- Email: [email protected]
102. CARPE DIEM MEDIUM: MAKING THE MOST IMPACT IN AN ACADEMIC HALF DAY
TAGEDENACADEMIC PEDIATRICS 1-on-1 education for inbox set-up and management; targeted education for particular residents; clinic timeouts; reminders in chief weekly email; utilizing medical assistants (MAs) to communicate normal results. MEASURES: Residents on the ambulatory rotation performed monthly audits of the continuity clinic residents’ inboxes (n = 60) before and after each of nine interventions. Rates of non-compliance, severe non-compliance, and absolute number of unaddressed items were tracked. RESULTS: Inbox non-compliance for residents decreased throughout 2018 from 51% in January to 17% by December. Severe non-compliance decreased from 17% to 3.3% over the same period. Not all inboxes were reviewed each month due to technology issues and supervisor availability, but the number of inboxes reviewed increased over time to include all by the end. CONCLUSIONS AND NEXT STEPS: While difficult to determine which intervention had the biggest impact, a significant drop occurred by utilizing MAs to communicate normal results. A large spike in non-compliance occurred in August, correlating with a new academic year. The cumulative effect of frequent reminders and status updates most likely led to steady improvement. The ongoing investment of new residents in the interventions was important for energizing and sustaining change. Next steps are to identify resident champions for each day of continuity clinic and to improve the training of new residents.
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MEASURES: Process, outcome and balancing measures were collected via electronic medical record review (resident documentation of EEC screening, dental referrals and developmental screening respectively). Statistical control charts were utilized to display and analyze the data. API rules were applied to detect special cause variation. RESULTS: 281 patients were screened. Oral health risk assessment improved from 37.84% to 77.74%. Initially, 72.22% of screened patients were at high risk for caries (with >1 risk factor for ECC on risk assessment tool). Over time, this rate significantly decreased to 52.46% largely due to family education. On average, 47.66% of screened patients had a dental home. Residents reached outcome goal of 90% referral rate for those patients without a dental home. Developmental screening rate, as a balancing measure, remained at 100% compliance. CONCLUSIONS AND NEXT STEPS: Implementation of this QI project showed our patient population was at high-risk for ECC, which had previously been unknown, and decreased with our interventions. Creation of an electronic screening tool facilitated screening. Family education and providing a referral list of community dentists were the most successful interventions. Next steps include creating an electronic dental referral system and partnering with community dentists to enhance ECC-related family and patient education.
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TAGEDEN TAGEDEN 101. RESIDENT-LED QI INITIATIVE TO IMPROVE ASSESSMENT AND CARE OF PATIENTS WITH EARLY CHILDHOOD CARIES Melanie Degliuomini, MD, Angela Chan, MD, Snezana Osorio, MD, MS, Erika Abramson, MD, MS, Robyn Rosenblum, MD, New York Presbyterian Hospital (Cornell Campus), New York, NY
102. CARPE DIEM MEDIUM: MAKING THE MOST IMPACT IN AN ACADEMIC HALF DAY Taylor Couch, MD, Michelle Escala, MD, Amy Hendrix, MA, Michelle Condren, PharmD, Keith Mather, MD, University of Oklahoma School of Community Medicine (Tulsa), Tulsa, OK
BACKGROUND: Early childhood caries (ECC), defined as one or more decayed, missing, or filled teeth in children under 6 years, is the most common, chronic, preventable condition in childhood. ECC affects 28% of US children 2-5 years of age, particularly children of lower socioeconomic status. The American Academy of Pediatric Dentistry (AAPD) and the AAP recommend that children establish a dental home by 12 months, but lack of standardized ECC assessments and dental referral processes are often barriers to optimal care. AIM STATEMENT: In this 12- month long resident-led QI project we aimed to improve the ECC risk assessment rate for children 6 months to 6 years to 70%, and to improve the dental referral rate to 90%. INTERVENTIONS: The Model of Improvement was used for this QI project from December 2017 to December 2018 at a community clinic affiliated with an academic center. An electronic Oral Risk Assessment Tool was created based on AAP guidelines. Residents performed 6 plan-do-study-act (PDSA) cycles utilizing 7 interventions derived from tertiary key drivers.
BACKGROUND: There are a variety of challenges to providing meaningful and relevant education to pediatric residents, including adapting to different adult learning styles, availability of lecturers, and balancing protection of educational times and coverage of patient care. In 2015, our program noticed a decline in our board pass rate to 25% for this graduating class, which lowered our three year pass rate for first time takers to 65% for 2013-15. AIM STATEMENT: Our educational goal is planned to improve in training exam (ITE) standard scores to national average and improve first-time-taker board pass rates to meet 3 year pass rate of at least 80% by 2019 and 100% by 2021. INTERVENTIONS: We used serial PDSA cycles with change processes during the academic afternoons from 2015 through 2019. In 2015-16, we initiated a standardized 18-month curriculum. In 2016-17, we revised curriculum focusing on American Board of Pediatrics (ABP) content specifications and providing residents with standardized pre-reading materials. In 2017-18, we adjusted the curriculum to 12-months and started to follow residents’ progress and assess knowledge gaps using an online pediatric
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question bank. This also helped us track residents considered “at risk” for board failure. MEASURES: We trended ITE scores and first-time-taker ABP board pass rates to measure effectiveness in changes to half day processes. RESULTS: When tracking ITE scores, our intern class in 2015 had a score 9 points below national average, and in their third year closed gap to 3 points below. As for our intern class from 2016, they averaged a 16 point deficit, improved to a 4 point deficit in 2017, and surpassed national average by 2 points in 2018. In regards to first-time-taker board pass rates, we had rates of 40% (2/5 residents) for 2015, 83% (5/6) for 2016, 83% (5/6) for 2017, and 100% (7/7) for 2018. Our 3 year first-time board pass rate increased to 85% for 2016-18. CONCLUSIONS AND NEXT STEPS: Academic half days do pose some challenges in regards to scheduling coverage and faculty lecturers; however, our utilization has been successful and well received by our residents. We have shown significant improvement in ITE scores and board pass rate with minor changes each year. Our next PDSA cycle now incorporates weekly board review for the third year residents and a longitudinal developmental/behavioral/psychiatric curriculum for first and second year residents.
*Winner* APPD trainee research award 103. IMPROVING SCREENING LAB COMPLIANCE IN AN URBAN PEDIATRIC PRACTICE Madhuri G. Dave, DO, Kaitlin M. McKenna, DO, Lauren E. Castaneda, MD, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI BACKGROUND: Screening laboratory evaluations are important components of pediatric primary care. Current AAP guidelines recommend hemoglobin and lead screening at 12 months as well as lipid screening between 9-11 years. Health disparities, including variable access to transportation, contribute to failure to complete recommended screening labs at an underserved urban pediatric clinic. Following urban clinic relocation from site 1 to site 2 and subsequent loss of on-site phlebotomy, the average lab completion rate declined significantly. AIM STATEMENT: Our primary aim is to increase the rate of screening lab completions in our urban pediatric population to 75% by December 2018. INTERVENTIONS: A multidisciplinary team completed a Quality Improvement study to evaluate barriers to completing screening labs. Standardized phone calls to families with incomplete labs were made and fishbone diagrams were created to categorize barriers. A process map was created to understand the steps required to complete screening labs. Interventions included: reminder phone calls, standardized instructions placed into After Visit Summary (directions to the lab location, lab hours and public transportation routes to the lab), initiation of access to onsite phlebotomy, and training of on site clinic staff in phlebotomy. MEASURES: Outcome measures were the percent of patients with completed screening labs. Process measures included percentage of patients without complete labs who received followup phone calls. Balancing measures were allocation and cost of staff resources. Plan Do Study Act (PDSA) methodology was used to implement and test interventions. Statistical process control charts were used to analyze the impact of interventions. RESULTS: 473 charts were reviewed. Average screening lab completion at Site 1 was 79% with decline to baseline of 21%
ACADEMIC PEDIATRICS with move to clinic Site 2. Lab completion rates increased to mean of 42% with initial interventions in action period. Lab completion increased to 90% with special cause improvement after on site staff phlebotomy training. Cost analysis data pending. CONCLUSIONS AND NEXT STEPS: Significant increase was noted in lab completion upon the addition of on-site lab phlebotomy at site 2. Initial interventions did not lead to increased compliance rates further highlighting the importance of accessibility in an urban population. Urban underserved clinics may consider addition of on-site phlebotomy to continue to close the gaps in health disparity.
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104. IDENTIFYING PATIENTS AT RISK OF CLINICAL DETERIORATION PRIOR TO PICU TRANSFER Hamza Nasir, MD, Sara Ghannam, MD, Sumeet Gill, DO, Scott Studeny, MD, Denrik Abrahan, MD, Archana Ramgopal, DO, Amanda Spicer, ANM, Jamie Fast, CNP, Arnaldo Zayas-Santiago, MD, Katie Pestak, DO, Nicholas Davalla, Amrit Gill, MD, Cleveland Clinic Foundation, Cleveland, OH BACKGROUND: Cleveland Clinic Children’s incorporated the Situational Awareness (SA) model in 2013 to prevent and reduce patient unrecognized clinical deterioration (UCD). The model equips healthcare providers to identify patients at risk of deterioration via use of various criteria and intervene in a timely manner. From April 2018 through August 2018, only 14% of patients transferred to the PICU from the RNF were identified as SA. Our goal was to increase utilization of the SA model to identify patients at risk of clinical deterioration to at least 50% prior to PICU transfer. This project was sponsored by an ACGME initiative aimed at supporting innovation to transform the clinical learning environment where residents pursue their training. AIM STATEMENT: Increase the percentage of patients identified as Situational Awareness prior to transfer to PICU from 14% to 50% by November, 2018. INTERVENTIONS: Interventions were implemented over a period of 4 months: 1) incorporating assessment of patients SA status during morning rounds with the multidisciplinary team including Nursing, 2) SA discussion during resident afternoon sign-out and 3) adding SA status identification box into the resident electronic sign-out form. The processes were audited randomly to ensure interventions were being carried out. MEASURES: Data were collected through a retrospective chart review surveying SA documentation of patients prior to PICU transfer from the RNF. Only patients under Pediatric residentrun services were included. Data were obtained from Cleveland Clinic Quality Data Registries and monitored bi-weekly. RESULTS: Following implementation of interventions, data show a median of 50% of patients being identified as SA prior to transfer to PICU. Based on observations and audits, those teams which included Nursing on morning rounds had better outcomes. Assessment of patients during morning rounds had the most
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MEASURES: Process, outcome and balancing measures were collected via electronic medical record review (resident documentation of EEC screening, dental referrals and developmental screening respectively). Statistical control charts were utilized to display and analyze the data. API rules were applied to detect special cause variation. RESULTS: 281 patients were screened. Oral health risk assessment improved from 37.84% to 77.74%. Initially, 72.22% of screened patients were at high risk for caries (with >1 risk factor for ECC on risk assessment tool). Over time, this rate significantly decreased to 52.46% largely due to family education. On average, 47.66% of screened patients had a dental home. Residents reached outcome goal of 90% referral rate for those patients without a dental home. Developmental screening rate, as a balancing measure, remained at 100% compliance. CONCLUSIONS AND NEXT STEPS: Implementation of this QI project showed our patient population was at high-risk for ECC, which had previously been unknown, and decreased with our interventions. Creation of an electronic screening tool facilitated screening. Family education and providing a referral list of community dentists were the most successful interventions. Next steps include creating an electronic dental referral system and partnering with community dentists to enhance ECC-related family and patient education.
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TAGEDEN TAGEDEN 101. RESIDENT-LED QI INITIATIVE TO IMPROVE ASSESSMENT AND CARE OF PATIENTS WITH EARLY CHILDHOOD CARIES Melanie Degliuomini, MD, Angela Chan, MD, Snezana Osorio, MD, MS, Erika Abramson, MD, MS, Robyn Rosenblum, MD, New York Presbyterian Hospital (Cornell Campus), New York, NY
102. CARPE DIEM MEDIUM: MAKING THE MOST IMPACT IN AN ACADEMIC HALF DAY Taylor Couch, MD, Michelle Escala, MD, Amy Hendrix, MA, Michelle Condren, PharmD, Keith Mather, MD, University of Oklahoma School of Community Medicine (Tulsa), Tulsa, OK
BACKGROUND: Early childhood caries (ECC), defined as one or more decayed, missing, or filled teeth in children under 6 years, is the most common, chronic, preventable condition in childhood. ECC affects 28% of US children 2-5 years of age, particularly children of lower socioeconomic status. The American Academy of Pediatric Dentistry (AAPD) and the AAP recommend that children establish a dental home by 12 months, but lack of standardized ECC assessments and dental referral processes are often barriers to optimal care. AIM STATEMENT: In this 12- month long resident-led QI project we aimed to improve the ECC risk assessment rate for children 6 months to 6 years to 70%, and to improve the dental referral rate to 90%. INTERVENTIONS: The Model of Improvement was used for this QI project from December 2017 to December 2018 at a community clinic affiliated with an academic center. An electronic Oral Risk Assessment Tool was created based on AAP guidelines. Residents performed 6 plan-do-study-act (PDSA) cycles utilizing 7 interventions derived from tertiary key drivers.
BACKGROUND: There are a variety of challenges to providing meaningful and relevant education to pediatric residents, including adapting to different adult learning styles, availability of lecturers, and balancing protection of educational times and coverage of patient care. In 2015, our program noticed a decline in our board pass rate to 25% for this graduating class, which lowered our three year pass rate for first time takers to 65% for 2013-15. AIM STATEMENT: Our educational goal is planned to improve in training exam (ITE) standard scores to national average and improve first-time-taker board pass rates to meet 3 year pass rate of at least 80% by 2019 and 100% by 2021. INTERVENTIONS: We used serial PDSA cycles with change processes during the academic afternoons from 2015 through 2019. In 2015-16, we initiated a standardized 18-month curriculum. In 2016-17, we revised curriculum focusing on American Board of Pediatrics (ABP) content specifications and providing residents with standardized pre-reading materials. In 2017-18, we adjusted the curriculum to 12-months and started to follow residents’ progress and assess knowledge gaps using an online pediatric
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question bank. This also helped us track residents considered “at risk” for board failure. MEASURES: We trended ITE scores and first-time-taker ABP board pass rates to measure effectiveness in changes to half day processes. RESULTS: When tracking ITE scores, our intern class in 2015 had a score 9 points below national average, and in their third year closed gap to 3 points below. As for our intern class from 2016, they averaged a 16 point deficit, improved to a 4 point deficit in 2017, and surpassed national average by 2 points in 2018. In regards to first-time-taker board pass rates, we had rates of 40% (2/5 residents) for 2015, 83% (5/6) for 2016, 83% (5/6) for 2017, and 100% (7/7) for 2018. Our 3 year first-time board pass rate increased to 85% for 2016-18. CONCLUSIONS AND NEXT STEPS: Academic half days do pose some challenges in regards to scheduling coverage and faculty lecturers; however, our utilization has been successful and well received by our residents. We have shown significant improvement in ITE scores and board pass rate with minor changes each year. Our next PDSA cycle now incorporates weekly board review for the third year residents and a longitudinal developmental/behavioral/psychiatric curriculum for first and second year residents.
*Winner* APPD trainee research award 103. IMPROVING SCREENING LAB COMPLIANCE IN AN URBAN PEDIATRIC PRACTICE Madhuri G. Dave, DO, Kaitlin M. McKenna, DO, Lauren E. Castaneda, MD, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI BACKGROUND: Screening laboratory evaluations are important components of pediatric primary care. Current AAP guidelines recommend hemoglobin and lead screening at 12 months as well as lipid screening between 9-11 years. Health disparities, including variable access to transportation, contribute to failure to complete recommended screening labs at an underserved urban pediatric clinic. Following urban clinic relocation from site 1 to site 2 and subsequent loss of on-site phlebotomy, the average lab completion rate declined significantly. AIM STATEMENT: Our primary aim is to increase the rate of screening lab completions in our urban pediatric population to 75% by December 2018. INTERVENTIONS: A multidisciplinary team completed a Quality Improvement study to evaluate barriers to completing screening labs. Standardized phone calls to families with incomplete labs were made and fishbone diagrams were created to categorize barriers. A process map was created to understand the steps required to complete screening labs. Interventions included: reminder phone calls, standardized instructions placed into After Visit Summary (directions to the lab location, lab hours and public transportation routes to the lab), initiation of access to onsite phlebotomy, and training of on site clinic staff in phlebotomy. MEASURES: Outcome measures were the percent of patients with completed screening labs. Process measures included percentage of patients without complete labs who received followup phone calls. Balancing measures were allocation and cost of staff resources. Plan Do Study Act (PDSA) methodology was used to implement and test interventions. Statistical process control charts were used to analyze the impact of interventions. RESULTS: 473 charts were reviewed. Average screening lab completion at Site 1 was 79% with decline to baseline of 21%
ACADEMIC PEDIATRICS with move to clinic Site 2. Lab completion rates increased to mean of 42% with initial interventions in action period. Lab completion increased to 90% with special cause improvement after on site staff phlebotomy training. Cost analysis data pending. CONCLUSIONS AND NEXT STEPS: Significant increase was noted in lab completion upon the addition of on-site lab phlebotomy at site 2. Initial interventions did not lead to increased compliance rates further highlighting the importance of accessibility in an urban population. Urban underserved clinics may consider addition of on-site phlebotomy to continue to close the gaps in health disparity.
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104. IDENTIFYING PATIENTS AT RISK OF CLINICAL DETERIORATION PRIOR TO PICU TRANSFER Hamza Nasir, MD, Sara Ghannam, MD, Sumeet Gill, DO, Scott Studeny, MD, Denrik Abrahan, MD, Archana Ramgopal, DO, Amanda Spicer, ANM, Jamie Fast, CNP, Arnaldo Zayas-Santiago, MD, Katie Pestak, DO, Nicholas Davalla, Amrit Gill, MD, Cleveland Clinic Foundation, Cleveland, OH BACKGROUND: Cleveland Clinic Children’s incorporated the Situational Awareness (SA) model in 2013 to prevent and reduce patient unrecognized clinical deterioration (UCD). The model equips healthcare providers to identify patients at risk of deterioration via use of various criteria and intervene in a timely manner. From April 2018 through August 2018, only 14% of patients transferred to the PICU from the RNF were identified as SA. Our goal was to increase utilization of the SA model to identify patients at risk of clinical deterioration to at least 50% prior to PICU transfer. This project was sponsored by an ACGME initiative aimed at supporting innovation to transform the clinical learning environment where residents pursue their training. AIM STATEMENT: Increase the percentage of patients identified as Situational Awareness prior to transfer to PICU from 14% to 50% by November, 2018. INTERVENTIONS: Interventions were implemented over a period of 4 months: 1) incorporating assessment of patients SA status during morning rounds with the multidisciplinary team including Nursing, 2) SA discussion during resident afternoon sign-out and 3) adding SA status identification box into the resident electronic sign-out form. The processes were audited randomly to ensure interventions were being carried out. MEASURES: Data were collected through a retrospective chart review surveying SA documentation of patients prior to PICU transfer from the RNF. Only patients under Pediatric residentrun services were included. Data were obtained from Cleveland Clinic Quality Data Registries and monitored bi-weekly. RESULTS: Following implementation of interventions, data show a median of 50% of patients being identified as SA prior to transfer to PICU. Based on observations and audits, those teams which included Nursing on morning rounds had better outcomes. Assessment of patients during morning rounds had the most