Digital Commons Network^™

A Model For Improving And Assessing Outpatient Antibiotic Stewardship Interventions For Common Upper Respiratory Tract Infections And Uti, To Improve Appropriate Outpatient Antibiotic Prescribing In Order To Improve Patient Safety, Patient Cost, And Reduce Antimicrobial Resistance In Accordance With The Joint Commission Goal Of Reducing Outpatient Antibiotic Prescriptions For 2020., Jennifer Garcia, Jasmina Demirovic, Melinda Montoya, Niraj Ganjawala, Michael Palestine, Abhishek Tomar, William Bowen

Quality Improvement/Patient Safety Symposium

Aim statement:

Reduce inappropriate antibiotic use by 20% for upper respiratory tract infection (bronchitis, sinusitis, pharyngitis) and UTI from December 2018-March 2019 compared to December 2019-March 2020.

Methods:

A single center before and after intervention study using a quasi-experimental design utilizing the electronic medical records system to identify patients diagnosed with URIs or UTI in six main ambulatory care settings.

• Inclusion criteria
  • Diagnosis of bronchitis, sinusitis, or UTI
  • Timeframe: December 1, 2018 through March 31, 2019

• Exclusion criteria
  • Requirement for antibiotics for other indication(s)
  • Immunocompromising conditions
  • Presence of COPD, cystic fibrosis or bronchiectasis

• The following data points were analyzed
  • Total …

Stop Testing The Patience Of Our Patients – Optimizing Workflow At A Cancer Center Infusion Suite, Shenthol Sasankan, Zoneddy Dayao, Bernard Tawfik, Andrea Cox, Candy Okino, Sandra Peacock, Janet Abernathy, Branda Chaleunphonh, Ron Kittson, Nick Crozier, Richard Lauer, Neda Hashemi

Quality Improvement/Patient Safety Symposium

Introduction

Nationwide, cancer centers experience challenges with infusion center efficiency while maintaining high safety standards, with some patients facing wait times as long as 102 minutes¹. This leads to decreased patient satisfaction and inability to provide optimal care. Lack of standardization among cancer centers results in a wide variation of infusion wait times for patients. In this study, we initiated five interventions at UNM Comprehensive Cancer Center to reduce the wait times for our patients and optimize workflow of the Infusion suite

Materials and Methods

A multidisciplinary working group was formed consisting of the infusion floor physician lead, …

Colon Cancer Screening: Flu-Fobt, Kavitha Kirubanandan, Michael Mckinney, William Bowen, Luis Rigales, Theresa Gonzales

Quality Improvement/Patient Safety Symposium

The Flu-FOBT Program is an innovative and effective way to increase colorectal cancer screening in primary care settings.

Improving Recognition Of Malnutrition At Unmh, Jens Langsjoen, Anthony Worsham, Alyse Raboff, Samantha Paltrow-Krulwich

Quality Improvement/Patient Safety Symposium

Introduction: Protein calorie malnutrition is the most common form of nutritional deficiency among patients who are hospitalized in the U.S. Malnutrition is a significant indicator for severity of illness and expected mortality measures. Previous audits have shown that malnutrition at UNMH is grossly under-recognized, with 4.7% of inpatients diagnosed at discharge compared with a national inpatient malnutrition prevalence of 20-50%. To improve the ultimate coding of a diagnosis of malnutrition, an interdisciplinary process has been developed. The nurse intake malnutrition screening assessments has been updated to be more sensitive, local consensus guidelines have been developed for malnutrition diagnosis and severity …

The Implementation Of The New Unm Operating Room Emergency Manual, Kar-Wei Leung, John R. Rask, Frank Jaime, Tim Petersen

Quality Improvement/Patient Safety Symposium

Introduction

Here we present the implementation of a new UNM Operating Room Emergency Manual (EM) as an improvement process conducted by the Department of Anesthesia in partnership with the operating room and surgical services. Emergency situations can occur in high risk environments such as the operating room. Cognitive aids such as an emergency manual have been demonstrated to facilitate the ease and speed of life saving actions during emergency situations. To improve and standardize our handling of emergency situations we decided to upgrade our operating room emergency manual.

Methods and Materials

This new manual was adapted from the Stanford Emergency …

Can Referrals To A Pediatric Osteopathic Manipulative Medicine (Omm) Clinic Be Increased Through Provider Education?, Arpita Sinha, Elizabeth Yakes Jimenez

Quality Improvement/Patient Safety Symposium

Purpose:

Many pediatricians in the U.S. have trained in osteopathic medicine and have a Doctor of Osteopathy degree. However, other members of the health care team are often unaware of what osteopathic manipulative medicine (OMM) is or its indication in pediatrics. This quality improvement (QI) project aims to increase the average number of referrals to the University of New Mexico Hospital’s (UNMH) pediatric OMM clinic by 25% by May 2020.

Methods:

The QI project was designed based on the Model for Improvement. As the first Plan-Do-Study-Act (PDSA) cycle, health care provider trainings on pediatric OMM were implemented in November 2019. …

Reducing Telemetry Alarm Fatigue, Karla B. Almaraz, Richard Snider, Theresa Mccarty, Amber Rymarz-Freitas, Emily Salmon, Gerald Charlton

Quality Improvement/Patient Safety Symposium

Introduction:

Cardiac Telemetry plays an important role in acute care, appropriate utilization can provide useful and critical information such as fatal arrhythmias and ischemia. Alarms are essential in telemetry, they alert the medical staff with critical patient’s needs, and if not managed appropriately it can compromise the patient’s safety. There are nearly 200,000 alarms generated during one month period, data suggest that about 99% of these alarms are clinically irrelevant or nonactionable. This results in considerable frustration for the telemetry nurses/techs, naturally developing alarm fatigue, becoming annoyed, desensitized and stop paying attention. Desensitization is concerning because clinically important alarms such …

Project Discharge: Implementing An Effective, Patient-Centered Discharge Process In Obstetrical Triage In An Urban Academic Medical Center, Noelle Borders, Amy Stuart, Beth Brown, Trish Mondragon, Gillian Burkhardt, Nicole Yonke, Gabrielle Rivera

Quality Improvement/Patient Safety Symposium

Background: An effective, patient-centered discharge process is the standard of care for any patient discharged from a hospital unit, including obstetrical triage units.

Local Problem: University of New Mexico Hospital’s obstetrical triage unit had no standardized discharge process for pregnant and postpartum women presenting for care. The aim of this quality improvement project was to discharge 65% of patients from OB Triage over an eight-week period using an effective, patient-centered discharge process by harnessing team and patient engagement and a discharge checklist and summary.

Methods: A quality improvement model involving four rapid-cycle plan-do-study-act (PDSA) cycles was utilized. …

Diagnostic Stewardship Interventions For Clostridioides Diffcile Infection, Luke A. Yeager, M E. Lacy

Quality Improvement/Patient Safety Symposium

Background:Our institution’s rate of hospital acquired Clostridioides difficile (C. diff) infection (CDI) is higher than expected based on documented severity of illness of our patients. The C. diff testing algorithm at our institution utilizes a multi-step approach. It begins with two tests (antigen EIA and toxin A/B EIA). If the results of these two tests are indeterminate, the algorithm then reflexes to a third test (NAAT-PCR). Non-toxin producing C. diff colonization can result in a positive C. diff test in the absence of active infection. ^{1, 2} Up to 20% of hospitalized patients are asymptomatic carriers of C. diff. …

Comparing Tdap In Pregnancy Rates Between Unm-Based Clinics: A Quality Improvement Project, Amber Lalla, Katarina Leyba, Taryn Mccue, Sarah Friedburg, Jody Stonehocker, Melissa Martinez

Quality Improvement/Patient Safety Symposium

Background: The American College of Obstetrics and Gynecology (ACOG) recommends the Tdap vaccine during 27-36 weeks of pregnancy protect the neonate from pertussis between birth and their first DTaP vaccine. Nationally the rate of Tdap vaccination in pregnant women is 48-55% with lower rates for women of color, uninsured, and non-English speakers. The Maternity and Family Planning (MFP) clinics at UNM are a federally funded clinics that provide comprehensive prenatal and postnatal care for women, especially low-income and/or at-risk pregnant women. The MFP clinics at UNM do not have Tdap vaccines on site and refer women to the Department of …

Co-Development And Execution Of A Group Qi Project To Meet Acgme Qips Requirements In The Department Of Pediatrics, Kelsey Fath, Lanier Lopez, Anjali Subbaswamy, Alfonso Belmonte, Rebecca Craig, Adam Cross, Anna Duran, Maria Heubeck, Stephen Lunderman, Elizabeth Yakes Jimenez

Quality Improvement/Patient Safety Symposium

Introduction: The Accreditation Council for Graduate Medical Education (ACGME) requires quality improvement and patient safety (QIPS) education for trainees, and faculty development in QIPS for residencies. We describe the process of co-developing and executing a group quality improvement project in the Department of Pediatrics to meet these requirements.

Materials/methods: Over the course of four Resident School lectures and several continuity clinic interactions, residents are being provided with an introduction to quality improvement topics and tools, including the Model for Improvement, Key Driver diagrams, Cause and Effect Diagrams, PDSA cycles and run charts, and are actively engaging with applying QI concepts …

Waste Anesthetic Gases Cost Unmh Money And Contribute To Our Institutional Carbon Footprint, Joe J. Freeman, Karyn M. Nunez

Quality Improvement/Patient Safety Symposium

Introduction: Waste anesthetic gases (WAGs) contribute to climate change. There is a national initiative to reduce greenhouse gas emissions from hospitals and specifically operating rooms and associated anesthetic gases. Various gases currently used have vastly different impacts (see table). Clinicians’ knowledge of these differences and attention gas flow rates and gas type choice can significantly reduce hospital costs and environmental impacts.

Methods: We started with baseline data of purchased anesthetic gases before intervention. Next we started an ongoing informational campaign to alert all members of our department about the effect of gas choice and flow rate. We aim to measure …

Overcoming Resistance In Learning: Bridging The Gap Between Educator And Learner, Phase 3, Alisa Illescas, Patrick Rendon, Rebecca Williams

Quality Improvement/Patient Safety Symposium

Background: Resistance in learning (RIL) defines a set of attitudes or behaviors demonstrated by learners in an educational setting that result in decreased learning. Literature describes the etiology as multifactorial, including learning environment, characteristics of the learner, and teaching style. In conjunction with a team of academic hospitalists, we are using quality improvement methodology to address an educational problem within Phase I of medical school- resistance in learning. We are conducting a series of PDSA cycles to identify types of RIL during the Phase I pre-clinical years of medical school with the goal of implementing and evaluating an informed intervention …

Lost Revenue And Subsequent Documentation Improvement Strategy In The Department Of Psychiatry, David Earl, Christopher Gaudiot, Elizabeth Richardson, Mario Cruz, Joshua Corbin, Donna Sigl, Leslie Montgomery, Ali Nakip, Kyle Foley, Shawn Hazlewood, Julia Nguyen, Mauricio Tohen

Quality Improvement/Patient Safety Symposium

Introduction

The department of psychiatry has been having ~30% of its bills down-coded because of missing elements in documentation. Review of down-coded documents revealed that the history of present illness (HPI), review of systems (ROS), and mental status exam(MSE) were the most common areas resulting in down-coding. Leadership in the department tasked the department’s quality improvement (QI) leaders to find a solution to the issue.

Materials/Methods

Department QI leaders established a committee that comprised of department leadership, billing and coding, compliance, trainees, and faculty. After multiple meetings, the issue of what was being downcoded was deciphered and a plan to …

Implementation Of An Enhanced Recovery After Surgery (Eras) Pathway For Benign Gynecologic Surgery, Brenna Mcguire, Tasha Serna Gallegos, Kate Meriwether

Quality Improvement/Patient Safety Symposium

Introduction:

Enhanced Recovery after Surgery (ERAS) protocols have gained traction in the surgical field as evidence-based interventions aimed at speeding functional recovery. These protocols are designed to minimize the physiological changes and stress associated with surgery, and have been demonstrated in other surgical settings such as Gynecologic Oncology and Colorectal Surgery to decrease medical costs and improve patient outcomes. Recently, ERAS protocols have been refined and adopted in the field of benign gynecology by various institutions following an important endorsement of ERAS protocols by the American College of Obstetricians and Gynecologists (ACOG). However, there is a sparsity of research looking …

Increasing Patient Satisfaction With Hospital Meals Through Cost-Effective Interventions, Venus Barlas, Diane Sun, Alexandra Mang, Tomas Escalona, Matt Whicker, Jens Langsjoen

Quality Improvement/Patient Safety Symposium

Background:

According to the 2019 Press-Ganey survey results, UNMH ranks low on overall patient satisfaction compared to peers within the University HealthSystem Consortium. Poor patient satisfaction with quality of food at UNMH (6th percentile) is likely a significant contributor to this problem. With the intent to improve patient satisfaction, our group aimed to identify and evaluate modifiable components of the meal experience as a first step in implementing simple, cost-effective interventions.

Methodology:

Anonymous surveys were created in RedCap and conducted electronically on 2-3 days per week over a 2-month period on two adult progressive care units at UNMH. Survey questions …

Physical And Emotional Pain Assessment In Outpatients Receiving Therapeutic Aphresis, D Sosnovske, C Reyes, M Prizzi, K Crookston, J Griggs, L Rosenbaum, J Huang, S Mertens, C Ornelas, M Santos, J Raval

Quality Improvement/Patient Safety Symposium

Purpose:

The Joint Commission has revised pain assessment standards and now requires health care entities to identify pain assessment as an organizational priority and monitor this data for hospitals, ambulatory care, and office-based procedures. However, assessments of pain in patients receiving therapeutic apheresis are currently lacking. In this prospective study, we queried our outpatients receiving therapeutic apheresis procedures to identify and characterize elements of both physical and emotional pain.

Methods:

In this prospective observational study, a pain assessment tool to address both physical and emotional pain was developed using elements of three validated pain assessment tools: the Wong-Baker FACES/Ten-Point Pain …

Geriatric Hip Fractures: Early Results Of A Multidisciplinary Approach, Edward Lu, Christopher Shultz, Sarah Burns

Quality Improvement/Patient Safety Symposium

Hip fractures are common in the elderly population and are a common cause of mortality. Hip fracture prognosis is poor and one-year mortality rates are between 20-30%. Current managements require expedient preoperative evaluation and clearance and recommend surgical intervention within 24-48 hours of presentation. Co-management services of elderly hip fracture have been shown to improve outcomes, reduce complications, and reduce healthcare costs. This study aims to analyze the co-management of elderly patient by orthopedic surgeons and internal medicine at the University of New Mexico Hospital. The aim of this quality improvement project was to decrease time between hip fracture diagnosis …

Establishing New Positive Ranges For Anti-Phospholipid Antibody Tests Based On The Local Population, Dennis Sosnovske, D G. Grenache, P Lowrey, D Rospopo, K Riley, R A. Marlar, M A. Rollins-Raval

Quality Improvement/Patient Safety Symposium

Introduction:

According to past and current guidelines from the International Society on Thrombosis and Hemostasis on the laboratory criteria for antiphospholipid antibody syndrome (APS), antiphospholipid antibody (anti-cardiolipin (aCL) and anti-beta2-glycoprotein 1 (aB2GP1)) concentrations are an integral component of the diagnostic criteria for APS. However, external quality control exercises have highlighted high variability between commercially available aCL and aB2GP1 assays. Due to lack of both international standards and common human monoclonal antibodies, guidelines recommend that test results be considered positive if greater than the 99th percentile of a particular population. The objective of this study was to determine the 99th percentile …

Longitudinal Assessments Using Validated Instruments In Myasthenia Gravis Outpatients Receiving Long-Term Therapeutic Plasma Exchange, Dennis Sosnovske, Chelsea Reyes, Margaret Prizzi, Kendall Crookston, Joseph Griggs, Lizabeth Rosenbaum, Jane Huang, Sarah Mertens, Cynthia Ornelas, Michon Santos, Jay S. Raval

Quality Improvement/Patient Safety Symposium

Purpose:

In the most recent American Society for Apheresis Guidelines on the Use of Therapeutic Apheresis in Clinical Practice, employing therapeutic plasma exchange (TPE) for long-term treatment of myasthenia gravis (MG) patients is a new indication and carries a category II, grade 2B recommendation. As data for this indication is evolving and subjective assessments of these patients are often uninformative, we sought to better characterize the impacts of long-term TPE in these MG patients using validated instruments.

Methods:

In this prospective observational study, we used a combination of validated instruments and openended questions clarifying concerns that are routinely applied to …

Expanding Hiv Screening In The Unmh Emergency Department, Zachary Pek, Tirajeh Saadatzadeh, Natalie Mariam Salas, Christopher G. Wilson, Charles Yaple, Carla Walraven, Preeyaporn Sarangarm, Cameron S. Crandall, Joy Crook, Dusadee Sarangarm, Amanda Stafford, Kimberly Page, Martha L. Carvour

Quality Improvement/Patient Safety Symposium

Introduction: Access to HIV screening and care may be limited in resource-constrained health care settings. The CDC recommends routine HIV screening for all patients aged 13-64 years, unless the prevalence of undiagnosed HIV in that population has been documented to be

New Mexico is ranked 34^th in the US for the rate of HIV diagnoses made per year—among the lowest of all 50 states. Meanwhile, NM is ranked 4^th for chlamydia, 22^nd for gonorrhea, and 20^th for syphilis [3]. This discrepancy in sexually transmitted infection rates suggests the possibility of underdiagnosis of HIV infection in NM …

Timely Screening Of Toddlers For Perinatal Hepatitis C Transmission, Leah F. Nelson, Sherry Weitzen, Sameul Baxley

Quality Improvement/Patient Safety Symposium

Introduction:

Approximately 5% of infants born to mothers with chronic Hepatitis C Virus (HCV) will acquire an vertically-transmitted infection. Untreated HCV in children can be devastating with onset of cirrhosis, fibrosis, and hepatocellular carcinoma within the first 15-20 years of life. Current national guidelines recommend delaying testing for HCV transmission until the infant reaches 18 months of age due to maternal antibody transfer. However, it is difficult to track the perinatal risk factor for 18 months during well-child care. The purpose of this project was to improve the process of tracking this exposure by increasing the use of the Problem …

The Use Of Weekly Podcasts As A Medium To Supplement Academic Internal Medicine Residency Didactics, Umar Malik, Krystal Chan, Matt Gerling, Jen Langsjoen

Quality Improvement/Patient Safety Symposium

INTRODUCTION:

The majority of resident physicians in the United States are from the Millennial Generation (born 1981 to 1996), currently aged 23 to 38 (1). It is estimated that 93% of Millennials have a smart phone (2). Podcasts represent almost 10% of audio listening among millennials (3), with the second-most preferred type of podcast among millennials being educational (28%) (4).

With this in mind, and in recognition of the demanding schedule of residents and interns on inpatient wards, the UNM Internal Medicine chief residents developed a podcast to supplement and reinforce the concepts taught in afternoon rounds on the inpatient …

Cqi Project Utilizing Pre-Transplant Frailty Assessment To Improve Transplant Outcomes, Rowan Al-Odat

Quality Improvement/Patient Safety Symposium

Background:

Frailty has long been recognized as a risk factor for prolonged hospitalization and discharge to skilled nursing facilities post general surgery in elderly patients (1). It has been shown that pre-operative rehabilitation programs can reduce length of stay and improve functionality post cardiothoracic surgery (2). In kidney transplant recipients, frailty is associated with 94% increased risk of delayed graft function (3) and 61% increased risk of early hospital readmission (4). In our center’s post-transplant population, we identified frailty as one of the factors that led to early mortality (within one-year post-transplantation) in two of our elderly patients.

CQI Project …

Increasing Dea-X Waiver Trained Providers Through Quality Improvement, Heather Metcalf, Sam Paltrow-Krulwich, Claire Sava, Kate Stanfield, Meagen Twyeffort, Ann Morrison, Vanessa Jacobsohn, Krystal Chan, Susarsri Prapasiri

Quality Improvement/Patient Safety Symposium

Introduction

New Mexico has long experienced challenges associated with opioid use disorder (OUD). In 2017, New Mexico had the seventeenth highest drug overdose death rate in the United States. Although this ranking has decreased since prior years, New Mexico experienced 16.7 overdose deaths involving opioids per 100,000 persons in 2017, compared to the national average of 14.6 per 100,000 persons. Additionally, New Mexico saw an 82% increase in opioid overdose related emergency department visits between 2013-2015, and this rate has stayed consistent since 2015.1 In 2017, of the 332 overdose deaths in New Mexico, the most common drugs causing overdose …

Fun With Control Charts: Monitoring Neoplastic Mutation Frequencies Over Time, Laura Toth, Teah Ruetschilling, Devon Chabot-Richards

Quality Improvement/Patient Safety Symposium

Introduction:

In order to ensure a laboratory assay is performing optimally and accurately results must be monitored over time. Per the College of American Pathologists (CAP) in general, for quality assurance purposes, results of any given assay must be reviewed monthly to assess for trends, outliers, and other possible problems to ensure timely investigation and/or remedy if needed. For molecular testing, choosing an appropriate method for monitoring can be difficult as the results of testing are not quantitative and the frequency of a positive finding may vary based of a patients clinical diagnosis and other demographic information.

Methods:

All result …

Sage Diagram Documentation In Burn Patients In New Mexico: Room For Quality Improvement, Mattalynn Chavez, Barkat Ali, Ryan Keffer, Victor Andujo, Whitney Elks, Sydney Cooper, Gregory Borah, Eugune Wu

Quality Improvement/Patient Safety Symposium

Objective

The first step in the management of burn patients is an accurate estimation of the body surface area. Based on percentage of body surface area involvement, burns are categorized as major (>20%) and minor (

Methods

This is a retrospective study of 327 consecutive patients from 2014-2018 at University of New Mexico Burn Center. Only patients undergoing surgical management were included. We recorded patient demographics, comorbidities, burn characteristics. The primary measure of interest was SAGE documentation and secondary measure of interest was outcomes associated with it.

Results

We found that SAGE diagram was completed on minority of patients …

Implementation Of A Shift Hand-Off Tool On The Va Psychiatric Ward, Hugo Gomez Rueda, Wayles E. Haynes, Ali Nakip, Samira Khalil, Dana Pinochotti

Quality Improvement/Patient Safety Symposium

INTRODUCTION:

The hand-off process is a common point of miscommunication which can compromise the quality of the provided clinical service and the safety of the patient. Currently, most Electronic Medical Records (EMR) software offers clinicians an embedded hand-off tool that allows clinicians to identify treatment plans, follow changes in patient care during shift transitions and address patient complications with efficiency. In this way, the most important information is communicated to on-coming teams and patient continuity of care is preserved. The Hands-Off Tool (H.O.T.) list on the Computerized Patient Record System (CPRS) EMR, can be used as an instrument to gather …

Truman Health Services Transitions In Care Clinic Quality Improvement Initiative, Quinn Jackson, Tracy M. Carlson, Lisette Infante, Lauretta England, Alan Saint, Natalie Mariam Salas

Quality Improvement/Patient Safety Symposium

Introduction:

Patients who are diagnosed with HIV but not retained in medical care have been identified as one of the highest risks for new HIV transmissions and have higher rates of all cause mortality ^1,2. Factors impacting retention in care include timely clinical follow up and timely prescription of anti-retroviral therapy³. We identified specific subpopulations among those living with HIV who are vulnerable to being lost to follow up, namely: patients newly diagnosed with HIV and patients transitioning across the healthcare system, such as those newly discharged from inpatient facilities ^4,5. We reviewed the processes for …

Process Improvement For Implementation Of A Verified Substance Use Screening Tool For All Patients In A General Medicine Inpatient Unit, Jera Davis, Dung Mac, Alexis Leyba, Alicia Meador, Cees Whisonant, Joanne Clinton, Loren Kelly, Charles Pizanis

Quality Improvement/Patient Safety Symposium

Introduction:

As of 2017, an estimated 21 million US adults, equivalent to 1 in 13 people, had a substance use disorder. Of those with a substance use disorder it was estimated that only 2.2 million received treatment. In 2015, New Mexico had the 8^th highest overdose death rate in the nation with the highest number of overall deaths attributed to Bernalillo County. The most common drugs used in overdose related deaths included heroin, benzodiazepines and prescription opioids. At the time of this study, it was found that the University of New Mexico Hospital did not have an identification tool …