Digital Commons Network^™

Improving Recognition And Reporting Of Blood Transfusion Reactions In The Inpatient Setting, Tara Rakiewicz, Douglas Russ, Juliana Guarente, Katy Loos, Mary Harach, Jeffrey Riggio, Elizabeth Teixeira, Adam Binder

Health Equity and Quality Improvement (HEQI) Summit

Background

• Blood product transfusion reactions are associated with a spectrum of signs/ symptoms and can be challenging to identify. Transfusion reactions occur in about 1.1% of transfusions and constitute a significant source of iatrogenic morbidity and mortality.
• There is a nationwide under-reporting of transfusion reactions to blood transfusion Services.
• At TJUH, formally reported reactions comprised 0.24% of all blood product transfusions in 2024, similar to the national reporting average of 0.22%.
• Transfusion associated circulatory overload (TACO), and Transfusion related acute lung injury (TRALI) are two leading causes of mortality of blood transfusion reactions (Figure 1).
• Under-reporting leads to false data …

Are Hospital-Acquired Sepsis Cases Over-Reported Due To How Sepsis Is Coded In Electronic Health Records?, Michael Sakarya, Cooper Roslund, Spencer Foreman, David Gaieski, Md, Shruti Chandra, Md, Wayne Bond Lau

Health Equity and Quality Improvement (HEQI) Summit

Introduction

• Hospital-acquired sepsis (HAS) is a preventable cause of morbidity and mortality for hospitalized patients and is associated with greater cost and resource utilization compared to non-HAS.
• International Statistical Classification of Disease (ICD) coding system is used to identify HAS.
• Patients assigned HAS by ICD coding are presumed to have a nosocomial infection.
• Errors by ICD coding may cause misclassification of HAS cases.
• Unclear whether misclassified HAS have different outcomes than actual HAS

Quantiferon Tb Gold Test Utilization During Inpatient And Emergency Department Encounters At A Multi-Site, Single Academic Institution, Laxman Singanamala, Bs, Laura Walters, Do, Devin M. Weber, Md, Courtney E. Comar, Phd

Health Equity and Quality Improvement (HEQI) Summit

Background

• The QuantiFERON-TB Gold Plus test (QG) is an in vitro Interferon Gamma Release Assay that can be used to assess for prior exposure to Mycobacterium tuberculosis (MTB). The optimal use is in screening for latent disease.
• The United States is a low endemic country for MTB infection with 2.5 cases/100,000-persons in 2022 (CDC). Yet, we noted high utilization of the QG in our institution.
• Our goal was to understand our patient population and the clinical rationale for testing to create an electronic medical record (EMR) order set to optimize appropriate test use, decreasing unnecessary testing for patients and healthcare …

Single Center Comparison Of Home Sleep Apnea Testing Based On Respiratory Polygraphy Vs. Peripheral Arterial Tonometry, Stephen F. White, Md, Praneet C. Kaki, Bs, Henry C. Ideker, Md, Ritu G. Grewal, Md

Health Equity and Quality Improvement (HEQI) Summit

Introduction

• Home sleep apnea testing (HSAT) is an accessible option for diagnosing obstructive sleep apnea (OSA) in patients with high pre- test probability of moderate to severe OSA
• Cardio-respiratory polygraphy (RP) has traditionally been utilized and involves wearing a nasal airflow cannula, pulse oximeter, and respiratory effort belt with actigraphy
• Peripheral arterial tonometry (PAT)-based testing is a newer technology that involves wearing a disposable smartwatch-sized computer on the wrist, sensor on the finger and sensor on the chest and has been validated for HSAT
• PAT-based HSAT has been increasingly utilized due to perceived ease of use, improved patient comfort, and …

Interpreting Difficult Conversations In The Virtual World - Interpreter’S Perspective, Joyce Zhang, Bs, Kaitlyn Williams, Ms, Kathleen Mechler, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

• Medical Interpreters are essential in language discordant patient-family-team interactions
  • Facilitate clear communication
  • Aid in understanding diagnosis, prognosis, and treatment options
• Prior studies highlight range in interpreter comfort with serious illness conversations (SIC) though limited to in-person interpreter experience
• Rise of quick-access virtual interpreter services across the nation in many healthcare setting

Ensuring Timely Interventional Radiology Biopsy Procedures With Standardized Pre-Procedural Protocol And Guidelines, Joy Zhao, Md, Mohsin Arsiwala, Md, Minki Hong, Md, John Scalise, Md, Limi Jamma, Md, Hanna S. Ellingsen, Md

Health Equity and Quality Improvement (HEQI) Summit

Proposal

• Aim
  • To decrease rate of canceled or delayed IR biopsy procedures by 25% by implementing pre-operative order sets for inpatient IR procedures at Jefferson Center City Hospital in the next 6 months 
• Population of Interest
  • Jefferson Center City teaching team patients requiring IR biopsies
• Intervention
  • Implementing pre-operative order sets that include diet restrictions, anticoagulation guidelines, pre-operative labs, and pre-operative blood pressure and glucose goals 
• Quantifiable Outcome Measurement
  • Comparing rates of canceled and/or delayed IR biopsy procedures in the patient group that use the pre-operative order set compared to those who did not use the order set 
• Data Collection Methods …

Weight Loss In A Predominantly African American Patient Cohort In Jeffwlp, The Jefferson Weight Loss Program, Muskaan Uppal, Nicholas Demario, Maxwell Reed, Tamanaa Atrafi, Cindy Cheng, Md, Phd

Health Equity and Quality Improvement (HEQI) Summit

Introduction and Objectives

• Minority groups, particularly African Americans (AAs), are disproportionately affected by obesity^{1, 5}
• Available diet programs and nutrition classes are assumed to be constructed for majority groups^{1, 2}
  • Research and clinical care includes fewer AA patients³
  • AAs may respond differently to the widely used conventional nutrition education¹
• Motivational interviewing (MI) is uniformly effective across diverse populations and empowers individual patients to initiate behavioral changes, especially in weight loss interventions^{3, 4}
• Our goal is to better support underserved communities, such as within the Philadelphia area, to provide further investigation involving diverse and marginalized communities, …

Evaluating Scheduling Tool To Improve Behavioral Health Counseling Scheduling Rates On Same Day Of Referral, Edward Delesky, Md, Oluwatoni Okuboyejo, Md, Elizabeth Franko, Md, Nwamaka Amobi, Md, Ronak Ahir, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

• Studies suggest 1 in 5 adults in the US suffer from mental illness, with up to 46% of Philadelphia residents reporting poor mental health.
• Care integration beginning with primary care physician evaluation and management is becoming more common.
• Behavioral health counseling (BHC), provided by a primary physician and trained psychologist, is vital in management of mental health conditions.
• Studies suggest same-day scheduling of follow up appointments improves treatment adherence.
• Goal: improve BHC scheduling rates on same-day of initial referral across two practice teams

Viral Hepatitis And Hiv Screening Amongst Inpatients With Substance Use Disorder: An Initial Pdsa Cycle Analysis, Christine Papastamelos, Md, Elizabeth Novick, Md, Carolyn Kramer, Md, John Zurlo, Md, Nikhil Seval, Md, Mollie Tucker, Md, Daniel Taupin, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

• ~67,000 individuals in Philadelphia county are estimated to be living with substance use disorder (SUD).¹
• Persons who inject drugs (PWID) are at disproportionately higher risk of acquiring HIV and viral hepatitis compared to the general public.² 
• A 3-month retrospective chart review (11/6/23-1/22/24) of 160 inpatient SUD encounters with an Infectious Disease (ID) consult showed that 35%-42% of HIV and hepatitis C screening opportunities were missed.

Reducing Symptomatic Postoperative Hyponatremia After Endoscopic Pituitary Tumor Surgery, Matthews Lan, Md, James J. Evans, Md, Christopher Farrell, Md, Richard Schmidt, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

Problem Statement: Postoperative moderate to severe hyponatremia is the most cause of readmission following transsphenoidal endoscopic resection of pituitary tumors, with reported rates up to 8%. The pathophysiology of water balance after pituitary tumor surgery is as below:

[See figure]

Although postoperative diabetes insipidus (resulting in hypernatremia) is a concern in the immediate postoperative period, this is often transient, and thus it has been proposed to implement a postoperative fluid restriction to prevent delayed hyponatremia

Safe Paralytic Reversal For Neurologic Examinations, Keenan Piper, Md

Health Equity and Quality Improvement (HEQI) Summit

AIM Statement

Institute a protocol for safe administration of sugammadex to obtain neurologic exams with a goal of 90% adherence and three or less agitation-related complications over a 6-month period

Enhancing Community Health Center Safety Through Participatory Co-Design, Arman Afifi, Kelsey Smith, Megan Reed, Phd, Mph, Lara Weinstein, Md, Mph

Health Equity and Quality Improvement (HEQI) Summit

Introduction and Objective

Pathways to Housing PA (PtHPA) is a permanent supportive housing program with a mission to end homelessness for people with serious mental illness and substance use disorders. This urban based program serves approximately 500 people and has an on-site integrated healthcare clinic. The PtHPA offices temporarily closed in October of 2020 after a serious onsite safety event. In preparation for reopening, the PtHPA community sought to cultivate a safer space through utilizing co-design as a vehicle to solicit feedback from program participants and staff. Co-design research is a collaborative approach where researchers and stakeholders—such as community members, …

Accelerating Initial Critical Care In Acute Intracranial Hemorrhage, James Castiglione, Md, Jessica Houser, Rn, Bsn, Jennifer Anderson, Rn, Bsn, Amanda Heran, Rn, Bsn, Bryan Voit, Rn, Bsn, Kathleen Kujawa, Rn, Bsn, Crystal Lozano, Rn, Bsn, Richard F. Schmidt, Md

Health Equity and Quality Improvement (HEQI) Summit

Introduction

• Initial steps in management for ICH/SAH transfers to JHN follow common pathway
• Roughly, pathway is as follows: place arterial line, achieve blood pressure control with continuous infusions, draw initial labs, initial doses of hyperosmolar therapy, obtain repeat CT head
• Timeliness of intervention is paramount, and further procedures such as decompressive hemicraniectomy or external ventricular drain placement require updated imaging
• Opportunities exist to accelerate aspects of care such as medication administration, coordination of transport, arterial line placement, etc. prior to obtaining that scan

Improving Viral Hepatitis Testing With A Clinical Scenario Based Order Set: The Viral Hepatitis Hub, Jordan Feingold-Link, Md, Elizabeth A. Braden, Md, Courtney E. Comar, Phd, Jonathan M. Fenkel, Md, Kory S. London, Md, Sean P. Moss, Md, Elizabeth Novick, Md, Matthew Pettengill, Phd, Christine Papastamelos, Md, Jeffrey M. Riggio, Md, Daniel Taupin, Md

Health Equity and Quality Improvement (HEQI) Summit

Background and Problem

Viral hepatitis disproportionately affects historically marginalized populations, with less than one-third of high-risk patients receiving appropriate screening. Racial and ethnic minoritized groups, rural residents, and PWID face significant disparities in both testing and treatment.

Paradoxically, while underserved populations remain undertested, providers frequently order inappropriate hepatitis tests, particularly acute- phase markers like HAV IgM and HBV core IgM, in clinical situations where guidelines do not indicate their use. This pattern of inappropriate testing is partly driven by provider uncertainty regarding the selection of appropriate serologic tests from a complex array of options. Clinical decision support (CDS) within computerized …

Enhancing Diabetes Management With Visual Tools: A Multimodal Approach For High-Risk Urban Populations, Mikyla R. Futz, Jesse Edwards, Md, Fhm

Health Equity and Quality Improvement (HEQI) Summit

Background & Objective

Patients from historically marginalized communities face disproportionate barriers to diabetes mellitus (DM) management due to limited health literacy, language discordance, and a lack of culturally responsive educational resources. These structural challenges contribute to poorer glycemic control, higher complication rates, and reduced adherence to recommended care. While visual communication tools have demonstrated efficacy in improving comprehension, self-efficacy, and disease outcomes in chronic illness, their integration into diabetes care remains limited and inconsistently implemented.

Visual interventions may be particularly impactful in populations with low health literacy or limited digital access, yet few have been embedded into routine outpatient workflows. …

Enhancing Primary Care Navigation For D/Deaf And Hard-Of-Hearing Patients: A Wayfinding Intervention Proposal, Mikyla R. Futz, Mary L. Micou, Robert S. Pugliese, Pharmd, Bcps, Jesse Edwards, Md, Fhm

Health Equity and Quality Improvement (HEQI) Summit

Background

Auditory-dependent healthcare environments present persistent barriers to patients who are d/Deaf or hard of hearing (d/DHH), particularly where verbal instructions and auditory notifications dominate communication workflows. This contributes to delayed access to care, decreased satisfaction and strained patient provider-relationships, and significantly higher hospitalization rates —16-21% for individuals with mild to moderate hearing loss, respectively. Additionally, these patients experience higher rates of chronic conditions, lower health literacy, and reduced healthcare satisfaction. Existing interventions are often fragmented and narrowly focused, failing to capture the heterogeneity of d/DHH patients’ needs. This project introduces a scalable, continuous solution grounded in inclusive design principles …

The Need For Innovative Changes In The Jackson-Pratt (Jp) Drain, Elizabeth Goldstein, Bs, Spencer Haber, Krishna Koka, Bs, Devin Williams, Bs, Andrew Newman, Md

Health Equity and Quality Improvement (HEQI) Summit

Purpose

The JP drain is a closed suction drain used in surgeries throughout the body. This design, introduced by Dr. Frederick Jackson and Dr. Richard Pratt in 1971, prevents seroma formation through continual negative pressure drainage while resisting drain collapse and obstruction. Through a focused literature review, we summarized findings on JP drain-related complications in breast reconstruction and mastectomy. Though the JP drain effectively reduces seroma formation, there has been a profound lack of innovation in how its design addresses Surgical Site Infection (SSI), Surgical Site Pain (SSP), and Quality of Life (QOL). In addition, there is no standardized, evidence-based …

Social Vulnerability And Health-Related Social Need Disparities Amongst Young Adults With Breast Cancer, Steven Manobianco, Md, Julia Palecki, Md, Alexis Bennett, Md, Fatoumata Diaby, Ms, Rebecca Cammy, Lcsw, Emmanuel Worede-Kal, Scott Keith, Phd, Maysa Abu-Khalaf, Md, Mba, Maria Hafez, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

- Breast cancer is the most common non-cutaneous malignancy affecting women in the United States, with a lifetime incidence of nearly 13%

- The incidence of female breast cancer is rising, especially for young women (age < 45)

- While only 5-10% of breast cancers in the general population are related to highly penetrant pathogenic germline mutations, pathogenic mutations in BRCA1, BRCA2, CHEK2, PALB2, BARD1, and ATM occur at higher frequency in women diagnosed age < 50 years

• Mutations in BRCA1, BRCA2, and TP53 account for nearly 50% of breast cancers diagnosed before age 30

- Women < 40 years old breast cancer have worse disease-related survival, especially from to early-stage disease

Curricular Impact: Training Dpt Students To Look Upstream, Rebecca Operacz, Pt, Dpt, Edd

Health Equity and Quality Improvement (HEQI) Summit

Background and Problem

• Healthcare literature highlights extensive health inequities and continued mistrust of the healthcare system among historically marginalized communities.
• Accrediting bodies advocate for inclusion of SSDH in training to prepare practitioners to address health inequities.
• Limited guidance exists regarding implementation of SSDH content or expectations for student clinicians.
• Effectiveness of education is typically measured by metrics with little connection to patients and populations (GPA, graduation rates, licensing exams).

Checklists To Improve Emergency Medicine Resident Confidence In Airway Management, Tiara Paul, Bs, Elizabeth Glowacki, Md, Sean Mcgann, Md

Health Equity and Quality Improvement (HEQI) Summit

Objectives

• Determine the level of confidence regarding airway management among TJUH emergency medicine residents
• Implement education based on identifiable knowledge gaps
• Assess for improvement in resident confidence and discover avenues to optimize the education program

Resumption Of Anti-Platelet/Anticoagulation Therapy Following Lumbar Spine Surgery, Stephanie Serva, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

• Problem: There is data on AC/AP use in perioperative period for patients undergoing spine surgery and no formal established guidelines on when to resume AC/AP medications after surgery
• Aim: To determine standardized protocol for resuming antiplatelet/anticoagulation therapy following lumbar surgery and to reduce combined post-operative cardiac/cerebrovascular/thrombotic events, and post- operative hematomas by 10% in 5 years
• Population: Patients undergoing elective lumbar spine surgery who take AC/AP at home

Oncology Infusion Center Hyperglycemia Protocol, Gunjan Umarji, Md, Eric J. Shiffrin, Md, Rose Dimarco, Pharmd, Bcps, Bcop, Emily Brand, Pharmd, Daniel Lin, Md, Ashley Miles, Msn, Rn, Helen Evers-Hunt, Msn, Anp-Bc, Ocn, Claudia Thomas-Nembhard, Msn, Rn

Health Equity and Quality Improvement (HEQI) Summit

Background

Problem: Patients receiving chemotherapy may find it challenging to get care in a timely fashion if they develop diabetes or dysglycemia while receiving chemotherapy. Preliminary research indicates that dysglycemia may reduce the effectiveness of chemotherapy.

Aim: To initiate a protocol to ensure adequate euglycemia in patients at the Oncology Infusion Center (OIC) to eliminate insulin treatment guesswork and create a pathway that is least disruptive to the timing of patients' chemotherapy regimens.

Improving The Quality Of Internal Medicine Discharge Summaries Via Accurate Admission Medication Reconciliation, Natasa Kostic, Md, Tammy Tran, Md, Kenneth Meserole, Md, Jon Zaid, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

• Transitions of care are a time of vulnerability for patients.
• Nearly 20% of patients experience an adverse event within 3 weeks of hospital discharge, with adverse drug events being the most common.
• Discharge (DC) summaries serve to provide safe transition of care by describing hospital course and medication changes for review by outpatient providers.
• At TJUH, DC summaries are completed by internal medicine (IM) senior residents, but there is variability in quality of hospital course and thoroughness of medication reconciliation.
• Inaccurate admission medication reconciliation may lead to inaccurate reporting of discharge medication lists, causing confusion for both patients and …

Project Proposal: The Impact Of The Septa Zero Fare Program On Healthcare Access Among Philadelphia's Refugee And Migrant Population, Emily Hashem, Bs, Paranshu Shah, Mitchell Kaminski, Md, Mba

Health Equity and Quality Improvement (HEQI) Summit

Background

Since the 1960s, private, state sponsored, and charitable programs have attempted to increase transportation programs to improve healthcare access. Among these are the Centers for Medicare and Medicaid Services' Non-Emergency Medical Transportation (NEMT) program, Pennsylvania’s Medical Assistance Transportation Program (MATP) benefiting Medicaid recipients, Southeastern Pennsylvania Transit Association’s (SEPTA) SEPTA Access (formerly known as CCT connect) for disabled and elderly people, and ModivCare, a social services corporation that offers non-emergency medical transportation for qualifying people with low incomes. The importance of these programs is emphasized by the body of evidence surrounding healthcare metrics and transportation access. A Robert Wood Johnson …

Readmission For Picc Line Placement In Spine Surgery, Joseph Schaefer, Md, Joshua Heller, Md, James Harrop, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

• Pseudoarthrosis is failure of adequate bony fusion after a spinal fusion
• Prior literature has implicated occult C. acnes infection in cases of pseudoarthrosis
• Intraoperative cultures are often sent in cases of pseudoarthrosis at Jefferson
• C. acnes cultures often result after discharge requiring readmission

Medical Assistance In Dying In A Profit-Driven Health System: Ethical And Equity Challenges In The U.S. Vs. Canada, Joseph A. Zwillenberg, Eric M. Teichner, Jacob Schwell, Cameron Haghshenas, Joseph F. Majdan, Md, Facp, Fcpp

Health Equity and Quality Improvement (HEQI) Summit

Introduction

Medical Assistance in Dying (MAID), legalized in Canada in 2016, now accounts for 4.1% of all deaths nationwide and 6.6% in Quebec as of 2022(1). In Canada’s single-payer system, MAID is integrated as a publicly funded medical service. In contrast, the U.S.’s fragmented, market-driven system is defined by profit maximization, inequitable access, and insurer- driven decision-making. While MAID aims to promote autonomy and compassion, introducing it into the American context raises profound ethical concerns, particularly regarding nonmaleficence and systemic coercion. This poster evaluates the unique risks MAID poses within the U.S. healthcare system, particularly for vulnerable populations.

Instituting A New Traumatic Ich Algorithm At Jefferson, Michael Baldassari, Md, Matthews Lan, Md, Caitlin Ritz, Md, Tyler Alexander, Bs, Richard Schmidt, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

Problem Statement: Traumatic brain injury (TBI) is a high-incidence condition causing substantial economic burden on trauma centers worldwide. Many institutions have begun using validated algorithms for safe management, such as the Modified Brain Injury Guidelines (BIG) Criteria. At Jefferson, tICH have not historically been treated algorithmically, and therefore, tICH patients are often subject to excessive imaging surveillance and admission lengths.

Aim Statement: To institute a new algorithm modeled off mBIG criteria for the management of tICH patient at Jefferson to streamline treatment and safely reduce the number of surveillance HCTs obtained, as well as length of stay in this …

Incorporation Of The 4ms, With A Focus On Mentation, Into The H&P For Older Adults Hospitalized With A Hip Fracture And Its Effect On Delirium Documentation, Emily Custer, Do, Kristine Swartz, Md, Lily Ackermann, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

Delirium affects 15% to over 50% of patients with hip fractures during their hospital stay (1) and is associated with increased mortality, increased length of hospital stay, poorer functional outcomes, and higher risk of nursing home placement (1,2). However, at Thomas Jefferson University Hospital, the prevalence of documented delirium post-hip fracture is only 5.22%, suggesting potential under recognition. Additionally, at the end of 2025, a new CMS inpatient quality metric will require public reporting on a hospital's capability to provide age-appropriate care for older adults, which can be done by utilizing the 4M framework of age-friendly health care. The …

Deprescribing Type 2 Diabetes Mellitus Medications In Older Adults In An Urban Primary Care Setting, Katelyn Koons, Md, Eugenie Hughes, Md, Eunice Choe, Md, Julio Garcia, Md, Munifa King, Md, Emily Lavell, Md, Michael Danielewicz, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

• Adults 65+ take on average five medications daily
• Polypharmacy increases risks of drug interactions and adverse events
• About 29% adults 65+ in developed countries have type 2 diabetes mellitus (T2DM) and the number of older adults living with these conditions is expected to increase rapidly in the coming decades
• Over-treatment of DM in older adults is common and increases risks of serios adverse outcomes including hypoglycemia
• Older adults with T2DM should have higher A1c goal consistent with ADA guidelines: [See Table on Poster]

Evaluation Of Immediate Postpartum Long-Acting Reversible Contraception For Reducing Short Interval Pregnancies, Andrew Grover, Md, Molly Haas, Bs, Amanda Ricard, Do, Heather Cunningham, Md, Joanne N. Quiñones, Amanda Flicker, Md

Health Equity and Quality Improvement (HEQI) Summit

Objective

• Short interval pregnancy (SIP): any pregnancy that occurs within 18 months of a previous delivery or pregnancy loss.
• SIP is associated with increased risk of gestational diabetes, placenta accreta spectrum,1preterm birth, low birth weight, and small size for gestational age.²
• Long-acting reversible contraceptive (LARC) methods such as intrauterine devices (IUDs) and subdermal implants offer solutions to the limitations of daily oral contraception. Despite these options, 45% of U.S. pregnancies in 2011 were unintentional.³

While immediate postpartum LARC has been shown to be effective for mitigating unintended pregnancy, implementation of programs providing access to this contraceptive option have …