prior to curriculum and knowledge questionnaire introduction. Finally, small sample size due to limited number of Geriatrics fellows annually.Future Directions: Addition of knowledge questionnaires pre-rotation and post-rotation with supplemental educational curriculum will continue for future classes of Geriatric Medicine fellows completing their Older Adult Mistreatment rotation. Assessment of question subgroups is planned with additional data. There are plans to evaluate differences in knowledge acquisition during the complete rotation experience versus simply reading the educational curriculum alone by using the existing questionnaires to compare knowledge pre-rotation or pre-curriculum and post-rotation or post-curriculum, respectively. Already underway are projects utilizing the curriculum with other healthcare professional learners, including existing education modules, didactic lectures, and scholarly concentrations. In the future, the curriculum will supplement workshops and specialized fellowship programs.

Participants:UTHealth McGovern Medical School Geriatric Medicine fellows, class of 2020-2021 (n=2) completing required 4-week Older Adult Mistreatment rotation.Recruitment: Initial recruitment was during pre-rotation knowledge questionnaire. Subsequent participation was confirmed during post-rotation knowledge questionnaire. Questionnaires had no grade or

evaluatory component, but simple completion was mandatory for rotation. Participation in research was voluntary. Data was deidentified for aggregate research purposes, but researchers were not blinded to individual results during the rotation for purposes of fellow education. IRB exempt educational research (IRB# HSC-MS-21-0045).Inclusion/Exclusion Criteria: Participation was limited to current UTHealth McGovern Medical School class of 2020-2021 Geriatric Medicine fellows only.Design

: During week 1 of the rotation, fellows completed 25 multiple choice questions online via Google Forms. Fellows agreed or declined participation in educational research simultaneously. Fellows were then provided 155 page educational curriculum on capacity and mistreatment for mostly self-study. Fellows also participated in virtual capacity assessments with varying degrees of independence and consistent attending physician supervision. During week 4 of the rotation, fellows completed post-rotation questionnaire, identical in content to pre-rotation questionnaire. Fellows agreed or declined continued research participation again.

Statistics

: Percent answers correct in pre-rotation and post-rotation questionnaires were compared. Delta improvement in percent answers correct was calculated. Graphs were created in Microsoft Excel and subsequently imbedded.

Overview/Problem Statement:

Capacity can be defined as one’s ability to have informed discussions about benefits, risks, and alternatives of self-care decisions with follow-through to complete those actions. As the older adult population increases, many adults will become incapacitated due to neuropsychiatric events, leaving them potentially unable to adequately care for themselves. Consequently, they are at risk for mistreatment: neglect, abuse, and exploitation.

It is imperative that healthcare professionals who regularly interact with older adults be able to identify incapacity and mistreatment, to intervene appropriately before harm happens whenever possible, but also to treat current and ongoing harm with skill and compassion. Unfortunately, there are few physicians who regularly assess for capacity and mistreatment, and even fewer Geriatricians trained, practicing, and educating in these areas. More and better education and training is needed.

Based on UTHealth’s Texas Elder Abuse and Mistreatment Institute (TEAM) and Forensic Assessment Center Network (FACN) processes, and with funding from the Consortium on Aging, an educational curriculum was created to enhance healthcare professionals’ knowledge in the areas of adult capacity and mistreatment.

Due to the COVID-19 pandemic, Geriatric Medicine fellows’ Older Adult Mistreatment rotation became an entirely virtual experience in 2020. Previously, the rotation consisted of both virtual and in-person capacity assessments. Continuing as before, fellows also participate in weekly telephonic or videoconference multidisciplinary team meetings, and informal teaching by supervising attending physicians.

With the goal of improving the educational quality of the newly virtual rotation, in order to eventually also support at-risk older adults, knowledge questionnaires and a supplemental educational curriculum on capacity and mistreatment were created and distributed to fellows during their rotation to supplemental the existing activities.

26

Slide30

Figures:

A Training Curriculum for Assessing Adult Capacity and Mistreatment

Julia Hiner, MD

; Jason Burnett, PhD; Cristina Murdock, MD; John Halphen, MD, JD

Slide31

Filling a Knowledge Deficit: Utilization of the

Sengstaken

-Blakemore Tube

Kavya

Kelagere

MBBS, Scott Larson MD PhD, Andrew Herman MD

Results:When respondents were asked about their comfort with placing the SBT tube rated as 1-10 with 10 being the most comfortable. Presurvey average of 35 respondents was 1 and post survey average was 4 (P<0.05). When asked what ports were part of the SBT presurvey results indicated a correct answer 26% of the time whereas postsurvey results indicated said answer 92% of the time (P<0.05). When asked what pressure the esophageal balloon should be inflated to in order to control bleeding pre survey results indicated a correct answer at a rate of 31% and post survey results indicated that answer at a rate of 95% (P<0.05). Conclusions:Data analysis demonstrated a significant improvement in knowledge among the house staff of the SBT. This project provides a proof of concept teaching model for the application of the Sengstaken-Blakemore tube. Future directions include 1) assessment of long term retention of the information given at the index seminar, 2) assembly and deployment of Blakemore tube kits with instructional cards and video containing instructions for application and re-stocking, and 3) post kit valuation of Blakemore tube use in clinical practice.

Methods:This quality improvement initiative first identified a SBT knowledge deficit among internal medicine house staff, second provided an educational seminar in the clinical application of the SBT, and third measured the increase in clinical knowledge and comfort of use of the SBT through post educational surveys. 35 members of the internal medicine residency were anonymously administered a pre-seminar survey. After completion of the survey a 15 minute seminar including a PowerPoint demonstration of the equipment and a video demonstrating its placement were given. After completion of the seminar a post seminar survey was administered. Scoring results was statistically analyzed using Chi-square analysis. Overview/Problem Statement:Variceal bleeding is a severe complication of cirrhosis leading to significant morbidity and mortality. The use of the Sengstaken-Blakemore tube (SBT) is a life-saving treatment for bleeding esophageal and gastric varices. The use of the SBT is becoming the least utilized method for the management of esophageal varices in part due to effective endoscopic management and the limited clinical knowledge of the SBT’s application. As the SBT is being used infrequently a knowledge gap has been created among practicing physicians in training. Knowledge of the clinical use of the SBT appears to be reliant on ad hoc experience and internet videos.

27

Slide32

Memorial Hermann-TMC

Abstracts

Slide33

Raising the bar on scanning medication and lab label compliance in the Neuroscience Service Line

Rachelle Bulan MSN, CVRN-BC, Della Mathew,

MSN, PGDHA, EDHI, RN

, Jessica Sajche BSN, CNRN, PCCN,

Kathryn Bernal BSN, CNRN, Janelle Headley MSN, RN

RESULTSWith the combination of education, monitoring and accountability, the Neuroscience Service Line is able to maintain its’ safety and quality standards. The highest metric is medication real time documentation (97.48-98.1%) followed by medication review (96.57-98.24%).

The overall value for lab scanning was between 93 and 96%. The PAID (Positive Accession Identification) is more than 99% while the PPID (Positive Patient Identification) ranged from 93.51 to 97.04%).

IMPLICATIONS OF PRACTICE The NSL met and maintained the goal of 95% compliance for PPID and PMID for fiscal years 2020 and 2021. Consistently monitoring and sharing quality metrics may help reach compliance goals in other service lines. OVERVIEW/PROBLEM STATEMENTMemorial Hermann Health system is a high reliability organization that focuses on quality and performance improvement initiatives. The Neuroscience Service Line (NSL) adheres to that standard by aiming for the goal of 95% compliance for PPID and PMID (medication safety) and 90% for lab scanning.

METHODSTwo patient safety aspects that the quality coordinator tracks are medication review and lab scanning compliance. On a monthly basis, quality metrics are monitored and shared with NSL leadership. Quarterly education around lab label compliance is provided to bedside nurses. Scanning medications using a barcode has been linked to a decrease in medication errors therefore increasing patient safety (Barakat, et. Al, 2020).In a study done by

Burkosi

, et al., it was deduced that the use of barcode scanning led to a lower number of medication errors within 5 years at a major acute care hospital in Canada (

Burkoski

, et al., 2019).

Slide34

Medications via Enteral Feeding Tubes in the Intensive Care Unit – An Evaluation of Pharmacy Practice

Bhooma

Rajanarayanan, Pharm D., M.S., BCPS., Eileen Tharp, Pharm D., BCPS.,

Sidney P Phillips PharmD, R.Ph, MBA

Results:

The survey response rate was 54%. Reported % of patients with EFT in ICU on an average was about 50-75%. Predominant type and cause of medication errors was stated to be prescribing errors when medication route was ordered incorrectly. Ability of Pharmacists to follow standard practices to review medication route decreased from 79% to 58% when alert on presence of EFT as medication route was not presented at the order verification stage. Different patient clinical characteristics among different ICU service lines creates challenges in decision making of appropriate EFT compatible medication formulations.

Conclusions:The KAP level of pharmacists /nurses were reported to be satisfactory. Feedback from interviews and the survey indicated challenges at both the system level and the pharmacy operational level leading to barriers in safe medication practices. They included the following: a)dynamic nature of patient acuity b)lack of health information technology support to present accurate information at every stage of medication process c) pharmacy workflow challenges, d) inadequate time/ staff and e) lack of formal guidelines and protocols. The evaluation found the need for exploration of strategies for implementation at both the system level and pharmacy level to improve the practice.

Overview/Problem Statement:Enteral Feeding Tubes (EFT) are frequently used to administer medications in patients who are unable to swallow. Erroneous ordering and administration of medications through EFT are often underreported and may lead to preventable adverse events. A literature review indicates that a gap in Knowledge, Attitudes and Practices (KAP) among healthcare professionals and a lack of unified multidisciplinary approach could be factors in causing these medication errors. This evaluation was conducted from a pharmacy practice perspective to understand what works well and what could be improved in the practice of medication management via EFT in Intensive Care Unit patients.Methods:This project was conducted using Mixed Methods approach combining qualitative and quantitative components. The qualitative component consisted of interviews with Clinical Pharmacy Specialist (CPS) of ICUs. The quantitative component assessed the knowledge, practice and challenges of the staff pharmacists involved in the medication process through an anonymous online survey.

Slide35

Comparing Central Line and Foley Catheter Bundle Compliance Between Night and Day Shifts in the Heart Failure Intensive Care Unit (HFICU)

Hannah Fuchs, MSPH, CIC; Rose Richmond, BSN, RN, CCRN-K

Results:

Over a three-month period, Foley bundle compliance was 4% higher on night shift than that on day shift with only 3 instances of non-compliance out of 88 observed bundle elements. Central line bundle compliance was similar between the two shifts. Despite the higher compliance, night shift staff identified the fact that there is no IP presence during their work shift for added support contributing to longer dwell times and missed opportunity to adhere to evidence-based practice.

Conclusions

:

The variation in Foley bundle compliance highlights the need for increased rounding and education efforts on dayshift. Going forward, interviews with frontline staff and variation of rounding times (i.e. around physical therapy) will help identify any barriers that may prevent full compliance. Additionally, nightshift could benefit from additional resources such as supplies and access to bedside commodes. This will aide all staff, regardless of shift time, to have the resources to adhere to evidence-based practices and subsequently help prevent hospital-acquired infections and lead to better patient outcomes.

Methods: Once a month IP and the Clinical Coordinator completed bundle rounds on HFICU patients with Foley catheters and central lines during the nightshift and once a week during the dayshift. Overall compliance scores were compared between the two shifts to identify any variance in practice. Overview/Problem Statement:Heart failure patients are a vulnerable subset of patients that often have high utilization of indwelling devices and extended lengths of stay, which puts them at increased risk of infection. Infection Prevention (IP) monitors compliance with evidence-based practices, or bundle elements, to help prevent infections associated with indwelling devices. However, since IP working hours are during weekday business hours, there is no data on bundle compliance during the night shift.

Slide36

The Effect of Preoperative Non NPO Feeding Protocol on Nutrition Delivery and Pneumonia Incidence in Critically-ill Trauma Patients

Jenny C. Lee, MS RD CNSC, Yew E. Tan, MD, Muaz Aijazi, MD, Roy Lei, MD, William S. Jones, MD, Candace Scheresky, BSN, RN, Xu Zhang, PhD, George W. Williams, MD

Results:

Conclusions:

The use of the preoperative non-NPO feeding (HUNGREA) protocol resulted in a significant decrease in nutritional deficit in critically-ill injured patients due to the reduced fasting time.

The implementation of the HUNGREA protocol is safe, as evidenced by zero incident of pulmonary aspiration and no significant increase of pneumonia incident among intubated patients. Overview/Problem Statement:Nil per os (NPO) after midnight (MN) is a common practice prior to scheduled procedures. As a result, nutrition is often withheld in critically-ill patients for prolonged periods of time. Our Shock Trauma ICU (STICU) has implemented a preoperative non NPO feeding protocol, known as Hermann Uninterrupted Gastric Route via Enteral Alimentation (HUNGREA), to reduce fasting time before planned procedures. In this quality improvement study, we compared

fasting time nutritional deficitspulmonary aspirationpneumonia between patients who were NPO after MN and patients who followed the HUNGREA protocol.Methods:Study Period: 11/2017 – 2/2018 (4 months)Inclusion: Trauma patients aged ≥18 years of ageExclusion: Non-trauma or fatal injuries; receiving small bowel tube feeds or parenteral nutrition Data collected: Demographics, admission diagnosis, duration of fasting, nutritional deficits, pulmonary aspiration incidents in operating room (OR) and pneumonia4 study groups: Intubated + NPO after MN: Enteral nutrition (EN) was stopped after MNIntubated + HUNGREA:

EN was stopped one hour before a scheduled procedure. At the time EN was stopped, gastric contents were aspirated via a nasogastric tube. Intubated +HUNGREA+ Procedure CanceledNon-intubated + NPO after MN: oral diet was stopped after MN. Statistical analysis was done by using Kruskal-Wallis test and Fisher’s exact test.

Total no. of patients: 138Total no. of procedures: 239Intubated +NPO after MN (n=63)

Intubated + HUNGREA

(n=68)

Intubated + HUNGREA

& Procedure Canceled

(N=34)

Non-Intubated + NPO after MN

(N=74)

P Value

Total no. of NPO hours

17 (14, 31)

5 (3,8)

0 (0, 9)

19 (14, 32)

< 0.001

No. of pulmonary aspiration incident

n (%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

N/A

No. of pneumonia (%)

5 (7.9%)

6 (8.8%)

2 (5.9%)

0 (0%)

N/A

Caloric Deficits (kcal per procedure)

1512

(960, 2040)

372

(186, 738)

 

 

<0.001

Protein Deficits

(grams per procedure)

94

(59, 116)

24

(12, 48)

 

 

<0.001

Total number of NPO hours and outcome of the study groups. Data are presented as median

(interquartile range) unless otherwise indicated.

Slide37

UTHealth Abstracts

Slide38

COVID-19: Perceived Infection Risk and Barriers to Uptake of Pfizer-BioNTech and

Moderna

Vaccines Among Community Healthcare Workers

Tolulope B. Famuyiro, MD, MPH; Nidia Perez, MD; Dalton Carter, MD; Deepa Iyengar, MD, MPH; Jude des Bordes

, MBChB, DrPH; Abayomi

Ogunwale, MD, MPH; and Larry R Butcher, MD, Nahid Rianon, MD, DrPHResults: Two hundred and five (82%) people out of 250 completed the questionnaire. Respondents were mostly HCWs ages 25-34 years ages (42%, n=86), females (75%, n=152), and Non-Hispanic Blacks (32%, n=64).

On bivariate analysis, females (compared to males) were less likely to agree to receive the vaccine (OR=0.22, P=0.014). Non-Hispanic Blacks (OR=0.066, P=0.010) and Hispanics (OR=0.11, P=0.037) were less likely to accept the vaccine compared to non-Hispanic Whites.Physicians (83%) and residents (81%) expressed more enthusiasm to receive the vaccine once available compared to other clinical staffConcerns regarding safety and side effects of vaccine served as a barrier to uptake, while the decision to receive the vaccine was driven by work exposure risk and data from vaccine experts. More respondents agreed to recommend COVID-19 vaccine to others. Respondents with moderate risk perception of becoming infected with COVID-19 were more likely to accept vaccine (OR=2.79, p=0.045) compared to those with low-risk perception. No association was found between high-risk perception and vaccine acceptance (p=0.226). Conclusions:Enthusiastic acceptance of the COVID-19 vaccine is lacking among surveyed HCWs, particularly among Hispanics and Blacks.Vaccine reluctance may be driven by lack of trust in the development process, as well as background historical vaccine apathy in minority populations. Failure to address vaccine hesitancy among HCWs may amplify the opposition to vaccine uptake that already exist among the general public.Early dissemination of educational resources emphasizing the safety and importance of vaccination should target community health workers. Creation of a vaccine champion coalition consisting largely of minority HCWs to act as mentors to their vaccine-hesitant colleagues.

Methods: A cross-sectional study was conducted in early December of 2020, before the arrival of the vaccines.All community health center clinic (Acres, Aldine, and UT Physician) staff affiliated with UTHealth Science Center were eligible to participate.Self-administered survey obtained:The respondent’s demographic information (race, clinical role, age, etc.)Perception of COVID-19 infection risk (mild, moderate, or severe) Readiness to accept COVID-19 vaccine (to receive once available, later, or not at all), and factors influencing the decision to receive or not receive the vaccine.Data responses were reported using the frequentist inference while associations between outcomes and the independent variables were analyzed using logistic regression.Overview/Problem Statement:The resulting health and economic ramifications of the COVID-19 pandemic prompted a timely development of two mRNA-based vaccines by Pfizer-BioNTech and Moderna. While the roll-out of these vaccines in record time is being hailed as scientific feat, concerns for vaccine uptake hesitancy remains a concern. The attitude of our community healthcare workers (HCWs) towards COVID-19 vaccine could proxy the vaccine uptake response of the patients they care for.Understanding vaccine uptake readiness among health care workers can inform design and implementation of public health programs to mitigate vaccine inertia.

Slide39

Optimizing Peer Feedback in Graduate Medical Education

Craig Authement MD, Frank Abene MD, Radhini Bell MD, Mauro Rodriguez DO,

Destiny Uwaezuoke MD, Jessica To MD, Esraa

Elsammy

MD, Shyam Popat MD, Erin Foster MD, Barbara Knight MD, Amber Gafur MD, Stephanie Zhao BS, Emma Omoruyi MD, MPH

Results:Baseline data from November 2019, found 2% (2/113) of comments were actionable. After PDSA cycle number 1 on November 2020, we found 13 % (19/144) comments were actionable. We are reviewing monthly audits from more recent data.

Conclusions:We would like to continue structured resident education in regard to quality feedback. Next steps include more formal in-person education sessions at the beginning of the academic year, including new interns starting in 2021 and possible modifications to the feedback tool. We hope for a cultural shift that results in more actionable feedback thorough the residency. Methods:We created a key driver diagram and tested interventions using PDSA cycles. Interventions included: structured brief reminders and education on ideal feedback examples via weekly emails and monthly lectures series. We changed the distribution time cycle for our evaluation forms so that residents felt more comfortable providing quality anonymous feedback.Narrative comments were scored for actionability using an evidence based rubric. Overview/Problem Statement:The Accreditation Council for Graduate Medical Education requires that residents have multimodal assessments. Peer review is one way that our residency provides feedback to its trainees. An audit of narrative comments provided in our peer feedback tool demonstrated that less than 3% narrative comments provided actionable feedback with specific examples. We plan to develop a more structured process and implement ways to improve the feedback that residents’ receive from their peers.Our primary goal is to improve and expand actionable peer feedback to >50% of audited narrative comments by June 2021.

Slide40

Sitting in the Dark; Improving Patient Access to Natural Light

Nitin Gupta, M.D., Elizabeth Nugent, M.D., Min Ji Kwak MD, DrPH

, Maureen Beck, DNP

Results: After intervention the median percentage closed in the unit at day 0 was 70%, day 7, 45%, and day 14, 55%. So the median amount that blinds were open improved by 35% after just 7 days (from 70% to 45%). By two weeks the value stabilized to an improvement of 15% see Figure 1. However, the difference did not show a statistical significance (p-value 0.0597 between day 0 to day 7, and p-value 0.2690 between day 0 to day 14).

Conclusions:We produced a substantial difference with practical interventions that improved patient access to sunlight. Future studies can consider adding active staff education as well for possibly statistically significant results.Methods:We placed reminders on every computer and nursing station in the 51 bed Jones 5 neuroscience unit at MH-TMC that encourage staff to open the window blinds in addition to posting placards that explained the benefits of natural light. We then documented each room’s blinds status in terms of percentage closed at 9AM on day 0, 7, and 14. 100% indicated completely closed while 0% indicated completely open. We started the intervention after the initial day 0 documentation and then assessed the blinds on day 7 and 14. Overview/Problem Statement:Reduced exposure to sunlight is known to be associated with increased delirium, ICU length of stay, and opiate requirements. This quality improvement project aimed to increase the prevalence of open window blinds in a hospital unit.

Slide41

Figure 1: Comparison of blinds distribution pre-intervention to day 14. So on day 0 most rooms had blinds that were 70-100% closed while on day 14 there was an increase in blinds that were completely open (0%).

Sitting in the Dark; Improving Patient Access to Natural Light

Nitin Gupta, M.D., Elizabeth Nugent, M.D., Min Ji Kwak MD, DrPH

, Maureen Beck, DNP

Slide42

An Algorithm for Hypertension in the Emergency Department

Tom Fadial MD, David Foreman MD, Taylor Martin MD

Conclusions:

We have taken a multi-disciplinary approach to the development of this algorithm with the objective of involving all stakeholders beginning with the Hospitalist Division in the Department of Emergency Medicine. Following guideline revisions and finalization, our Department will extend the algorithm to nursing leadership for review and incorporation into facility admission criteria/guidelines.

Methods:

We developed a comprehensive, guideline-based diagnostic, management and disposition algorithm for patients presenting to the emergency department with significant hypertension warranting hospitalization (See Figure 1). The algorithm encourages a systematic approach to the evaluation of end-organ dysfunction with suggested diagnostic tests, target blood pressure goals, preferred agents and recommended disposition LOC.For patients without identified hypertensive emergencies, the algorithm encourages resumption or initiation of oral anti-hypertensives with hospitalization to the LOC determined by the condition warranting admission.Overview/Problem Statement:Hypertension is common among patients being admitted from the emergency department and ranges from being a known, well-managed, chronic condition unrelated to the reason for hospitalization, to an insufficiently-treated but otherwise uncomplicated secondary finding, to a true emergency with associated end-organ dysfunction and the principal indication for admission.The disposition level-of-care (LOC) for patients along this spectrum is similarly broad. The appropriate LOC for individuals with uncomplicated hypertension should be based on the severity and anticipated course of the diagnosis warranting hospitalization. However, unrelated and provably uncomplicated hypertension occasionally results in unnecessary escalation of LOC (with associated unjustifiable resource consumption, prolonging emergency center length-of-stay), and/or inappropriate blood pressure lowering with risk for precipitation of ischemia. Similarly, inadequate recognition and management of hypertension with end-organ dysfunction (hypertensive emergency) may result in worsened patient outcomes.

Slide43

Figure 1:

An Algorithm for Hypertension in the Emergency Department

Tom Fadial MD, David Foreman MD, Taylor Martin MD

Slide44

Depression Screening in Hospitalized Adolescents

Yancovich

S, Wahba A,

Nasrazadani

A, Wilson A, Harris N, Francisco R,

Lahiri S, Reddy S Supervising Faculty: Mona A Eissa, MD Results:

Monthly screening rate in 2019 presented in figure 1. Screening rate has improved after presenting the project and its goals during the resident academic session in early January 2020. After this announcement, 26.6% of patients were screened. In subsequent months, no further announcements were made and screening rates decreased (figure 2). Conclusions:PHQ-9 screening tool can be used in inpatient setting to identify adolescent patients with depression and may provide a crucial opportunity for intervention and management. Our results show that frequent reminding the residents with the importance of the screening, will improve the rate of screening. Methods: Between Nov 2019 and April 2021, residents of the inpatient primary teams screened patients ages 12 to 18 yrs. Patients completed the PHQ 9 on admission. Completed questionnaires are collected and reviewed by the residents. According to the severity of the score, residents would order social work and/ or child psych consult, if needed. QI project residents entered the results into an encrypted excel file in UT secured share derive. In January 2020, project residents presented their project to other pediatric residents during one of the resident academic sessions to improve the rate of screening. Overview/Problem Statement:Depression prevalence is 8% among adolescents, but only 50% of adolescents with depression are diagnosed. Depression is a known risk factor of suicide. This QI project intended to use the PHQ -9 to screen for depression in adolescent patients admitted to Children’s Memorial Hermann Hospital. Using a validated screening tool will improve depression screening rate.

Slide45

Figure 1: Monthly reminders given at AHD in Nov, Dec, Jan Figure 2: One reminder given at AHD in Jan

Depression Screening in Hospitalized Adolescents

Yancovich

S, Wahba A,

Nasrazadani

A, Wilson A, Harris N, Francisco R, Lahiri

S, Reddy S Supervising Faculty: Mona A Eissa, MD

Slide46

The Rate Debate: The Perils of Aggressive Rate Control in Atrial Fibrillation

William Ciozda MD, Thomas

Gerbus

MD, Ben Cooper MD

Results

: Ten total cases were found that pertained to negative outcome stemming from AV nodal blockade while rate controlling atrial fibrillation with rapid ventricular response. These patient had differing etiologies for which the rapid ventricular response was compensatory.

Conclusions: Among the ten cases identified, morbidity of rate control of rapid ventricular response was associated with patients that had evidence of hemorrhagic shock, cardiogenic shock, AV nodal blocking overdose, pulmonary embolism or distributive/septic shock.Methods: A retrospective case analysis was performed using a quality assurance database at the University of Texas Health Science Center at Houston called the Medical Incident Reporting System or MIRS to identify cases pertinent to mortality or morbidity stemming from rate control of atrial fibrillation with rapid ventricular response. Cases were reviewed over a four year period between 01/01/2016 to 12/31/2020. Overview/Problem Statement: Atrial fibrillation is one of the most common cardiac arrhythmias encountered in the emergency department and the most common sustained arrhythmia. Often times, the patient has associated rapid ventricular response. Frequently, in the emergency department, symptomatic atrial fibrillation is treated with rate control whereby drugs are used to slow conduction through the AV node. However, in some patients, a rapid ventricular rate is a compensatory mechanism for underlying shock or cardiovascular instability. In these instances, rate control therapies can have deleterious effects on the patient’s hemodynamics. It is crucial to differentiate benign rapid ventricular rate from a compensatory rapid ventricular rate.

Slide47

Implementation and de-implementation of Hydroxychloroquine among Coronavirus disease 2019 (COVID-19) patients at a large university-affiliated hospital system

Siddharth Karanth, Swaroop Gantela, Kavitha Gopal, Bela Patel

Results:

Among all COVID-19 inpatient admissions, 7% of hospitalized patients received

Hydroxychloroquine

during the study period. Hydroxychloroquine was not associated with death/hospice in inpatient COVID-19 patients. The use of Hydroxychloroquine was higher in the initial months of the pandemic coinciding with initial recommendations and increased news media coverage. On March 20, the Food and Drug Administration (FDA) gave

Hydroxychloroquine an emergency use authorization (EUA). In March, Hydroxychloroquine was given to 50% of COVID-19 patients. As more evidence was published, the use of Hydroxychloroquine declined in April, and by April 24, the FDA issued a warning against the use of Hydroxychloroquine. Utilization had dropped to 32% of hospitalized patients. By June 15, the FDA had rescinded the EUA given to Hydroxychloroquine with utilization less than 2% by June 1 in hospitalized patients.Conclusions:The increasing COVID-19 patient counts and a lack of effective treatments for this new disease lead to a rapid implementation of Hydroxychloroquine which wasn’t meticulously studied for efficacy. De-implementing inappropriate care is important for patient safety and reduces unnecessary care. As more evidence was published on the efficacy of Hydroxychloroquine, it was immediately de-implemented in the hospitals. Non-randomized controlled studies with small sample sizes should be used for informing associations and generating hypothesis and not for basing treatment off of. Case reports and case series are anecdotal evidences and must be backed by rigorous studies. In the time of rapid nontraditional communication of disease therapies, Hydroxychloroquine utilization in COVID-19 may have demonstrated most rapid implementation and de-implementation of any intervention in modern medicine.Methods: The study was conducted at a large university-affiliated hospital system. The study collected data from electronic medical records on all COVID-19 patients from March-November 2020. Data was also collected on medication usage for all patients in 2019. The association of death/hospice with each medication usage among inpatient COVID-19 patients was assessed using unadjusted logistic regression analyses. The medication usage was graphed using Tableau.

Overview/Problem Statement: The first cases of Coronavirus disease 2019 (COVID-19) were reported in Houston, Texas, in March 2020. There has been a rush to find a cure for COVID-19 since the early days of the pandemic. In March 2020, results from a non-randomized controlled trial conducted on a few COVID-19 patients showed that Hydroxychloroquine reduced viral load. As other treatments were not available for this disease, Hydroxychloroquine, a drug used to treat malaria and autoimmune disorders, received a lot of media attention. This was followed by an emergency use authorization by FDA in March 2020, which was later withdrawn in June 2020. These events led to a sudden implementation of a treatment that was based on preliminary data followed by de-implementation when evidence emerged of its lack of efficacy in COVID-19.

Slide48

Figure 2: Percent of patients given

Hydroxychloroquine

in 2019 and 2020

Figure 3: Timeline of medication use

Figure 1: Timeline of percent of positive cases receiving

Hydroxychloroquine

Table 1: Medication use among inpatient admissions Medication% pts who receivedHydroxychloroquine7%Remdesivir

23%Kaletra0%Azithromycin40%Steroids

68%Tocilizumab2%

Convalescent plasma19%

Implementation and de-implementation of Hydroxychloroquine among Coronavirus disease 2019 (COVID-19) patients at a large university-affiliated hospital system

Siddharth Karanth, Swaroop Gantela, Kavitha Gopal, Bela Patel

Slide49

Bone Health Monitoring And Management In Inflammatory Bowel Disease Patients In The Harris Health Gastroenterology Specialty Clinic.

S

ruthi Kapliyil Subramanian MD,

Adrainne Tsen MD, Shaheer A Siddiqui MD, Scott Larson MD PhD FASGE.

Results:

Of 116 patients evaluated, 58 had undergone DEXA scan (50%) and 58 did not (50%). Of the 58 patients who underwent DEXA scan, 10 had osteoporosis (17.2%), 19 had osteopenia (32.8%) and 29 had normal bone density (50%). Vitamin D was checked in 98 patients (84.4%). There were 3 patients (2.5%) who developed fracture due to decreased bone density. The study characteristics are summarized in Table 1.

Conclusions:From our study the DEXA scan compliance in IBD patients in HH GI clinic is 50% (Goal 100%). The study also shows a 17% prevalence of osteoporosis in patients with IBD. Our next step is to identify barriers to bone health assessments in IBD patients within the HH GI specialty clinic and implement clinical practices to reach and maintain national standards.Methods:We retrospectively evaluated a total of 116 IBD patients seen in HH GI clinic from Feb 2019 to March 2020. We assessed the number of patients who had undergone DEXA scan and had their vitamin D level checked during clinic visits. Introduction: Approximately 1.4 million people in the United States suffer from inflammatory bowel disease (IBD) and are at higher risk of developing osteoporosis and osteopenia than the general population. The prevalence of osteopenia and osteoporosis in patients with IBD ranges from 22%-77% and 17%-41%, respectively, with a 40 % higher relative risk of fracture. It is imperative that physicians recognize patients at risk for osteoporosis, screen appropriate patients, and prevent or treat accordingly. The primary objective of this study is to assess and improve the quality of bone health monitoring and management, which include both Vitamin D level and Dual-energy X-ray absorptiometry (DEXA) scan evaluation in patients with IBD in Harris Health (HH) Gastroenterology specialty (GI) clinic.

Slide50

Table 1. The Study Characteristics

AGE

46 +/- 12

SEX

Male – 57 Female - 59ETHNICITYCaucasian- 36African American – 15 Hispanic – 56 Other – 9 BMI27+/- 6TYPE OF IBD

Crohn’s disease – 44 Ulcerative Colitis- 72MEDICATIONSBiologics – 87Immunomodulators – 27Steroids – 15 5- ASA - 49VITAMIN DChecked – 98 Not checked – 18FRACTUREPresent – 3 Not present - 113Bone Health Monitoring And Management In Inflammatory Bowel Disease Patients In The Harris Health Gastroenterology Specialty Clinic.Sruthi Kapliyil Subramanian MD, Adrainne Tsen MD, Shaheer A Siddiqui MD, Scott Larson MD PhD FASGE.

Slide51

Follow Up Labs after Discharge Quality Improvement Project

Katherine

Bastie

, Tiffany Blankenship, Sarah Coyle, Divya Dhoot, Kevin Doan,

Nhat

Hoang, Jean Hsu, Aman Jain, Kimberly Vu, Catherine Yang Results: We found the Physician Handoff Tool to be most efficient and effective for residents to follow up labs on patients who are discharged from the hospital.

Conclusions: We plan to continue to implement this solution with all pediatric teams. Methods: First we tried the notification system within Cerner where all labs on patients came into our inbox. This system resulted in too many labs and was not a viable solution. Next we tried a google document. However it is difficult to access UT google docs within the Memorial Hermann network at times and would also require logging into a different website. The final solution was using the Physician Handoff tool. Upon discharge from the hospital, the pediatric residents add the patient to a follow up list indicating which labs are pending. They check the list regularly to see if labs have resulted. Overview/Problem Statement: After patients are discharged from the hospital, they frequently have laboratory results that have not resulted yet. We have had some issues with follow up of these pending labs. The goal of our project was to ensure that all laboratory studies that are ordered on patients at Children’s Memorial Hermann Hospital are followed up in an appropriate manner. This issue is significant because we could potentially delay treatment for a diagnosis for a patient.

Slide52

Improving transitions of care for Geriatric patients with dementia: Post-acute care coordination of resources

Andrew M. Albrecht, MD; Michelle R.

Klawans

, MPH; Terry Jennings, Geri Hart,

Jude des

Bordes,DrPH, Nahid Rianon, MD, DrPH

Results:Seven common barriers were noted:Discharge on the weekend or on Friday afternoonDementia Unit availabilityDementia Unit requirements regarding psychiatric medications/need for sitter/restraints while inpatientCommunication and agreement from family or MPOA/Next of KinInsurance issues (No SNF coverage, Medicaid pending, and self-pay)DME such as Oxygen, IV Abx, BiPAP/CPAP, etcTransportation issues.

ConclusionsThe barriers to discharge identified are consistent with the literature regarding geriatric transfer of care Addressing these would assist provider teams in discharge preparation. Methods:Phase 1: A family medicine resident attended multidisciplinary rounds in neurovascular and geriatric wards and compiled a list of common barriers to discharge of elderly patients with neurocognitive deficits. Phase 2: A list of post-acute care facilities within 10 mile radius of an urban university based hospital was compiled and facility coordinators were contacted by phone for their acceptance/transfer criteria. A list of general and specific requirements for each facility will be created to assist in discharge planning of patients with dementiaWe report the findings from Phase 1Overview/Problem Statement:Hospitals stay may be prolonged for older adults who may unable to return home or to their previous state of living prior to hospitalization, particularly those with dementia and other states of impaired cognition

This takes a toll on hospital resources and staff, and reduces the quality of life of both patients and caregiversInadequate information on long-term dementia care facilities and their acceptance criteria become a barrier to discharge teamsWe aimed at creating a list of available facilities with requisite resources and criteria for intake, to help with discharge planning

Slide53

Skilled Nursing Facility Discharges for Memorial Hermann Hospital Texas Medical Center

Christian Hernandez, Andrew Albrecht, Terry Jennings, Geri Hart,

Jude des Bordes,

Nahid

Rianon Results:35 out of 40 facilities provided information

No facility had restrictions for mentation or level of mobility, permitted continuation of restraints, or had certified dementia care units. All facilities permitted continuation of Foleys as appropriateMedications were reviewed on a “case by case” basis 18 facilities allowed sitter for fall risk 30 facilities had PEG-tube feeding accommodations, 30 could not continue NG-Tube feeding, 27 could not continue TPN 5 (14.2%) had memory care wingConclusions:Facilities had varied capabilities and lacked dementia-specific care units. Conditions requiring more frequent or costly care were commonly not accommodated. Many facilities lacked established criteria for particular conditions and reviewed patients on a “case-by-case” basis. Recent COVID19 precautions may limit certain current capabilities thus the need for future review

Methods:In collaboration with hospital multidisciplinary rounding teams, a master list of SNFs within a 10-mile radius of urban university hospital was createdFacility coordinators were interviewed over the phone about capabilities of their facilities and whether they were limited by predetermined set of geriatric and dementia care factorsResults were recorded for each facility and summary data of particular capabilities of facilities were describedOverview/Problem Statement:Older patients with dementia may have a prolonged length of hospital stay, partly as a result of disposition factorsFactors like inability to return home, to prior state of living, or need for monitoring for medical care may require consideration of appropriate post-acute care facility at time of dischargeSkilled nursing facilities (SNFs) comprise roughly half of all post-acute care discharges Our aim was to compile a list of neighborhood SNFs and their relevant medical capabilities for geriatric patients to guide discharge teams

Slide54

Figure: Approximate catchment area of facilities

Skilled Nursing Facility Discharges for Memorial Hermann Hospital Texas Medical Center

Christian Hernandez, Andrew Albrecht, Terry Jennings, Geri Hart,

Jude des

Bordes

, Nahid Rianon

Slide55

Identifying Resident Burnout and its Manifestations

Anabel Ruiz, MD; Michelle R. Klawans, MPH; Chermaine Tyler, PhD; Yu Wah, MD; Nahid Rianon, MD DrPH

Results:

Ninety-one percent (N=33) of residents responded to the survey.

Overall, 27% (n=9) of the residents who completed the survey endorsed burnout.

Residents who experienced work related anxiety and who attributed feeling irritable or moody due to high workload reported higher burnout rates than those who did not.

Conclusions:Compared to a January 2019 QI project, resident self-report of burnout increased by 28.6%.Probable reason: COVID-19 pandemicIn 2020, PGY-2s and PGY-3s, appeared marginally more likely to experience burnout as compared to PGY-1s. Interventions are needed to reduce resident burnout. Methods:An electronic survey (Qualtrics) was distributed to all family medicine residents. The survey was anonymous.The survey contained the Abbreviated Maslach Burnout Inventory tool, as well as questions on physical symptoms of burnout and stress. The survey measured the three dimensions of burnout: emotional exhaustion, depersonalization and personal accomplishment. Further, the survey asked residents questions on eating habits, exercise, and meditation.

Overview/Problem Statement:Burnout is characterized by depersonalization, emotional exhaustion, and low personal accomplishment, leading to detrimental professional and personal consequences.An estimated 48% of Family Medicine physicians are experiencing burnout. In a January 2019 QI project, 21% of McGovern Family Medicine Residents screened positive for burnout.

Slide56

Figure:

Identifying Resident Burnout and its Manifestations

Anabel Ruiz, MD; Michelle R. Klawans, MPH; Chermaine Tyler, PhD; Yu Wah, MD; Nahid Rianon, MD DrPH

Slide57

Clinic Education on HPV Vaccination and Vaccination Rate Outcomes

Isabelle Zare, MD; Michelle R. Klawans, MPH, & Shira Goldstein, MD

Results:

Twenty-four surveys were distributed and returned.

Following receipt of the pamphlet, 95.8% of respondents reported that the understood the importance of HPV vaccination, and 100% reported that they were willing to discuss vaccination with their provider.

Additionally, 13 patients aged 26 to 45 years were vaccinated in the post-intervention period as compared to none in the pre-intervention period.

Conclusions:Patient education DOES work in terms of increasing education and self-reported understanding of vaccine administration and efficacy.However, it is not an effective stand-alone method of increasing rates of vaccine administration in the office.In addition, the rates of vaccination even in clinics with a high rate of insured patient population remain low.As evidenced in previous studies, patient education alone is not as effective as it is in combination with community and government policy efforts.Methods:Data collection was comprised of a qualitative assessment of yes/no questions directed at patients that focused on their subjective understanding of HPV vaccination.Surveys were administered at the beginning of patient clinic visits and collected prior to discharge.Data was extracted from the EMR concerning the total number of HPV vaccinations administered in the trial period of 6 weeks survey administration.This number was compared to the number of vaccinations administered in a 6-week dummy period without intervention. Overview/Problem Statement:Vaccination against HPV prevents cervical, oropharyngeal, and anorectal cancers by protecting against strains for the virus with higher rates of transformation to malignant lesions.

In the United States, 4 categories encompass the main drivers of vaccination refusal: religions, personal beliefs, safety concerns, and desire for additional education.In 2017, approximately 49% of adolescents in the US were vaccinatedPilot studies on targeted educational pamphlets showed upwards of 60% of recipients reporting follow-up conversations on HPV and vaccination with family members and close friends.

Slide58

Figures:

Clinic Education on HPV Vaccination and Vaccination Rate Outcomes

Isabelle Zare, MD; Michelle R. Klawans, MPH, & Shira Goldstein, MD

Slide59

Adequacy of follow-up in patients with depression: A pilot study

Naveen Mahmood, MD; Shira Goldstein, MD; Brenda Cazares

Cerecero

, LCSW;

Jude des

Bordes, MBChB; Chermaine Tyler, PhD; Nahid Rianon MD, DrPH

Results:N= 24 patients, median age= 58 (23-82) years, female=16 (66.7%) At enrollment, moderate disease=3 (12.5%), moderate-to-severe= 10 (41.7%), severe = 11 (45.8%) Mean PHQ-9 score was 18.8 (±4.5) in 2019 and 17.7 (±4.5) in 2020All patients received anti-depressants. No. improved after one year = 13 (54.2%) Improvements by initial disease severity: moderate - 1 of 3 (33.3%), moderate-to-severe - 3 of 10 (30%), severe - 9 of 11 (81.8%) No meeting adequacy criteria= 3 (12.5%) Conclusions:Although some improvement was seen in over half of the patients after one year of follow-up, only 3 (12.5%) met adequacyMore patients with severe disease improved compared to those with less severe disease. This could be due to severe disease receiving more attention or having more room for improvement. There is the need for a larger study.

Methods:We reviewed medical records of patients 18 years and older who screened positive for depression using the Patient Health Questionnaire (PHQ-9) in July 2019 PHQ-9 is scored from 0 to 27, higher scores indicating more severe diseaseWe compared the initial PHQ-9 scores with scores after one year of follow-upImprovement in scores is any decrease in PHQ-9 score on follow-up. We operationally defined adequacy of follow-up as a decrease of 5 units or more.Overview/Problem Statement:Detection of depression through routine screening in primary care offers opportunities for early diagnosis and managementPatients seen at UTP family medicine are routinely screened for depressionIt is uncertain however, if such screened-detected patients receive adequate follow-up by their primary care physicians We aimed to assess the adequacy of follow-up of patients with screen-detected depression

Slide60

Evaluation of patient experience of telemedicine in primary care: a pilot study

Olasunkanmi

Adeyinka,MD

; Shira

Goldstein,MD

; Jude des Bordes, MBChB;Nahid Rianon, MD, DrPH

Results:10 of 35 (28.6%) patients contacted completed the interview. Median age was 54.5 years (range: 22-80), 90% were female, 50% were Black, 80% were non-Hispanic. Mean usability score was 82.5% (range: 52.5-100). Mean scores: -Ease of learning - 6.3 (±1.1) /7-Ease of use - 6.18 (1.2)/7-Satisfaction - 5.8 (1.5)/7.All respondents would recommend telemedicine to friends and family.Conclusions:Most participants found telemedicine very usable. There is the need to do the study in a larger sample

Methods:A pilot cross-sectional study using telephone surveysParticipants were patients who had received care through telemedicine at one clinic in July 2020Data collected:demographics( age, sex, race/ethnicity, level of education)Usability using the Systems Usability Scale (SUS)Ease of use, Ease of learning and Satisfaction using the Usefulness, Satisfaction and Ease of Use (USE) questionnaireA descriptive analysis was done Overview/Problem Statement:Telemedicine is the application of telecommunication technologies to healthcare delivery over a distanceUTHealth had been exploring use of telemedicine platform before COVID-19 outbreak, pandemic necessitated quick deployment Used by over 1500 UT Physicians (UTP) patients from March to May 2020We aim to improve quality of care by evaluating patient experiences in use of telemedicine

Slide61

Figures:

Percentage of agreement with items on Ease of Use

Percentage of agreement with items on satisfaction

Figure 1

Figure 2

Evaluation of patient experience of telemedicine in primary care: a pilot study

Olasunkanmi Adeyinka,MD; Shira Goldstein,MD; Jude des Bordes, MBChB;Nahid Rianon, MD, DrPH

Slide62

Cardiac Arrest Resuscitation Workshop

John Waller-Delarosa MD, Richard

Witkov

MD,

Andreea

Xavier MD, Kevin Schulz MD, Benjamin Cooper MD, Joseph Gill MD, Greg Ducach MD, Erin Hanlin MD, Evan Kuhl MD

Results: The simulation cases were selected to highlight certain special considerations and advanced resuscitative techniques beyond ACLS. Included within the cases were key procedural skills (LMA placement and intraosseous line placement). Afterwards, a video conference format code debrief was held with the group followed by discussion of the evolving literature and various aspects of critical communicationsConclusions:After 6 simulation and 5 debrief sessions, nearly all 35 of the hospitalists were able to participate in the cardiac arrest resuscitation workshop. It served as an example of interdepartmental, attending-level simulation and analysis as a quality improvement intervention.Methods: The hospitalist group partnered with the emergency medicine department to create a two-part workshop with both a simulation session and small group discussion. In small groups of 4-6, the participants alternated running simulated cardiac arrest resuscitations with limited resources and novice team members.

Overview/Problem Statement:Cardiac arrest is a highly time sensitive and highly lethal pathology. If a patient is to be effectively resuscitated, a team-based approach with clear communication, rapid interventions, and high-level diagnostic considerations is required. The complexity of these resuscitations is, in addition, compounded by resource limitations and variable level of experience with each member of the care team. Amplifying these challenges is the rarity of this clinical scenario on the medicine floor.

Slide63

Adaptive Education Curriculum for Emergency Medicine Providers During the Early Stages of a Global Pandemic

Richard

Witkov

MD, John Waller-Delarosa MD, Samuel Prater MD, Kunal Sharma MD

Results:

From March 2020 to July 2020 a series of talks were incorporated into the existing conference format to address a range of arising topics. A unique format dividing time between departmental protocols and evidence base complemented by case discussions allowed providers to not only be aware of changing guidelines but also understand the context around those guidelines in order to allow for future adaptation. Furthermore, an open format allowed for real-time discussion and adjustment of practice based on consensus opinion in the face of the unknown. Topics such as thrombosis, awake proning, aerosol versus droplet spread, non-invasive management, STEMI management, anti-viral agents, and steroids were addressed.

Conclusions:Fundamental to new data acquisition are sound physiologic principles, prior evidentiary basis of similar disease processes, and rigorous analysis of novel publications. As such, the education curriculum developed applied the known to the unknown and may serve as a blueprint for dealing with education during future medical catastrophes.Methods:Rapid utilization of a video-based lecture series created a shared practice model in the Emergency Department while maintaining flexibility for incorporation of novel information.Overview/Problem Statement:The emergence of COVID-19 as a global, deadly pandemic in early 2020 posed significant challenges in information deployment and acquisition for physicians in the Emergency Department acting upon often limited management guidelines and knowledge base. Additionally, complicating the situation, a need existed for accurate dissemination of changing protocols at two different clinical sites to an audience including residents, attendings, and advanced practice providers.

Slide64

Protected Code Blue Deployment in the Emergency Department During a Global Pandemic

Richard

Witkov

MD, John Waller-Delarosa MD, Samuel Prater MD, Salil Bhandari MD, Eddie Mejia MD, Krystal

Turgiss

MDResults:Components of the created pathway are demonstrated on the figures and diagrams slide which follows this one. Additionally, the instructional video is available on

Youtubetm.Conclusions:Valuable lessons learned from the rapid deployment of a protected code blue protocol during the SARS-CoV-2 pandemic can serve to guide management of cardiac arrest in future pandemics and guarantee delivery of high-quality CPR while protecting providersMethods:Based on the available evidence from SARS-CoV-1, the experience of other institutions whose peak surge preceded that of Houston, and based on local expert consensus, a protected code blue pathway was established. This protocol aimed to minimize the number of care team members in the room, ensure proper PPE compliance, utilize mechanical chest compression devices, incorporate mechanical barriers to droplet spread, and ultimately deliver high quality cardiac arrest resuscitation with minimized risk of disease transmission. The pathway was also bundled with a code blue bag, an updated code cart with PPE, and an instructional video for dissemination. Overview/Problem Statement:Patients who undergo cardiac arrest have a narrow critical time window to treat the underlying cause and restore spontaneous circulation. During this interval, maintaining some systemic perfusion via chest compressions is key for neuro intact survival. Additionally, securing a definitive airway to allow for mechanical ventilation is a key step. However, evidence from SARS-CoV-1 suggested that CPR and intubation both increase the risk of airborne spread. During the SARS-CoV-2 outbreak, the challenge of delivering rapid, effective cardiopulmonary resuscitation to patients while also minimizing the risk of disease transmission became of critical importance.

Slide65

Figures (if any):

Protected Code Blue Deployment in the Emergency Department During a Global Pandemic

Richard

Witkov

MD, John Waller-Delarosa MD, Samuel Prater MD, Salil Bhandari MD, Eddie Mejia MD, Krystal

Turgiss

MD

Slide66

rTEG

Quick Reference Cards

Samuel Prater MD, John Waller-Delarosa MD, Brad Egbers MD

Methods:

After identifying an opportunity within our internal quality case database (Medical Incident Response System or MIRS) to improve dissemination and access to the

rTEG values and their clinical implications, rTEG quick reference cards were constructed. The evolving literature on rTEG was appraised, and the values along with their interpretation were vetted by trauma surgery and emergency medicine leadership. The values and their interpretation were placed on a quick reference sheet along with graphical depictions of the rTEG

coagulation curve. These quick reference sheets were laminated and placed in high yield areas near workstations in both the trauma side of the adult emergency department and the pediatric emergency department. Overview/Problem Statement:Trauma is a leading cause of morbidity and mortality in all age groups. The lethal triad of trauma consists of acidosis, hypothermia, and coagulopathy. Many institutions have moved to advanced methods of evaluating the coagulation parameters of a patient, such as thromboelastography, as a means of more accurately assessing and reversing the coagulopathy of trauma. However, this test can be complex to interpret rapidly with various parameters and cutoffs, each representing a different transfusion intervention.

Slide67

Emergency Medicine Standardized Handoff Process

Yashwant Chathampally MD,

Chigozie

Dike MD, Katrina

Nemri

MDResults: We have recruited faculty and resident champions for SHOP that will assist us in our current pilot phase. During this phase, champions are observing sign outs including duration, complexity, and efficacy. In addition, we are obtaining feedback through resident questionnaires to document results (positive, negative, areas of improvement) regarding SHOP.

Conclusions:Our plan is to implement department wide use of SHOP and continue to obtain feedback on our progress to reduce medical errors and enhance patient safetyMethods: Our Standardized Hand-over Process (SHOP) at UT McGovern is a quality improvement project built similarly, with a goal to make sign out the safest time for our patients. It involves a brief patient introduction to the oncoming team by using patient identifiers, patient stability, working diagnosis and disposition, followed by brief ED workup summary and pending actions. The oncoming team then asks questions on the patient signout they have received and then briefly summarizes before moving on to the next patient.Overview/Problem Statement:The verbal hand-off of patient care during change of shift in the emergency department has been recognized as a potentially hazardous process as large volumes of clinical information must be relayed concisely without omitting key data points. Inefficient or incomplete hand-off can result in significant delays in patient management, and miscommunications in the care plan contributing to medical error. Studies have demonstrated that by implementing a standardized handoff protocol, we can reduce medical error in our patients. I-PASS and ED-VITALS are some examples that have been effective in many departments.

Slide68

Incidence of Vitamin D Deficiency in the Operative Pediatric Orthopedic Patient

Brennan Roper, M.D.

Results:

85 patients were consented and successfully had lab values obtained between the months of January 2021 – April 2021 in our specified population. Of these 85 operative pediatric Orthopedic patients, 75 patients (88%) demonstrated insufficiency (25(OH)D of 21–29 ng/ml) and 51 patients (60%) demonstrated deficiency (25(OH)D of 20 ng/ml or below). Of these deficient patients, 30/51 (59%) demonstrated 25(OH)D values equal to or less than 15 ng/ml – less than half of the minimum normal value (30ng/ml) in the pediatric population.

Conclusions:

A concerning incidence of vitamin D insufficiency and deficiency exists in our current operative pediatric Orthopedic patient population. This pilot study prompts further and more expansive investigation into vitamin D deficiency in the pediatric Orthopedic population and should prompt changes in the standard of care.

Methods:A prospective pilot study was performed in which a 25-hydroxyvitamin D lab value (25(OH)D) was obtained on all consenting patients taken to the operating room for bony procedures between the ages of 1 – 18 years old. Criteria for insufficiency and deficiency was based upon the most recent recommendations published in the Endocrine Society Clinical Practice Guidelines.Overview/Problem Statement: Vitamin D plays an important role in bony metabolism and remodeling. Reports over the past decade have documented incidence of vitamin D deficiency in the general pediatric population ranging from 49% – 61% 1-4. Additionally, vitamin D deficiency has been associated with increased severity of fracture in the pediatric Orthopedic patient population.

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Mobile Stroke Unit Computed Tomography Angiography Substantially Shortens Door-to-Puncture Time

Alexandra L Czap, Noopur Singh, 

Ritvij

Bowry

, Amanda Jagolino-Cole, Stephanie A Parker, Kenny Phan, Mengxi Wang, Sunil A Sheth, Suja S

Rajan, Jose-Miguel Yamal, James C GrottaResults:Median DTPT was 53.5 (95% CI, 35-67) minutes shorter with onboard CTA and direct ET team notification: 41 minutes (interquartile range, 30.0-63.5) versus 94.5 minutes (interquartile range, 69.8-117.3; P<0.001). Median on-scene time was 31.5 minutes (interquartile range, 28.8-35.5) versus 27.0 minutes (interquartile range, 23.0-31.0) (P<0.001). Shorter DTPT correlated with greater improvement of National Institutes of Health Stroke Scale (correlation=-0.2, P=0.07). Conclusions:Prehospital Mobile Stroke Unit management including onboard CTA and ET team alert substantially shortens DTPT.

Methods:We compared DTPT between patients having CTA onboard the Mobile Stroke Unit then subsequent ET from September 2018 to November 2019 and patients in Mobile Stroke Unit from August 2014 to August 2018, when onboard CTA was not yet being used. We also correlated DTPT with change in National Institutes of Health Stroke Scale between baseline and 24 hours.  Overview/Problem Statement:Endovascular thrombectomy (ET) door-to-puncture time (DTPT) is a modifiable metric. One of the most important, yet time-consuming steps, is documentation of large vessel occlusion by computed tomography angiography (CTA). We hypothesized that obtaining CTA onboard a Mobile Stroke Unit and direct alert of the ET team shortens DTPT by over 30 minutes.