Quality Improvement Commons^™

Evaluating Referral Coordination And Scheduling In Primary Care: A Qualitative Study Of Workflow Gaps, Aprupa Alahari, Philycia Foote, S. Vincent Grasso

Rowan-Virtua Research Day

Background

Healthcare referral workflows remain fragmented despite widespread adoption of electronic health records. Primary care to specialty referrals frequently rely on fax, phone calls, manual scheduling, and disconnected communication systems, creating delays, incomplete referrals, and administrative burden.1,2 Prior literature has identified a lack of referral tracking, referral leakage, and lack of closed-loop communication as major barriers to coordinated care. Altogether, efforts are required to keep cases from falling into the “referral black hole” that plagues health systems.2-4

Hypothesis

We hypothesized that:

1. there is substantial patient burden

2. there is substantial operational fragmentation

3. current referral systems contain limited visibility or verification

Methods …

Reframing The Ed–Hospitalist Admission As A Clinical Handoff: The Ed To Hospital Admission As A Cross-System Handoff In A Complex Adaptive Clinical Environment. The Case For Systems Approaches To Enhance Safe And Effective Transitions Across A True System Interface, James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Background

Transitions from the Emergency Department (ED) to hospital medicine represent a high-stakes clinical handoff across systems. While often experienced as challenging, these interactions are better understood as occurring between services operating under different cognitive loads, operational priorities, and time horizons. Reframing the ED–hospitalist admission as a structured handoff aligns this process with broader patient safety efforts.

Objective

To characterize the ED–hospitalist admission as a cross-system clinical handoff and to identify practical strategies that enhance safety, clarity, and alignment during this transition.

Methods

Conceptual analysis informed by clinical experience, systems theory, and teaching observations. Key domains of potential misalignment were …

Reducing Pharmacy Callbacks And Improving Workflow Efficiency In The Emergency Department: A Quality Improvement Initiative, Philip .. Carhart, Hannah Culleny, Alexis Schuitema, James Espinosa, Robin Lahr, Sergey Medlenov, Gabriel Meister, Alan Lucerna

Rowan-Virtua Research Day

A simple educational intervention combined with structured provider feedback reduced ED pharmacy callbacks by 86%. While individual call duration remained unchanged, the reduction translated into nearly eight hours of provider time saved annually. This study highlights the impact of targeted quality improvement efforts on: • Workflow efficiency • Interprofessional communication • Patient care reliability. Small systems interventions can produce disproportionate operational benefits.

Detecting Early Operational Turbulence In The Emergency Department Using Fourier And Wavelet Analysis: A Conceptual Framework For Signal-Informed Anticipation And Prediction In The Ed Complex Adaptive System, James Espinosa, David Ho, Alan Lucerna

Rowan-Virtua Research Day

Background:

We theorize that Emergency Departments (EDs) function as complex adaptive systems characterized by nonlinear interactions, oscillatory demand patterns, and abrupt phase transitions from stable flow to turbulent states. Traditional dashboards rely on threshold metrics that detect instability after degradation becomes visible. Many ED data streams are significantly retrospective as well as compression-averaged into temporal systems such as days, months, quarters or even years. Signal processing methods—particularly Fourier and wavelet analysis—offer the  framework for detecting latent oscillatory shifts preceding overt operational change from laminar to transitional to turbulent flow states. This could lead to better methods of adaptation.

Conceptual Framework: …

The Safety Paradox Of Emergency Department Shift Length: Why The Relationship Between Hours Worked And Patient Safety Is More Complex Than It Appears, James A. Espinosa Md, Alan Lucerna

Rowan-Virtua Research Day

Background: Emergency department shift duration has long been debated as a determinant of patient safety. While longer shifts may increase cognitive fatigue, shorter shifts may increase the frequency of patient handoffs, which themselves introduce communication risk. Objective: To conceptualize emergency department shift length as a safety paradox arising from the balance between fatigue and handoff-related communication risks. Conceptual Framework: We propose the Emergency Department Shift Length Safety Paradox model illustrating the nonlinear relationship between shift duration and patient safety. Implications: Optimal shift design may depend on balancing fatigue risk and communication risk within a complex adaptive healthcare system. Conclusion: Emergency …

Reframing Outpatient-To-Ed Transitions As A Patient Safety Interface: Recognizing, Structuring, And Preserving Signal Across Clinical Boundaries Conceptualizing The Call-In To Ed Referral Model As A Handoff Of Care Model, James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Background

Transitions of care are recognized sources of patient safety risk. Structured handoff processes have improved communication reliability in inpatient and emergency department (ED) settings. However, outpatient-to-ED referrals—despite representing a transfer of care—are not consistently conceptualized or operationalized as formal handoffs.

Objective

To reframe outpatient-to-ED referrals as clinical handoffs occurring across a system boundary, and to propose a conceptual and operational framework to improve safety through recognition, structure, and signal preservation.

Methods

Conceptual analysis informed by clinical experience, systems thinking, and existing literature on handoffs and patient safety. Comparative evaluation of structured (ED→ED, ED→inpatient) versus less-structured (outpatient→ED) transitions.

Results

Outpatient-to-ED …

Designing Patient Update Intervals In The Emergency Department: A Queueing-Theory And Operational Science Model Of Patient Updates And Progress Signaling To Improve Patient Experience, James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Background Patients in the Emergency Department (ED) frequently experience uncertainty while awaiting diagnostic results, reassessment, and disposition. Even when clinical processes are progressing, prolonged informational silence may create the perception of that those processes are not advancing.

Objective To develop a conceptual and operational mathematical, queuing-theory based  model linking bedside communication, conversational time, and informational silence to patient experience.

Methods A back-of-the-envelope operational model was constructed to estimate the time required for bedside update communication during a typical physician shift. A queueing-theory framework was applied to examine how intervals between informational updates influence perceived waiting burden. Concepts from queueing theory …

The Obstacles Of Performing A Retrospective Chart Review, Emily Reilly, Robert Hudrick D.O.

Rowan-Virtua Research Day

Introduction: This research project "Comparing timing of care for skin cancer patients with limited English proficiency who require interpretation during medical visits to patients with English proficiency" was accepted under the CREATE Grant. The hypothesis was that patients who require medical interpretation during their visits would show a longer period of time between noticing a skin lesion to definitive diagnosis. Previous research has shown improved health care outcomes, but has mixed results on patient satisfaction and health care experience. This poster aims to detail the limitations faced during the execution of a retrospective chart review from the perspective of a …

Cardiovascular Risk Factors In The Autism Spectrum Disorder Population, Christian C. Iannuzzelli, Andrea L. Iannuzzelli

Rowan-Virtua Research Day

The population of patients with Autism Spectrum Disorder (ASD) have multiple risks and barriers that may make access to proper health care more difficult. After extensive research, some of these barriers may have been identified that pose greater risks to generating proper care for those with ASD. Some of these barriers include medical complexity, more sedentary lifestyles, poor food choices, as well as health comorbities. Some of these health comorbidities include hypertension, metabolic dysfunction, sleep apnea, and inflammation. This study aims to understand what barriers and risks for CVD are present in those with ASD.

Photodynamic Therapy Vs. 5-Fluorouracil For Field-Directed Treatment Of Actinic Keratosis: A Comparative Literature Review, Bhumik Patel

Rowan-Virtua Research Day

BACKGROUND: Actinic keratosis (AK) is a common precancerous skin condition arising from chronic UV exposure and often involves field cancerization, where visible lesions coexist with subclinical damage. Effective field-directed treatments are critical for preventing progression to squamous cell carcinoma.

HYPOTHESIS: Photodynamic Therapy (PDT) may offer superior efficacy, cosmetic outcomes, and patient adherence compared to topical 5-Fluorouracil (5-FU), despite its higher cost and clinical setting requirement.

METHODS: This literature review analyzed peer-reviewed studies from 2015–2025 comparing PDT and 5-FU for field-directed AK treatment. Outcomes assessed included lesion clearance, recurrence, tolerability, adherence, cost, and patient satisfaction.

RESULTS: PDT demonstrated high clearance rates …

Evaluating The Effectiveness Of A School-Based Cognitive Behavioral Youth Depression Prevention Program In Improving Life Satisfaction, Roshani Patel, Steven M. Brunwasser, Alissa Hochman

Rowan-Virtua Research Day

Depression is the leading cause of disability worldwide, known as the global burden of disease. Incident cases from 1990 to 2017 have increased by 49.86%. Additionally, rates have been seen to dramatically rise in adolescents aged 18-25 (17%) compared to rates in individuals aged 10-14 (1.1%). This makes it beneficial to have prevention programs for middle school aged children. The Penn Resiliency Program (PRP) is a youth depression prevention program focused on cultivating healthy thinking styles and behavioral coping skills. In our study, we used archival data from a randomized control trial of PRP to evaluate whether the program led …

Case Report: A Case Of Ttp In The Ed, Brian F. Lim, Andrew Caravello, James A. Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 54-year-old female who presented with mild shortness of breath, lower chest discomfort, fatigue, and weakness ongoing for several days and was diagnosed with thrombotic thrombocytopenic purpura (TTP). TTP is characterized by microangiopathic hemolytic anemia and thrombocytopenia due to either an inherited or immune-mediated reduction in von Willebrand Factor (VWF) cleaving protease ADAMTS13.

Patients presenting with non-specific symptoms is becoming increasingly common and initial bias could be to attribute symptoms to viral syndrome or upper respiratory tract infection. However, the differential for non-specific complaints is extensive and thorough review of labs and re-evaluations of patients …

Lep Prevalence In Southern New Jersey And The Use Of Interpreting Services In Healthcare Settings, Katherine Chavarria, Ariana Blake, Marlyn Valentin

Rowan-Virtua Research Day

Language barriers pose a great challenge to populations of Limited English Proficiency (LEP) in understanding their health, diagnosis, and treatments in healthcare settings. Our research aimed to gain a better understanding of the language access needs in Southern New Jersey. We analyzed census data in order to determine the prevalence of LEP populations in Southern New Jersey, as well as the languages most spoken by LEP populations. Additionally, our research looked at the use of interpreting services in healthcare settings. In Camden county, specifically we found that the top 3 languages spoken by LEP populations were Spanish, Vietnamese, and Chinese. …

Management Strategies For Traumatic Injuries In Pregnant Women: A Comprehensive Literature Review, Jaylyn D. Thompson, Jenna Zappetti, Clarence Julian Clark Ii

Rowan-Virtua Research Day

Introduction: Traumatic injuries in pregnant women are the leading cause of non-obstetric death and affect 6% to 8% of all pregnancies. Therefore, it is imperative to maintain updated guidelines to construct a framework for the optimal management strategies for traumatic injuries in pregnant women, considering the perspectives of obstetrics/gynecology, emergency medicine, and orthopedics.

Methods: To conduct this study, research was done via a database search through the Rowan-Virtua School of Osteopathic Medicine’s research library. PubMed was the sole database used to review 8 peer-reviewed sources. Articles that were published within the last 10 years were chosen.

Results: Every woman with …

Cva In Patient With Systemic Sclerosis On Aspirin Therapy: A Case Report, Rahyan Mahmud, Bianna Koutsenko, Kenneth Goich, Usaid Hasan

Rowan-Virtua Research Day

Introduction

Systemic sclerosis is an autoimmune disorder characterized by microvascular damage and multiorgan fibrosis. These patients have a higher risk of cerebrovascular events, but it is difficult to develop strategies for prevention due to limited understanding of underlying pathophysiology.

Case Presentation

A 76-year-old female with a history of systemic sclerosis presented to the emergency department with acute onset slurred speech, facial droop, and left arm pain with a National Institutes of Health (NIH) Stroke Scale of 1. She was outside the thrombolytic window. Other history includes hypertension and hyperlipidemia; both were well controlled. MRI confirmed right frontal lobe ischemic stroke …

Between Nsaids, Local Anesthetics, And Non-Medicinal Analgesics, Which Method Is The Most Effective At Providing Pain Relief During Iud Insertions For Nulliparous And Multiparous Women?, Natali Sharma

Rowan-Virtua Research Day

Objective: One major barrier for usage of intrauterine devices (IUD) includes a widespread sense of fear regarding pain during insertion of this contraception. By researching the most effective IUD insertion analgesics available and standardizing these pain management methods, women may be less fearful of obtaining IUDs.

Methods: A comprehensive literature review was conducted using Scopus, PubMed, Web of Science, EMBASE and Cochrane Library to compare methods of pain relief during IUD insertions. Outcomes measured include the pain management method used, the dosage administered, the pain experienced by patients evaluated using a Visual Analog Scale (VAS) prior to insertion …

Addressing The Health Needs Of The (D/D)Eaf And Hard Of Hearing Community, Zainab Krayem, Rachel Jeff-Macauley, Nicolette Falco, Vanesa Pizutelli

Rowan-Virtua Research Day

The term deaf refers to individuals with total or partial hearing loss. However, it encompasses much more, representing a culture—Deaf culture. The distinction in spelling is important: "Deaf," with an uppercase "D," refers to individuals born Deaf who have been raised within Deaf culture, while "deaf," with a lowercase "d," typically refers to those who lost their hearing later in life and may not have grown up in Deaf culture. People who identify as deaf, Deaf, or hard of hearing (d/D/hoh) are often mistakenly assumed to have cognitive impairments or are broadly categorized as disabled. However, many in the community …

The Effectiveness Of Cleaning Protocols In Medical School Omm Labs By Medical Students, Harrison Patrizio, Riley Phyu, Thomas Boyle, Todd Schachter

Rowan-Virtua Research Day

In light of the COVID-19 pandemic, disinfection in healthcare has taken center stage. Healthcare has adjusted workflows to accommodate for more robust cleaning regimens to help protect the community. This has resulted in the need for medical institutions to reevaluate the current cleaning protocols down to the student level. Osteopathic Manipulative Medicine (OMM) lab provides an optimal avenue for assessing medical student’s examination table cleaning effectiveness. With OMM labs being an activity with a high level of interaction, the quality of examination table cleaning is important for the health and safety of students and teaching faculties. Our study highlights that …

Healthcare Disparities In The Lgbtqia+ Community: A Scoping Review Of Community Vs Provider Experiences, Uttara Hardikar, Alisha Vincent, Venkateswar Venkataman, Millicent Channell

Rowan-Virtua Research Day

Background: It is well-established that healthcare disparities exist in the LGBTQIA+ community. The divide is a growing concern exacerbated by recent changes in the healthcare and sociopolitical climate. To eliminate this divide and find ways to deliver better outcomes to the LGBTQIA+ is a dire need. This report analyzes the possible reasons from the community as well as the providers perspective, with a goal to find best practices that could be implemented in both components.

Methods: A scoping literature review was carried out as described below to collect perspectives from both sides: patients as well as providers.

Results: From patient …

Standardizing Sti Screening In Child Sexual Abuse Cases At The Cares Institute, Usha Modukuru, Sarah Kleinle, Laura Brennan

Rowan-Virtua Research Day

Children who are sexually abused have a higher risk of contracting STIs and/or becoming pregnant. CDC STI testing guidelines should be adhered to in order to provide the safest outcomes for patients. Physician compliance with testing guidelines plays a significant role in ensuring patient safety, which highlights the importance of ensuring high physician compliance. Identifying ways physicians can improve compliance can enhance patient care. In order to determine compliance rates of the CARES Institute physicians, data was extracted from 275 patient charts from 2017 and 100 patients charts from 2021, before and after a continuing medical education (CME) training was …

Clinical Practice Workflow Implementation For The Improvement Of Diabetic Metric Compliance, Sugosh Anur, Sohil Khanna, Alison Mancuso, Alexander Kowalski

Rowan-Virtua Research Day

Recent guidance suggests the management of screen-detected diabetes can be optimized using multifactorial interventions to improve overall disease burden, patient outcomes, and cost-savings. We explored preventive diabetic care and implemented interventions to increase recommended testing compliance among patients with Type II Diabetes Mellitus. This study employed a multi-faceted approach beginning with the distribution of surveys to patients in the Stratford Family Medicine Office in order to gauge their health literacy level pertaining to Diabetes management. Patient electronic medical records were evaluated to determine baseline levels for all laboratory values. Data analysis was completed using Statistical Package for the Social Sciences …

Gestational Diabetes Among The South Asian Diaspora In The United States Of America: A Scoping Review, Anudeep Deevi, Mariam Sharobeem, Gabrianna Andrews, Rahul Ubrani, Venkateswar Venkataraman

Rowan-Virtua Research Day

Aim: The scoping review was conducted to review the current knowledge base regarding gestational diabetes mellitus (GDM) among South Asians in the United States. In addition, the review was meant to identify any gaps in knowledge, specifically about the current care received by South Asians as well as the associated adverse health outcomes.

Methods: A systematic search of PubMed, Web of Science, Embase, and Scopus was conducted. Key words ""gestational diabetes South Asians in the United States" were used as search terms. Search was restricted to U.S. articles published on or after 01/01/2013 with key words. Articles were screened by …

The Effectiveness Of Examination Table Cleaning Protocols In Osteopathic Family Medicine Offices, Riley Phyu, Harrison A. Patrizio, Thomas Boyle, Todd Schachter

Rowan-Virtua Research Day

Contaminated environmental surfaces are responsible for acquisition of healthcare associated infections. In 2002 there were approximately 1.7 million healthcare associated infections, resulting in about 99,000 annual deaths. Appropriate disinfection of environmentally contaminated surfaces are required to reduce transmission of pathogens. Adenosine triphosphate (ATP) bioluminescence is being used in hospital settings to audit the cleanliness in the hospital settings. However, there is a paucity of literature in different healthcare settings outside of hospital settings. This may unintentionally result in a more relaxed cleaning protocol in outpatient settings.

Objective: To assess the effectiveness of disinfecting protocol in osteopathic family medicine offices using …

Improving Diabetic Retinopathy Screening Practices With Qi Methodology In Family Medicine Offices, Rea Isaac, Anne Jones

Rowan-Virtua Research Day

Early detection and treatment of diabetic retinopathy (DR) is crucial in preventing vision loss and blindness in vulnerable diabetics. With around 7.7 million patients having DR, and the target population being 20 -75 years old, the potential for improving their quality of life is substantial (WHO, 2022). Despite the importance of timely and routine eye exams, 45% of diabetic patients do not complete an exam despite physicians recommendations (Lu, 2014). This project aims to standardize eye exams, improve process flow, and improve patient understanding of the urgency of timely and comprehensive eye exams for DR. Multiple PDSA cycles and QI …

The Efficacy Of Osteopathic Manipulative Treatment In Reducing Pain Medication Usage In Chronic Pain Patients: A Brief Literature Review, Catherine Alapatt, Kinjal Shah

Rowan-Virtua Research Day

Chronic pain is one of the most common complaints for adult patients. Chronic pain almost always includes a pharmacological approach which can involve opioids and non opioids. Non-pharmacological approaches are less commonly used by patients with chronic pain, despite the significant misuse of opioids in the treatment of chronic pain. There is a need for nonpharmacological therapies in the treatment of chronic pain patients to lessen the misuse of opioids. One underused form of nonpharmacological therapy for chronic pain is OMT. There have been several studies demonstrating OMT to be effective in treating chronic pain conditions. In addition, there is …

Case Report: The Challenge Of Balancing Stewardship And Advocacy, Samuel Thalathoti, Kishan Patel, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 62-year-old female who presented with chief complaint of generalized weakness and was ultimately diagnosed with hypereosinophilia. This chief complaint is challenging for many EM physicians, and the differential diagnosis of generalized weakness is vast. Etiologies of generalized weakness in the adult population ranges from infection, dehydration, cardiovascular disease, to neurologic compromise. It is crucial for the Emergency Physician to put emphasis on proper history collection, detailed physical exam, and appropriate ancillary testing. In this case report we showcase the significance of the optimal evaluation of life-threatening disorders that presents as generalized weakness, as well …

Impact Of Behavioral Health Consultant Intervention On Health Outcomes In An Integrated Primary Care Setting, Arpita Suri, Attiyah Zaheer, Christine Leroy, Robert Steer, Bhavin Shah, Sahil Zaveri, Shideh Doroudi

Rowan-Virtua Research Day

Integrated Primary Care Models are fast gaining popularity, and often being advocated as an important step in enhancing patient care within a primary care setting. Several studies have shown a positive impact of Behavioral Health Consultant (BHC) intervention in terms of patient satisfaction, improvement in patient symptom scores and global mental functioning. However, additional studies are needed to assess if integrated behavioral health consultations can demonstrate measurable outcome improvements to quantify the benefits of this approach, related to some of the most commonly seen and treated medical diseases in a primary care setting. This study aims to measure three outcomes: …

The Need For Depression And Anxiety Screenings At A Student-Run Clinic, Shayna Peterzell, Sahil Parikh, Alicia Podwojniak, Vibha Chauhan, Riya Tandra, Emily Forester, Saumil Parikh, Jessica-Sophie Horoschak, Patrick Pearce, Roma Padalkar, Sobiah Khan, Tara Pellegrino

Rowan-Virtua Research Day

General anxiety and major depressive disorder are common and treatable mental health disorders. The US Preventive Services Task Force provides strong evidence that early screening helps identify depression in primary care settings, promotes intervention and facilitates treatment. Many medical offices use validated screening tools, GAD-7 and PHQ-9, to measure symptom severities and further help guide treatment modalities for patients with anxiety and depression, respectively. The Rowan Community Health Clinic (RCHC) in Lindenwold, NJ is a student-run free clinic that serves patients regardless of patient gender, race, income, or insurance status. This study aims to determine if there is a need …

Preferences For Support Resources Among Loved Ones Of Adults Prescribed Opioid Medications, Mansi Patel, Desta M. Pulley, Daniel Manvich

Rowan-Virtua Research Day

The opioid epidemic continues to be a leading cause of overdose and related deaths in America. While most interventions are focused on the individuals with opioid and substance use disorder (OUD/SUD); the impact caregivers and family can have on the treatment of patients with OUD is non-existent. The purpose of this study is to collect pilot data on peers, friends, and family members of patients with SUD/OUD to understand the barriers in psychosocial support and maintaining treatment retention; barriers to accessing medication assisted therapy (MAT) and naloxone; and caregiver fatigue and barriers for caregivers. The collected data will be used …

Advanced Scoliosis Impact On Copd: Worsened Outcomes Due To Lack Of Motivational Interviewing And Shared Decision Making - A Case Report, Deval Jhaveri, Sidharth Sahni, Kishan Patel, Artiom Efimenko, Aleesa Mobley

Rowan-Virtua Research Day

The case presented describes an advanced COPD patient with a history of progressive scoliotic curvature who presented multiple times with complaints of worsening respiratory symptoms. Thus, it is important to emphasize how the lack of meaningful patient communication and patient participation in the plan of care can lead to increased symptoms of anxiety, declining quality of life, and unnecessary medical testing. In addition, the case explores how applying a holistic combination of strategies including motivational interviewing, shared-decision making and proper communication can improve the level of patient care.