Recent ucsdsom_gmepsqisymposium_2023 items

Implementing a structured transition from pediatric to adult care can impact clinical outcomes in young adult kidney transplant recipients.

Fri, 14 Jul 2023 00:00:00 +0000

Background:

The transition period between pediatric and adult care is a challenging time marked with high risk and vulnerability. This is especially true in adolescent patients with a transplanted kidney, which is described as the period with the highest rate of graft loss. Studies demonstrate that 83% of young adult with special health care needs (SHCN) and 86% of young adults without SHCN do not meet the national health care transition (HCT) measures published in a clinical report authored by the AAP in collaboration with the AAFP and ACP. Studies demonstrate that there are adverse effects associated with a lack of structured HCT interventions including medical complications, limitations in health and well-being, problems with treatment and medication adherence, discontinuity of care, patient dissatisfaction, higher emergency department use, and higher costs of care. Data are limited regarding HCT outcomes, but studies in the US and internationally demonstrate improvements...

Patient Empowerment through After Visit Summary (AVS) Redesign: A Cutting-Edge Approach to Reducing Hospital Readmissions

Thu, 29 Jun 2023 00:00:00 +0000

Issues Addressed/Background: Hospital readmissions are a significant problem in the healthcare industry, contributing to increased costs, decreased quality-of-care, and patient dissatisfaction. One potential solution to reduce readmissions is to improve the post-discharge process, including the use of after visit summaries (AVS) to help patients understand and follow their care plans. However, traditional inpatient AVS documents are often lengthy, confusing and lack patient-centered design, leading to poor patient comprehension and adherence. In response, our team undertook a redesign of the inpatient AVS to create a more effective and patient-friendly tool.In our current state, the inpatient AVS document contains unclear discharge instructions, misinformation, outdated information, conflicting information, duplicate information, and information that is simply too difficult for many patients to understand. Additionally, there is seemingly no prioritization...

Scalpels and Solutions: The Cutting-Edge Surgeon Feedback Platform Streamlining Operational Efficiency

Thu, 29 Jun 2023 00:00:00 +0000

Issues Addressed/Background: The quality and efficiency of surgical operations are crucial for both patient outcomes and healthcare institutions. Despite advancements in surgical techniques and technology, operational issues persist, leading to suboptimal performance, increased costs, and patient dissatisfaction. Surgeons in the UCSDH operating rooms (ORs) under-report adverse events and process improvement concerns through the existing iReport system, hampering the ability of the system to provide safe and efficient patient care. Traditional surgeon feedback methods are often too broad given inclusion of patient safety issues (e.g. iReport), have a high access barrier, and/or limited in effectiveness, necessitating an innovative approach to address these challenges.

Description of Project: This project aims to design and implement a specialized surgeon feedback platform tailored to address operational issues in the perioperative...

Utilizing the electronic medical record for preeclampsia screening and low-dose aspirin prescription for obstetric patients at UCSD Health

Fri, 16 Jun 2023 00:00:00 +0000

Issue:

The Society for Maternal-Fetal Medicine (SMFM), California Maternal Quality Care Collaborative (CMQCC) and the United States Preventative Task Force (USPTF) recommend low-dose aspirin (LDASA) for preeclampsia risk reduction in at-risk pregnancies. However, current evidence suggests that low dose aspirin (LDASA) prescribing practices for patients with risk factors for preeclampsia are inconsistent and preeclampsia risk screening practices vary. SMFM developed a checklist for preeclampsia risk factor screening and LDASA prescribing to make these practices more uniform. To our knowledge, there is no published literature of its use by prenatal care providers as it pertains to LDASA prescription patterns or medication adherence. The purpose of this intervention is to use electronic medical record (EMR) tools to increase appropriate preeclampsia risk screening and to increase evidence-based...

Planning ahead: preparing for discharges

Fri, 16 Jun 2023 00:00:00 +0000

Background: Systems-based practice is one of the core competencies that has been identified by the Accreditation Council for Graduate Medical Education (ACGME) as a foundational skill for resident physicians to learn so that they can “work in interprofessional teams to enhance patient safety and improve patient care quality.” In real-world practice, effective discharge planning is an important element of systems-based practice because delayed discharges are costly to health systems and harmful to patients. To prepare future resident physicians for this core competency, we developed an interactive workshop about discharge planning for graduating medical students during the Residency Transition Course.

Methods and Results: The interactive workshop consisted of a 30-minute didactic component that reviewed the importance of effective discharge planning. The didactics also introduced a systematic approach to discharge planning...

Discharge Instructions for Spanish-Speaking Patients: A House Staff Perspective

Thu, 8 Jun 2023 00:00:00 +0000

Background

UC San Diego Health has a diverse patient population with a large portion of its hospitalized patients speaking Spanish as their primary language. Several measures have been taken to overcome barriers to quality healthcare in this subgroup of patients, including easy access to medical translators and post-discharge follow-up efforts; however, there may be room for further improvement. One barrier that remains is providing written hospital discharge instructions for Spanish-speaking patients in their native language. The purpose of this study was to measure the overall perspective of physicians practicing hospital medicine at UC San Diego regarding our ability to effectively provide discharge instructions to Spanish-speaking patients that maximize positive health outcomes after hospitalization.

Methods

A seven-question survey was designed to measure the perspectives of hospital staff, including...

Facilitating access to diabetes prevention program for women with Gestational diabetes after delivery to prevent type 2 Diabetes.

Tue, 6 Jun 2023 00:00:00 +0000

Gestational diabetes mellitus (GDM) that affects 2-10% of pregnancies in the United States is a harbinger of future GDM, type 2 Diabetes Mellitus, Hypertension, and cardiovascular disease. This risk can be significantly reduced with weight loss. Lifestyle changes are often intensive processes that require involvement in a program with skilled and certified educators such as Center for disease control and prevention’s (CDC) National Diabetes Prevention Program (DPP), however due to insufficient provider knowledge and the time lapse between GDM and development of type 2 DM, the risk is often forgotten or lost in the transition of healthcare from a women’s obstetric care to primary care. This QI project sought to address this issue with a multifaceted approach to the issue and incorporates community involvement, multispecialty collaboration, and health communication.A community needs assessment was conducted through focus group interviews of women with history of GDM. 8 demographically...

Implementation of Medication Abortion in UCSD Family Medicine Continuity Clinics

Mon, 5 Jun 2023 00:00:00 +0000

Title: Implementation of Medication Abortion in UCSD Family Medicine Continuity Clinics

Author: Kenya Lyons

Specialty: Family Medicine

Background:

Nationwide, access to abortion has been significantly restricted due to the Supreme Court’s ruling in Dobbs v. Jackson Women’s Health (June 2022), which overturned Roe v. Wade (1973). This has led to the activation of “trigger laws” effectively banning abortion in many regions throughout the United States, leading to an influx of patients into neighboring pro-choice states such as California. Prior to the Dobbs decision, 89% of U.S. counties did not have an abortion provider[1]. The vast majority of abortions are performed at stand-alone clinics that prove ready targets for restrictive anti-choice legislation[1]. Thus, the integration of abortion into primary care clinics has the potential to relieve strain on the healthcare system, shorten patient wait times, facilitate presentation earlier during pregnancy,...

Brief Psychotherapeutic Intervention in Pediatric Acute Settings (BPI-PAS): Implementation of a Multidisciplinary Approach in a Dedicated Pediatric Psychiatric Emergency Department and its Effect on Stress Management

Thu, 1 Jun 2023 00:00:00 +0000

Over the last few decades, pediatric visits for mental health concerns have been rapidly increasing in the United States with recent studies suggesting that the number of mental health emergency department (ED) visits from 2012 to 2016 was four times greater than ED visits for other medical concerns. This crisis has only worsened in the waning emergent phase of the COVID-19 pandemic; many patients experience extended wait times and often spend days in the ED awaiting placement and stabilization. Rady Children’s Hospital houses a psychiatric emergency department within the emergency department (ED) to evaluate and stabilize patients in acute mental health crises. Pediatric emergency departments rarely offer therapeutic interventions or protocols for patients awaiting evaluation or placement. Our goal is to implement psychosocial and therapeutic modalities as a crisis intervention to improve perceived stress and the ability to manage stressors.

Efficacy of Radiation Reduction Protocols for Diagnostic Angiography and Basic Interventions in Endovascular Neurosurgery

Wed, 31 May 2023 00:00:00 +0000

Efficacy of Radiation Reduction Protocols for Diagnostic Angiography and Basic Interventions in Endovascular Neurosurgery

Arvin R. Wali MD, MAS, Michael G. Brandel MD, MAS, Sarath Pathuri BS, Brian R. Hirshman MD, PhD, Javier Bravo MD, Jeffrey Steinberg MD, Scott Olson MD, J. Scott Pannell MD, David R. Santiago-Dieppa MD, Alexander A. Khalessi MD, MBA

Background

Safe radiation practices and “As Low As Reasonably Achievable” (ALARA) principles are critical to mitigate unnecessary radiation to patients, providers, and staff. Radiation has stochastic and deterministic effects that have deleterious effects on health and lead to complications such as cancer, leukemia, and cataracts. As the indications for neuroendovascular procedures continue to grow, Neurointerventionalists must have a strong command over practices that reduce unnecessary radiation dose. We applied a quality improvement...

Getting Mammograms Shouldn’t Be So Bumpy- Improving Mammogram Workflow in VA Community Care

Tue, 30 May 2023 00:00:00 +0000

Category: Quality/Systems Improvement | QI/Research

Title: Getting Mammograms Shouldn’t Be So Bumpy- Improving Mammogram Workflow in VA Community Care

Primary Author: Aaron M. Lee, DO, MS (Internal Medicine, Chief Resident)

Co-Authors and Specialty Program Affiliations:

Jack Temple, MD (Internal Medicine), Susan Macdonald, RN (VA Community Care), Shayne Ovalles, RN (VA Community Care)

Background

The interplay between Community Care (CC) and VA-based care has long been important for continuity of patient care, though transitioning care between the two is often fraught with problems. Mammograms ordered at VA San Diego (VASD) are often deferred to community care; while this process should be smooth and seamless, the process is instead convoluted and ripe for errors. The lack of standardization, disconnect between the interface between...

I’ll make a “Patient” out of you: An Update to “Physicians as ‘Patients’”- Design, Implementation, and Challenges of Novel Immersive Simulated Patient Experiences to Foster Physician Empathy and Compassion

Tue, 30 May 2023 00:00:00 +0000

Title: I’ll make a “Patient” out of you: An Update to “Physicians as ‘Patients’”- Design, Implementation, and Challenges of Novel Immersive Simulated Patient Experiences to Foster Physician Empathy and Compassion

Author: Aaron M. Lee, DO, MS (Internal Medicine, Chief Resident)

Co-Authors and Specialty Program Affiliations:

Khanh Hoang Nicholas Le, MD (Internal Medicine, PGY-1), Preetham Suresh, MD (Anesthesia, faculty), Ricardo Wood (UCSD Simulation Center), Sean Kenmore, MD (Internal Medicine, faculty)

Issues Addressed/ Background

The importance of fostering physician empathy and compassion has become increasingly recognized as a critical aspect of physician training, with the ACGME and AAMC both acknowledging empathy as a key component of professionalism, with recommendations to incorporate empathy education into core medical...

"Less Ouch IV": Minimizing Pain for Non-critical IVs in a Pediatric ED

Tue, 30 May 2023 00:00:00 +0000

Background:

Peripheral intravenous (IV) line insertion is a common pediatric procedure performed in the emergency department (ED). At an early age, painful IV experiences can have a long-term impact, leading to needle phobia, decreased medical adherence, and negative nurse and physician satisfaction. Fast-acting interventions to reduce IV insertion pain are available. We aimed to decrease pain associated with non-critical IVs without increasing time to IV insertion in our pediatric ED. Our primary aim was to increase the proportion of “less ouch” IVs from a baseline of 8% to 50% within 12 months.

Methods:

A multidisciplinary team of pediatric ED nurses, physicians, child life specialists, and pharmacists created an evidence-based pain reduction algorithm for IV insertions. The algorithm is age-based and prioritizes fast-acting interventions, such as oral sucrose for patients under 1 year old and Buzzy®...

Beta-blockers versus calcium channel blockers as first line therapy for the initial management of rapid ventricular response in patients with atrial fibrillation

Tue, 30 May 2023 00:00:00 +0000

Background

Atrial fibrillation (AF) is a common arrhythmia with two general treatment approaches: rate or rhythm control. Rate control in AF is achieved by decreasing AV nodal conduction velocity with beta blockade or calcium channel inhibition. Based on the result of the AFFIRM trial, beta blockers (BBs) were more commonly used, and a higher percentage of the patients achieved adequate heart rate (HR) control (< 110 bpm) compared to calcium channel blockers (CCBs). In addition to the choice of medication, the dosing strategy of diltiazem is explored. Guidelines The 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation recommend 0.25 mg/kg IV bolus. An additional bolus of 0.35 mg/kg can be given if no therapeutic response within 15 minutes. Which body weight to use (actual vs. ideal) is not specified by the guidelines but actual body weight (ABW) is commonly used. However, in an obese patient, the use of ABW may lead to more side...

Rec It Up! Improving Safety Through Better Understanding of the Medication Reconciliation Best Practice Advisory

Fri, 26 May 2023 00:00:00 +0000

Background:

Best practice advisories (BPAs) are integrated into the electronic health record (EHR) to implement evidence-based practices, but not all alerts are effective and can even contribute to alert fatigue and burnout. This project focuses on optimizing the admission medication reconciliation (AMR) alert, which is the most common alert UCSD Internal Medicine residents face. Medication reconciliation is a pillar of patient safety, especially during the admission process. A reconciliation completion rate of >90% within 24 hours has become a UCSD Health performance metric. This alert is triggered when a medication reconciliation is not finished within 24 hours of admission and appears every time orders are opened until the reconciliation is completed. This project aims to analyze this alert to understand its high fire rate, maximize its effectiveness, and improve patient safety and overall provider experience.

Methods:

This retrospective...

The Antiseizure Medication Handbook: A Call Companion

Fri, 26 May 2023 00:00:00 +0000

Issues addressed and background:

The landscape of pediatric epilepsy is rife with difficult medication decisions in a vulnerable patient population. The decision of which antiseizure medications to use, dosage, the side effect counseling, and the idiosyncrasies of each medication can be overwhelming. The barriers to prescribing these medications are even higher to new child neurology trainees with little experience prescribing seizure medications, as well as rotating adult neurology colleagues who do not typically have to consider weight-based dosing and pediatric-specific considerations. The antiseizure medication handbook aims to improve trainees’ comfort on overnight call, decrease medication dosing errors, and improve identification and counseling of medication side effects by providing vetted weight-based dosing and clinical pearls for each medication. Outcome measures will be obtained by end-user post-survey data on self-assessed efficiency...

Semi-Automated Software Analysis of CT Scans Can Determine Carotid Plaque Morphology

Sun, 21 May 2023 00:00:00 +0000

Background:The gold standard for determining carotid artery stenosis is based on percent stenosis and symptomatic status. Few studies have assessed plaque morphology as an additive tool for stroke prediction. Our goal was to create a predictive model and risk score for 30-day stroke and death inclusive of plaque morphology.Methods:Patients with a CT angiography head/neck between 2010-2021 at a single institution and a diagnosis of carotid artery stenosis were included in our analysis. Each CT was used to create a 3D image of carotid plaque based off image recognition software. A stepwise backward regression was used to select variables for inclusion in our prediction models. Model discrimination was assessed with receiver operating characteristic curves (AUC). Additionally, calibration was performed and the model with the least Akaike Information Criterion (AIC) was selected. The risk score was modeled from the Framingham Study. Primary outcome was mortality and stroke.Results:We...

Implementation of Multidisciplinary Cesarean Practice Guidelines to Reduce Decision-to-Incision Time

Sun, 21 May 2023 00:00:00 +0000

Issues Addressed/Background: Urgent and emergent cesarean deliveries remain an important intervention to reduce maternal and neonatal morbidity. Recent studies suggest that initiatives to reduce the decision-to-incision time (DTI) can improve neonatal outcomes without compromising maternal outcomes. Presently at UCSD, documentation of the DTI is inconsistent, which limits our ability to track and evaluate this metric. A preliminary analysis of cesarean deliveries between August-October 2022 showed that only 185 out of 380 (49%) of non-scheduled cesareans were appropriately documented in the medical record. Therefore, we aim to develop and implement a DTI protocol to streamline communication, team-based roles, and improve documentation for cesarean deliveries at UCSD.

Description of Project: Multidisciplinary Cesarean Practice Guidelines were developed to define categories for cesarean deliveries: 1) Emergency, 2) Urgent,...

Using a Best Practice Advisory and an Epic Order Set to Improve Mineralocorticoid Receptor Antagonist Prescription after Admission for HFrEF

Fri, 19 May 2023 00:00:00 +0000

Introduction:

Mineralocorticoid receptor antagonist (MRA) therapy improves survival in patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and is recommended by heart failure guidelines. Prescription rates of MRA therapy after hospitalization for HFrEF for eligible patients are sub-optimal, usually between 30%-40%. A 2020 study from UC San Diego showed that only 38% of eligible HFrEF patients on the heart failure service were prescribed an MRA after hospitalization. Since this 2020 publication, UC San Diego’s heart failure team has strongly encouraged increased prescription of MRA therapy through departmental presentations and email reminders. In this study, we evaluate the impact of this encouragement on MRA prescription at UC San Diego. We have also created new interventions to further improve hospital-wide MRA prescription, including Best Practice Advisories (BPA) and an order sets.

Methods:

All patients admitted for at least 3 days to the...

Down the Drain: Overuse of Screening Preoperative Urinalysis in Orthopedic Surgeries

Wed, 17 May 2023 00:00:00 +0000

Background:

Asymptomatic bacteriuria (ASB), the presence of bacteria in urine without signs or symptoms of a urinary tract infection, is a common finding. The Infectious Diseases Society of America recommends against screening for and treating ASB in patients undergoing non-urologic surgeries, due to the lack of demonstrable benefit in reducing the risk of surgical site or prosthetic joint infection. Despite this, the existing practice at UC San Diego (UCSD) has been to recommend a preoperative urinalysis (UA) on every patient undergoing an orthopedic surgical intervention. The goal of this project is to quantify the rate of this low-value practice and identify opportunities for antibiotic stewardship.

Methods:

A retrospective chart review was conducted of patients admitted to UCSD to undergo surgical repair of hip or femoral fractures from January to December of 2020. Data elements abstracted included a documented recommendation for a screening...