System Quality Review SPECIAL ISSUE

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1 System Quality Review SPECIAL ISSUE PROCEEDINGS OF THE SYMPOSIUM Innovative Differentiation: Distinguishing Yourself From Other High Performers November 13, 2013 Co-sponsored with the Healthcare Association of New York State & Greater New York Hospital Association

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3 Editorial Board Steven J Corwin, MD Chief Executive Officer NewYork-Presbyterian Hospital and Healthcare System Robert E Kelly, MD President NewYork-Presbyterian Hospital Laura L Forese, MD MPH Group Senior Vice President & Chief Operating Officer NewYork-Presbyterian Hospital/Weill Cornell President, NewYork-Presbyterian Healthcare System Arthur J Hedge, Jr. Trustee, NewYork-Presbyterian Hospital and Healthcare System George F Heinrich, MD Chair, Performance Improvement Committee NewYork-Presbyterian Healthcare System Chairman, Board of Trustees, New York Hospital Queens Trustee, NewYork-Presbyterian Healthcare System Marc L Boom, MD MBA FACHE President & Chief Executive Officer Houston Methodist (Houston, Texas) Roberta L Schwartz Executive Vice President Houston Methodist Hospital (Houston, Texas) Robert A Phillips, MD PHD FACC Executive Vice President & Chief Medical Officer Houston Methodist (Houston, Texas) President & Chief Executive Officer Houston Methodist Physician Organization (Houston, Texas) Wayne M Osten Eliot J Lazar, MD MBA Brian K Regan, PhD Aileen Maderich, MBA Grimilda Mendez-Augsburg, MBA Marcia Brinson, RD MPH Kathleen Ciccone, RN MBA Margaret L Fracaro, MA CIC RN Orpha J Gerundo, RN MPA CPHQ Natalee Hill, MPA Deborah Hollenberg, RN MSN Patricia Keill, RN Nancy Landor, RN MS CPHQ Jamie R MacDonald, RN MSN MBA Lisa-Vanessa Magtibay, RN MS Tochi N Okorie, MBA RN Scott W Possley, PA-C MPAS Lorraine M Ryan, Esq RN Karen A Scott, MD Brian R Taylor, PhD Kenneth E Raske President & Chief Executive Officer Greater New York Hospital Association Dennis Whalen President Healthcare Association of New York State Acknowledgements The editors of SQR gratefully acknowledge the assistance of Inez Horton for their dedication, organizational skills, and planning expertise. Gratitude is expressed most especially to those practitioners and performance improvement leaders who show their commitment to quality patient care through their contribution herein.

4 Page Children's Hospital at Montefiore 1 Implementation of Daily Goals Sheet to Enhance Communication Among NICU Staff Jennifer McGuirl, DO CMH; Zahava Cohen, RN MSN; M Susan LaTuga, MD MSPH Cohen Children's Medical Center of New York 4 Raising Situational Awareness Through the Implementation of a Daily Safety Brief Linda Jendresky, MPH; Fiona Levy, MD; Andrew Steele, MD; Vincent Parnell, MD; Maria Esperanza, MD; Jahn Avarello, MD; Nancy Palumbo, MD; Peter Silver, MD; Carolyn Quinn, RN; Ann McGrath, RN; Eric Chakin, MPA; Kathy Albert, DNP; Charlotte Smith, RN 3. Cohen Children's Medical Center of New York 7 Reorganizing the System of Care and Workflow in the Pediatric Ambulatory Chemotherapy and Transfusion Center: A Cost-Effective Analysis Using Simulation and Lean Methodology to Improve Environmental Management and Organizational Quality Kathy Albert, DNP CPHQ; Christopher Pinna, BS MSc; Donna Newman-Beck, RN BSN CPN; Charlotte Smith, RN MSN NE-BC; Lawrence Wolfe, MD; Ruth Masarik 4. Elmhurst Hospital Center 13 Reducing Mortality in Sepsis through the Implementation of Early Goal-Directed Therapy Protocol Ram Parekh, MD (Attending, Emergency Medicine); Scott Weingart, MD (Director of Emergency Medicine Critical Care); Martin Warshawsky, MD (Director of Respiratory Intensive Care Unit) 5. Elmhurst Hospital Center 16 Assisting the Patient to Navigate Safely Throught Healthcare Reform: The Project Red Congestive Heart Failure Initiative Janet Carr, MD; Milton Espinoza RPh; Marlaina Norris, MD MBA Department of Care Management Helen Hayes Hospital 20 Hourly Rounding Initiative and Other Practices Contribute to a Low Fall Rate Kerry Sokolohorsky, RN BSN Hospital for Special Surgery 25 Prospective Study on Inpatient Falls in an Orthopedic Hospital Setting Lisa A Mandl, MD; Wei-Ti Huang; Jaimie Lee; Tina Bailey, RN; Danielle Edwards, DPT; Mayu Sasaki, MPH; Patricia Quinlan, DnSC MPA RN CPHQ; Steven K Magid, MD Houston Methodist Hospital 28 Pharmacist Active Involvement in Patient s Continuity of Care After Hospital Discharge Rafael Felippi, PharmD BCPS; Michael Liebl, PharmD BCPS; Janice Finder, RN MSN Houston Methodist Hospital 29 Utilization of Shared Governance to Sustain Continuous Improvement Janet Gilmore, MSN RN CMSRN; Sandra Prevost, MSN RN CPPS; Elizabeth York, MSN RN Volunteer Engagement in Patient Safety Fall Prevention Houston Methodist Hospital 30 Mary E Woodard, MSN RN CPPS; Pamela D Salyer, PhD RN BC

5 Page 11. Houston Methodist Hospital 32 A Venture in Par Level Savings: Improving Cardiac Catheterization Lab Inventory Utilizing 5S Methodology Charmaine D Shields, MSN RN CVRN II; Andrew Brown, MBA 12. Jacobi Medical Center 37 Goal Toward Zero Catheter Associated Urinary Tract Infections (CAUTI) - Eliminating Harm Melvin Stone, MD; Amit Tibb, MD; Christina Coyle, MD; Regina Modica, RN; Swati Raja, BS M(ASCP); Hilda Diongon, RN; Mila Quinones, RN; Carol Sheridan, RN 13. Jacobi Medical Center/ North Bronx Healthcare Network 40 Impact of a Nutrition Educational Intervention Coupled with Improved Access to Fresh Produce on Fruit and Vegetable Purchase and Consumption in Patients with Type 2 Diabetes E Weinstein, MD; J Galindo, MD; M Fried, MS; L Rucker, MD; N Davis, MD Kings County Hospital Center 44 Patient Engagement - Prescribed Group Treatment Carlos J Rodriguez Perez, RDT BCT LCAT (Director of Therapeutic Rehabilitation Department) Kings County Hospital Center 46 Reducing Restrictive Interventions Karen Mohamed, RN MSN ACNS BC; Chinmoy Gulrajani, MD Medical Director Adult Inpatient; Paul O'Keefe DO Medical Director CAPIS; Sally E Riggs, DClinPsy Adult Inpatient Psychologist II; Liliane Rocha, MA MPhil BCBA Director of Behavior Support Team; Anne Paulin, Associate Director Risk Mgt; Annahit Daglyan, PharmD BCPP Assistant Director Kings County Hospital Center 48 Road To Home George Jagatic, LCAT; Suzanne Garrison, CAT; Dana Trottier, CAT Kings County Hospital Center 50 Primary Nursing as a Behavioral Health Nursing Care Delivery Model Linda Paradiso, RN MSN NPP NEA-BC; Ihsaan Alim, RN MSN Krasnoff Quality Management Institute - A division of the North Shore-LIJ Health System 52 At Your Fingertips: Web-based Sepsis Data Collection and Analysis Kevin D Masick, PhD; Marcella De Geronimo, MS; Eric Hamilton, BA; Carol Cross, MBA; Rosemarie Linton, MPH Lawrence Hospital Center 54 Quiet Time: A Bright Spot Spreads Tina Sokolik, BSN MSN Map to Achieve 100% Compliance in DVT Risk Assessment and Prophylaxis for the Hospitalized Patient New York Hospital Queens 57 Nejat Zeyneloglu, MD; Keziah NarayanaJaya, R-PAC; Jean Versace, RN BS; Al Caligiuri R-PAC MBA; Kenneth Ong, MD MPH; Karen Nefores RN BSN MBA; Regina Langer, BS PharmD; Helena Hizon, RN; Nancy Moybed, RN MS; Todd Kerwin, MD

6 Page New York Hospital Queens 60 Stroke Center Check List to Optimize Care and Resource Use and to Reduce Practice Variability Nejat Zeyneloglu, MD; Roxana Lazarescu, MD; Patrick Wang, MD; Samar Hameed, MD; Sheela Mehra, MD; Lotus Ahmed, MD New York Hospital Queens 62 Stroke and the Electronic Health Record: Improving Quality and Reporting Ken Ong, MD MPH; Bebe Z Rahamatalli, RPA-C MPAS; Jean Versace, RN BS; Edward Chai, MD; Anna Delios, MD; Helena Hizon, RN MS; Alfred Caligiuri, PA MBA; Karen J Nefores, RN BSN MBA New York Hospital Queens 71 Improved Clinical Documentation: Ensuring Effective Medical Records to Support High-Quality Care Lucia Lagan-Rinando, RN BSN; Karen Nefores, RN BSN MBA New York Hospital Queens 75 SPRINT - A Call to Action for Resident Led Performance Improvement Armando E Castro, MD FACS; Anita Ayrandjian Volpe, DNP APRN; Pierre F Saldinger, MD FACS 25. New York Hospital Queens 77 Performance of a Lab Alert Query Integrated into the Electronic Medical Record to Actively Inform Emergency Department Providers of Pending Lab Tests at the Time of ED Discharge David Barlas, MD; Al Caligiuri, PA-C MBA 26. New York Hospital Queens 79 First Year Experience of a Hospital-based Out-Patient Antimicrobial Parenteral Therapy Unit Joanna Kopacz, MD [1]; Javeria Shakil, MD [1]; Nauman Piracha, MD [1]; Deborah Figueroa, PharmD [2]; Caroline Keane, ANP [3]; Ruth Hopkins, RN [4]; Alexander Melchert [2]; Michaelle Williams, RN [4]; Marcia Levine, RN [4]; Stephen Rimar, MD [5]; Sorana Segal-Maurer, MD [1] [1] The Dr. James J. Rahal Jr. Infectious Disease Division; [2] Pharmacy; [3] Case Management; [4] Nursing; [5] Administration 27. New York Hospital Queens 81 Evaluation of Patients with a Chief Complaint of Syncope in an Observation Unit: A Quality Assurance Assessment William Apterbach, MD; Johnathon LeBaron, DO; Greta Apterbach, PhD New York Hospital Queens 88 Medication Reconciliation Process Improvement and Redesign Susan Denn, PA-C MPAS; Valantina Soni, PA-C MPAS; Patricia Roccisano, PA-C MPAS; Anna Kula, PA-C; Wehbeh Wehbeh, MD A Novel Approach to Foster A Culture of Safety in Radiation Oncology New York Hospital Queens 90 Dattatreyudu Nori, MD FACR FACRO; Akkamma Ravi, MD; Baoqing Li, MD PhD; Adrian Osian, MS; Annu Kapoor, RNC MS; Jennifer Modena, BS RTT; Samuel Maiorano, MPA RTT; Catherine Lagos, BS RTT; Migdalia Sotillo, RN; Seshadri Sampath, PhD; Natalie Masino; JoAnn Pizzicarola Cruz; Maureen Buglino, RN MPH; Stephen Rimar, MD

7 Page 30. New York Methodist Hospital 105 Improving Transitional Care Processes Between Hospital and Post Acute Care Partners Reduces Readmissions Steven H Silber, DO ScM; Kathleen P Treacy, MS RN NEA-BC; Carol Farina, RN BSN CCM; Dan Nguyen, MD; Amy E Boutwell, MD MPP New York Methodist Hospital 107 Impact of a Proactive Intravenous to Oral Antibiotic Conversion Program at a Tertiary Teaching Hospital Gary Wu, PharmD BCPS; Teena Abraham, MS PharmD BCPS; Nasser Saad, BS PharmD; Eric Balmir, BS MS PharmD; Steven Silber, DO FACEP New York Methodist Hospital 109 The Use of Tranexamic Acid in Orthopedic Surgery: Retrospective Study Henry Tischler, MD; Nasser Saad, PharmD; Teena Abraham, PharmD BCPS; Eric Balmir, PharmD; Orrin Robert, RPA; Steve Silber, DO; Eileen Tang, PharmD; Joseph Samide, PharmD 33. New York Methodist Hospital 111 Multidisciplinary Rounds: The Answer to Fostering Teamwork and Education While Reducing Length of Stay Parmeet Saini, MD; Anthony Saleh, MD 34. New York Methodist Hospital 113 Development of Triage Criteria Protocol for Critical Care Patients in the Emergency Department Joanna Zanko, MS CCRN; Liziamma George, MD FCCP; Bashar Fahoum, MD FACS; Terence Sacchi, MD; Joseph Bove, MD FACEP; Anthony Tortolani, MD; Steve Silber, DO SCM 35. New York Methodist Hospital 115 The Effect of a Rapid Evaluation Unit on Our Emergency Department Door-to-Disposition Times and Workload Barbara Gatton, MD; Lawrence Melniker, MD; Josef Schenker, MD; Nicholas Vaccari, MD; Joseph Moss, MD; Joseph Bove Jr, MA; Joseph Bove, MD New York Methodist Hospital 117 The Use of EHR Tools to Improve Physician Overall Efficiency and Satisfaction Eric Karu, MD; Parmeet Saini, MD; Parag Mehta, MD New York Methodist Hospital 119 Optimizing Patient Tracking to Improve Patient Safety and Increase Efficiency Eric Karu, MD; Parmeet Saini, MD; Parag Mehta, MD New York Methodist Hospital 121 Successful Project Implementation Following the New York State Mandate of HIV Testing Eric Karu, MD; Parmeet Saini, MD; Parag Mehta, MD EHR Alerts: Are They Serving Their Intended Purpose? New York Methodist Hospital 124 Eric Karu, MD; Parmeet Saini, MD; Parag Mehta, MD

8 Page 40. New York Methodist Hospital 129 Development and Implementation of New Physician Handoff Tool in the Department of Medicine Eric Karu, MD; Parmeet Saini, MD; Parag Mehta, MD 41. New York Methodist Hospital 136 Process Improvements Decompress Emergency Department in the Face of Increased Admissions and Decreased Capacity Steven H Silber, DO ScM; Joann Amitrano, RN; Carol Farina, RN BSN CCM; Eric Karu, MD; Parag Mehta, MD; Todd Simon, MD; Paul Weissblatt, MD; Aown Syed. 42. New York Methodist Hospital 138 Integrating and Analyzing Patient-Level Electronic Health Records and Risk Adjusted Outcomes Data for Performance Improvement - Laparoscopic Cholecystectomy at New York Methodist Hospital: July December 2012 Donald A Risucci, PhD; John G Hunter, MD; James A Rucinski, MD; Rasha Jadalhack, MPA; Anthony J Tortolani, MD New York Methodist Hospital 145 Clinical Decision Making Tools Used to Reduce Cost and Improve Patient Care at a Teaching Hospital Parmeet Saini, MD; Eric Karu, MD; Parag Mehta, MD New York Methodist Hospital 151 The Process of Becoming Near Paperless at a Community Hospital Eric Karu, MD; Parag Mehta, MD; Mena Foaud New York Methodist Hospital 153 The Big Picture From EHR Data Collection at a Community Hospital for Practice Based Learning Parag Mehta, MD FACP; David Conner, MD; Eric Karu, MD New York Methodist Hospital; New York Medical College 155 Process Improvement: Best Practices for Dysphagia Screening in Patients Post-Stroke Barbara Gatton, MD; Luis F Riquelme, PhD CCC-SLP BRS-S; Rebecca D Kaplan, MS CCC-SLP; Matt Dros; Lawrence Melniker, MD; Waleed Mina 47. NewYork-Presbyterian - Lower Manhattan Hospital 159 Disproportionate Effects of Dementia in Predicting Home Discharge in DRG Hospitalizations Prevalent with Dementia: Implications in Prevention Quality Assessments Robert Y Lin, MD; Brian C Scanlan, MD; Truc Phuong Thanh Nguyen, BA 48. NewYork-Presbyterian Hospital 164 Utilization of EMR Technologies to Improve Safety of Anticoagulation Therapies Lynn I Kim, RPh; Liz Ramos, PharmD; Karlene Ma, PharmD; Matthew Fred, MD; Robert Green, MD; Karen A Scott, MD MPH 49. NewYork-Presbyterian Hospital 171 Design and Implementation of a Process for Periodic Review of Order Sets in the Electronic Medical Record Adam Rio, MPA RN CPHQ; Amy Reiterman, RN BSN; Jamie MacDonald, RN MSN MBA; Karen Scott, MD MPH; Robert Green, MD; Susan Bostwick, MD MBA

9 Page NewYork-Presbyterian Hospital 176 Reducing LOS for the Admitted Non complicated Cellulitus Patient Anna Maw, MD; Anthony Ogedegebee, MD; Nell Eisenberg, MD; Paula Tinghitella, MSN RN NewYork-Presbyterian Hospital 182 Emergency Medicine Physician Hand Hygiene Improvement Jordan Foster, MD; Nicole Bouchard, MD; Grimilda Mendez-Augsburg, MBA; Lesley Covington, MSPH CIC; E Yoko Furuya, MD MS; Lisa Covington, MPH CIC; Fergus Scully; Dale Arnold; Ricky Gonowrie; Eileen Carter; Vepuka Kauari, RN; Germaine Nelson, RN; Rita Murray; Frank Rudilosso; Hani Nasrallah, MPH; Jamie Beyer, MS 52. NewYork-Presbyterian Hospital 190 Automated Identification and Communication of Patient Isolation Information via the EMR at a Large Academic Center Barbara Ross, RN BSN CIC; Frank Hong, MA; David K Vawdrey, PhD; Rohit Chaudhry, MS 53. NewYork-Presbyterian Hospital/ Weill Cornell Medical Center 193 Implementation of Alert in the Electronic Medical Record Reduces Incidence of Non-OR Blood Transfusions for Hb > 8.0 g/dl James E Littlejohn, MD PhD; Sean D Till, BA; Robert Green, MD; Michael Nguyen, MPH; Peter M Fleischut, MD 54. NewYork-Presbyterian Hospital/ Weill Cornell Medical Center 197 Provider Perspectives on Use of Indwelling Urinary Catheters in Older Adults in the Emergency Department: A Valuable First Step in the Development of a Clinical Protocol Mary R Mulcare, MD; Tony Rosen, MD MPH; Sunday Clark, ScD; Benjamin A Scherban, BA; Michael E Stern, MD MA; Neal E Flomenbaum, MD 55. NewYork-Presbyterian Hospital/ Weill Cornell Medical Center 199 Identifying and Analyzing Patient Volume Fluctuations on Labor and Delivery Maricela Castillo, MBA MD candidate; Matthew Raible, MHA candidate; Sharon Abramovitz, MD; Hillary Shaw, MPA; Klaus Kjaer, MD MBA 56. NewYork-Presbyterian Hospital/ Weill Cornell Medical Center 203 Improving Emergency Department Identification and Management of Agitated Delirium in Older Adults: Implementation and Impact Assessment of a Comprehensive Clinical Protocol Emphasizing Commonly Missed Contributing Causes Using an A-B-C-D-E-F Mnemonic Tony Rosen, MD MPH; Scott Connors, BS; Alexis Halpern, MD; Michael E Stern, MD; Sunday Clark, MPH ScD; Benjamin A Scherban, BA; Mary R Mulcare, MD; Mark S Lachs, MD MPH; Neal Flomenbaum, MD 57. NewYork-Presbyterian Hospital/ Weill Cornell Medical Center 205 Indwelling Urinary Catheters in Older Adults: Baseline Emergency Department Provider Knowledge, Attitudes, and Practice Prior to Implementation of an Evidence-Based Protocol Kartik Viswanathan, PhD; Mary R Mulcare, MD; Tony Rosen, MD MPH; Michael E Stern, MD; Sunday Clark, MPH ScD; Mark S Lachs, MD MPH; Neal Flomenbaum, MD

10 Page 58. NewYork-Presbyterian Hospital/ Weill Cornell Medical Center 207 Evaluating Adherence to Clinical Guidelines for Thrombophilia Screening Amy Kwon, Medical Student; Mikhail Roshal, MD PhD; Maria Teresa De Sancho, MD MSc 59. NewYork-Presbyterian Hospital/ Weill Cornell Medical Center 209 Streamlining the Process of Transferring Patients from the Emergency Department to an Intensive Care Unit: A Housestaff Perspective Samuel Sultan, MD; Heidi Charvet, MD MPH; Susan L Faggiani, RN BA CPHQ; Gregory E Kerr, MD MBA FCCM 60. NewYork-Presbyterian Hospital/ Weill Cornell Medical Center 212 Using Wireless Voice over IP (VoIP) Phones in the Emergency Department (ED) to Improve Housestaff Communication Heidi Nicewarner, MD MPH; Samuel Sultan, MD; Abra Fant, MD; David Bodnar; Jose Fernandez, MD; Jennifer Lee, MD NewYork-Presbyterian Hospital/ Weill Cornell Medical Center 214 Improving Alpha-Numeric Paging on a General Medicine Floor Parag Goyal, MD; Shirley Cohen-Mekelburg, MD; Celia Egan, MD; Marianne Moore, MS RN PMHNP-BC; Matt Tiede, PA-C; Renuka Gupta, MD; Art Evans, MD MPH NewYork-Presbyterian Hospital/ Weill Cornell Medical Center Department of Anesthesiology 219 Effects of Real-Time Data Integration Technology on Compliance with Postoperative Documentation Zachary A Turnbull, MD; Susan L Faggiani, RN BA CPHQ; Jonathan Eskreis-Winkler, BA; Christian P Tope, BS; Niloo Sobhani; Ilirjan Decka; Madhu Mazumdar, PhD; Stavros G Memtsoudis, MD PhD; Peter M Fleischut, MD NewYork-Presbyterian Hospital/ Weill Cornell Medical Center Department of Anesthesiology 220 Streamlining Electronic Anesthetic Records to Patient s Electronic Medical Record and the Impact on Cost Zachary A Turnbull, MD; Juliet Jackson; Christian P Tope, BS; Wei Wei Xu; Mitchell F Berman, MD MPH; David K Vawdrey, PhD; Madhu Mazumdar, PhD; Stavros G Memtsoudis, MD PhD; Peter M Fleischut, MD NewYork-Presbyterian Hospital/ Westchester Division 221 Fall Safety Group to Reduce Falls in an Inpatient Geriatric Psychiatry Unit Danielle Struble-Fitzsimmons, PT DPT; Kaitlyn Giordano, MS LMHC; Elizabeth DiPersia, RN MS 65. NewYork-Presbyterian/ Allen Hospital and Columbia University 227 Status of Advance Care Planning in Elderly Patients and Impact of Physician Education in a University- Owned Community Hospital Deepa Shah, MD; Rebecca Eskin; Beth Barron, MD; Zorica Stojanovic, MD; Greg Pappas; Evelyn Granieri, MD 66. Improving Patient Experience with Lean Methodology North Central Bronx Hospital 232 Vimala Ramaswamy, MD; Calvin Hwang, MD MPH

11 Page North Central Bronx Hospital 235 Reducing Acute Length of Stay with Lean Methodology Bojana Milekic, MD; Varun Jain, MD; Vimala Ramaswamy, MD; Calvin Hwang, MD MPH Nyack Hospital 238 Model-based Optimization of Daptomycin Dosing during High-Intensity Renal Replacement Therapy Andras Farkas, PharmD 69. Nyack Hospital 239 Pharmacodynamic Profiling of Prolonged Infusion of Ertapenem in Critically Ill Patients with Early Onset Ventilator-Associated Pneumonia Through the Use of a Population Pharmacokinetic Model Andras Farkas, PharmD; Gergely Daroczi, PhDc 70. Nyack Hospital 240 Individually Designed Optimum Dosing Strategies (ID-ODS): A Multi-Model Based Online Application to Individualize Antibiotic Dosing in Critically Ill Patients Andras Farkas, PharmD; Gergely Daroczi, PhDc 71. Nyack Hospital 241 Site-Specific Target Attainment Rates of Meropenem for Central Nervous System Infections Andras Farkas, PharmD 72. Nyack Hospital 242 Pulmonary Target Attainment Rates of Short and Extended Infusion Meropenem Regimens Based on Simulated Epithelial Lining Fluid Levels Andras Farkas, PharmD 73. Nyack Hospital 243 Selection of Optimal Empiric Antimicrobial Therapy Against Pseudomonas aeruginosa in the Greater New York City Area Andras Farkas, PharmD; Thomas Jodlowsky, PharmD BCPS; Yuman Lee, PharmD BCPS; Patricia Saunders-Hao, PharmD BCPS; Keren Avisrur, PharmD Nyack Hospital 244 Our Intention Is Fall Prevention Colleen Beirne, RN CSHA NYU Hospital for Joint Diseases 250 Using Near Misses Analysis to Prevent Wrong-Site Surgery Richard S Yoon, MD; Michael J Alaia, MD; Lorraine H Hutzler, BA; Joseph A Bosco III, MD Integrating Graduate Medical Education in Quality and Patient Safety NYU Hospital for Joint Diseases 252 Joseph A Bosco, MD; Lorraine Hutzler, BA; Kenneth Egol, MD; Eric Strauss, MD; Jed Maslow, BA

12 Page 77. NYU Hospital for Joint Diseases 253 Geographic Differences in Hospital Charges and Infection Rate for Total Hip Replacement in New York State Rebecca Boas; Kelsey Ensor; Edward Qian; Lorraine Hutzler; James Slover, MD; Joseph A Bosco, MD 78. NYU Hospital for Joint Diseases 255 The Relationship of Hospital Charges and Surgical Volume to Surgical Site Infection After Total Hip Replacement (THR) Rebecca Boas; Kelsey Ensor; Edward Qian; Lorraine Hutzler; James Slover, MD; Joseph A Bosco, MD 79. Richmond University Medical Center 258 The Impact of Implementing CPOE Electronic Verification Process on Patient Safety at a Large Teaching Hospital Joseph Conte, MPA CPHQ; Lenny Shats, PharmD; Nancy Taranto, RN; Angela Gilbride, RPh; Jessie Saverimuttu, MD 80. Richmond University Medical Center 261 Improving Resident Safety Culture in Large Teaching Hospital Joseph Conte, MPA CPHQ; Edward Arsura, MD FACP; Jesse Savermuttu, MD; Jane Ponterio, MD FACOG; Ann Broz, MD; Sherifat Ope, MD; Lizette Kristine Lopez, MD; Ayaa Zarm, MD; Eskinder W Hadgu, MD; Matthew Clarke, MD; Muner Mohamed, MD; Almas Zane, MD; Sabrina Dukach, MD; Nida Khan, MD; Rodwan Mahfouz, MD; Rex Pillai, MD; J Pino, MD 81. St. Catherine of Siena Medical Center 269 Reducing Incidence of Hospital Acquired Pneumonia After Acute Stroke Through Implementation of Simple Bedside Dysphagia Screen Catherine Videtto, RN MSN ANP CCRN CPHQ; Mary Jane Finnegan, RN MSN; Donna Thomson, RN BSN 82. Stamford Hospital 272 Bundle Up: Five-Year Reduction in Hospital-Acquired C. difficile Infection Despite High Community Prevalence Merima Sestovic, BSN RN CIC; Michael F Parry, MD; Brenda Grant, RN MPH CIC CHES; Paula Castellano-Flynn, BSN RN 83. Stamford Hospital 275 Post-Operative Urinary Retention: A Collaborative Approach on Reducing the Risk of POUR for the Total Joint Population Deb Valentine, BSN CCM ONC; Ami Dalal, MHA; Orthopedic Service Line inclusive of Physician Assistants, Perioperative Services, Orthopedic Nurses, Orthopedic Surgeon 84. Beyond 39 Weeks: Sustainability in Decreasing Cesarean Rates in Elective Inductions Stamford Hospital 278 Donna Bowman, MSN DNP-c FNP-BC RNC-OB; Kathy LiVolisi, RN-C BSN MHA; Paul Bobby, MD DABOG; Lance Bruck, MD FACOG; Ami Dalal, MHA; Laura Edelberg, BA; Jamil Elfarra, MD; Patricia Howard, RNC-OB; Elizabeth Kelley, RNC-OB; Fal Len, RNC-OB

13 Page 85. Stamford Hospital 282 Improving ED Throughput: Creating Change in a Challenging Climate Rohit Bhalla, MD MPH; Ritu G Jain, MPH; Maher Madhoun, MD; Jayson Podber, MD; Eilish C Hourihan, RN; Sarah Sanders, RN; Elizabeth E Longmore, RN MSN; Theresa Miano, RN; John Hegarty; Janet Palladino; Scott Dunn; Gayathri Ramabadran; Tim Woodward; Kathleen A Silard, RN MS 86. Stamford Hospital 285 Implementing a CCHD (Critical Congenital Heart Defects) Screening Program in a Community Hospital Setting Donna Bowman, RNC APRN; Gerald Rakos, MD; John Ciannella, MD; Theresa Rovegno, RNC BSN 87. Stamford Hospital 288 Improving Outcomes for Patients with Severe Alcohol Withdrawal Delirium Through Symptom- Triggered Pharmacotherapy in the Critical Care Setting Christin Joy Lucia, RN BSN CCRN; Sokhak So, PharmD; Elizabeth Longmore, RN MSN; Tina Strazza, RN BSN; Araceli Moreno, RN BSN; Helen Tracey, RN; Michael Bernstein, MD; Dominic Roca, MD PhD FCCP; James Krinsley, MD FCCP FCCM Stamford Hospital 296 Maintaining our Hustle for Muscle: Hard-wiring Primary PCI Performance Perry Burgess BSN RN; Edward Portnay, MD; Steven Horowitz, MD Stamford Hospital 299 Improving Sickle Cell Patient Outcomes Through Decreasing Length of Stay and Standardized Practice Maher Madhoun, MD; Anne Brewer, MD; Amanda Shreders, MD; Pragya Singh, MD; Mary Coppolo, RN; Lisa Colberg, MSW; Jackie Gordon, RN; Kara Rossi, RN; Diane Washburn Stamford Hospital 302 Innovating and Sustaining Outcomes with a Patient Satisfaction Steering Committee Ellen Komar, RN BSN MPA NEA-BC; Sarah Sanders, BSN RN; Liz Longmore, MSN RN CEN; Kathy Livolsi, RN BSN MHA NEA-BC; Eilish Hourihan, MSN RN NEA-BC; Tim Woodward; Christina Curtin, BSN RN; Geoff Gittleson, PharmD; Deborah Fedeli Stamford Surgical Center 306 The Multidisciplinary Approach to a Nerve Block Program in the Ambulatory Setting Paulette Harris, RN BSN CNOR; Gayle Appleby, RN MSN 92. Stony Brook University Hospital 309 Electronic Medical Record: Friend or Foe? Utilizing the Electronic Medical Record to Assist in the Early Detection of Severe Sepsis Christine McMullan, MPA CPHQ; Paul Murphy, Data Analyst; Grace Propper, MS RN CPNP NNP- BC 93. An Application of Systems Redesign / Lean Six Sigma Methodology to Hand Hygiene Compliance VA New York / New Jersey Health Care Network (VISN3) 311 Jacqueline Parker, MS MPH RN; Sharon Tanks, MSN MPA RN; Cranston Darris, MBB MBA PMP

14 Page 94. White Plains Hospital 315 Implementation of Immediate Use Steam Sterilization Evidenced Based Practice Guidelines Andrea Lacourciere, MS RN CNOR; Samantha Silverstein, BSN RN CNOR; Meghan McAvoy, MS RN 95. White Plains Hospital 328 Integrated Delivery System of Disinfection Cap & Flush Syringe, Plus Staff Education, Lowers Bloodstream Infection Rate & Treatment Costs Saungi McCalla, MSN MPH RN CIC; Janet Greco, MA RN-BC OCN; Meg Warren, MSN; Joyce Bogetti, RN; Patricia Byrne, RPh MPA Winthrop University Hospital 330 Debriefing to Improve Teamwork and the Quality and Safety of Patient Care Margaret T Celenza, MSN RNC-OB C-EFM; Mary Lynn Brassil, MS RN CES C-EFM Winthrop University Hospital 332 Impact of a Hospital-Wide Comprehensive Pain Management Initiative Paula E Lester, MD FACP (certified in IM, Geriatric Medicine, Hospice & Palliative Medicine); Janet Shehata, MSN RN OCN; Shahidul Islam, MPH; Melissa Fazzari, PhD Winthrop University Hospital 335 A Quality Improvement Initiative to Attain Normothermia in the Delivery Room in VLBW Infants Amrita Nayak, MD; Shahidul Islam, MPH CPH; Phyllis Wan-Huen, MD Winthrop University Hospital and Children's Medical Center 338 Using the Electronic Health Record Meaningfully in a Patient-Centered Medical Home Cristina Mendes, RN; Ulka Kothari, MD 100. Winthrop University Hospital and Children's Medical Center 341 Maximizing Team Based Care in a Patient-Centered Medical Home - Elevating the Role of Medical Assistants Jennifer Bermudez, MA; Imelda Valente, MA; Eliana Elmeghrabi, MA; Mary Mehlman, MD; Ulka Kothari, MD

15 Implementation of Daily Goals Sheet to Enhance Communication Among NICU Staff Jennifer McGuirl, DO CMH; Zahava Cohen, RN MSN; M Susan LaTuga, MD MSPH Children's Hospital at Montefiore Introduction Daily goals sheets were first introduced in the adult ICU setting as a means to improve communication amongst the staff, improve patient outcome and decrease length of stay (LOS). It then made its way into the pediatric ICU where it was implemented with the same goals in mind. The last review of the literature revealed only one account of daily goals sheets being implemented in the neonatal ICU. The review of the literature of the experiences of various units regarding the implementation in the adult, pediatric and neonatal ICU s have demonstrated improvement in communication amongst the staff with scattered positive results on patient outcomes and LOS. Problem I hypothesized that implementation of the daily goals sheet (DGS) would improve communication among the NICU staff by: 1) Acting as a catalyst to encourage multidisciplinary involvement including nurses and respiratory therapists who had not routinely participated actively in rounds. 2) Documenting a readily accessible care plan for the day for all involved in the patient s care. 3) Highlight certain pertinent policies such as target oxygen saturations ensuring that they are discussed daily on rounds improving compliance with such policies. Goals 1) Improve communication between attending, fellow, nurse, resident, NP/PA, respiratory therapist and with the family 2) Incorporate and reinforce current policies regarding Central Line Associated Blood Stream Infections, Ventilator Associated Pneumonia, oxygen saturation parameters and nutrition optimization 3) Create a more multidisciplinary approach to daily rounds in the NICU Methods In the initial PDSA cycle, a survey was sent to attendings, fellows, NP/PAs, nurses and respiratory therapists to determine if there was a need and willingness for change amongst the staff. Respondents indicated a desire for improved communication and willingness to trial a daily goals sheet (DGS) as a means of improvement. During the 2nd PDSA cycle, a Daily Goals sheet (DGS) was filled out daily during morning rounds, given to the night nurse who placed it in a folder. There was a new DGS each day. After two weeks, nurses and providers felt the DGS was too much paper and difficult to track. The residents were very resistant to the implementation. For the third PDSA cycle, the DGS was compressed and printed on a double-sided sheet of paper encompassing one week s care goals on each sheet. In tandem with this the nursing staff was in the process of implementing a weekly care goals (WCG) form as part of incorporating care maps as required by the Joint Commission in order to integrate short and longer term care goals for each patient in as a means to optimize treatment goals and outcomes. The DGS informs whether the WCG targets, assessed once per week, are achieved. Folders were provided at the bedside to keep the DGS. Residents were educated on the DGS during their rotation orientation. Nurse feedback regarding the DGS System Quality Review Journal Page 1

16 was very positive. The 4th PDSA cycle was the distribution of a post-implementation survey to evaluate if the DGS has improved communication, understanding of the care goals, willingness of the staff to continue using it. Since residents rotate every four weeks there will be an orientation during the first week for all the new residents to ensure compliance and understanding of the DGS. Results There were 29 respondents to the pre-survey, which included attendings (17%), fellows (3%), NP/PAs (17%), and nurses (62%). Residents were not included on the initial survey. No respiratory therapists responded. Out of the 29 respondents, 26 indicated that they would be willing to use a DGS as a method to improve communication. The communication pre-implementation of DGS between nurses and providers was thought to be fair by 45% of the respondents, very good by 31%, good by 21% and excellent by 3%. To date there have been 25 respondents to the follow-up survey, which included attendings (35%), NP/PAs (15%), nurses (30%) and residents (20%). No respiratory therapist or fellows have completed the survey. 75% of the respondents felt they completely understood the daily goals of care compared to 65% on the initial survey. Impact of DGS on communication between the NICU staff was felt to be moderate by 40%, small by 30%, large by 20% and not at all by 10%. No one felt that it had a negative impact on patient care. 69% of respondents said they would continue using the DGS to improve communication. Conclusions Overall, there was a positive response to the DGS. It has helped improve communication among the NICU staff. The DGS contains some very simple information such as team to which the infant belongs and the provider following the infant for the week. This helped to facilitate communication regarding the infant s care with the correct provider or team member. Nurses indicated that this was a timesaver not having to ask multiple people who was caring for the infant. I expected more resistance from the nursing staff and less from the medical providers, but the reverse occurred. As a result, I needed to better engage and provide more education to the providers than initially anticipated. The follow-up survey indicates that there was better understanding of the plan of care by all of the NICU staff, improved communication and there is a willingness amongst the entire NICU staff to continue using the DGS with modification and more education. For the future, I plan to modify the DGS making two versions, one for the critically/acutely ill infant and one for the recovering infant in preparation for discharge. I also intend to have a designated place for the DGS at the infant s bedside that is easily identifiable. I also think with more education and consistent use it will become part of the routine on morning rounds. I would also like to look at some more objective measures to evaluate an effect on patient care before and after implementation of DGS. Two options include the time to removal of central line after it has been deemed not necessary and adherence to oxygen saturation policy. My intention had been to include respiratory therapist in the implementation of the DGS. At this point I have not been System Quality Review Journal Page 2

17 successful. I plan to explore the RT perceptions and reasons for not engaging in this initiative in order to collaboratively develop a strategy that will facilitate their participation. Based on the current literature, DGS are being used routinely in the adult and pediatric ICU setting and have become standard of care. Though use in the NICU is not yet routine, I anticipate it will become standard of care in the NICU in the near future. System Quality Review Journal Page 3

18 Raising Situational Awareness Through the Implementation of a Daily Safety Brief Linda Jendresky, MPH; Fiona Levy, MD; Andrew Steele, MD; Vincent Parnell, MD; Maria Esperanza, MD; Jahn Avarello, MD; Nancy Palumbo, MD; Peter Silver, MD; Carolyn Quinn, RN; Ann McGrath, RN; Eric Chakin, MPA; Kathy Albert, DNP; Charlotte Smith, RN Cohen Children's Medical Center of New York Introduction Cohen Children s Medical Center (CCMC) of New York is a 164-bed pediatric teaching hospital "children's hospital within a hospital" and a member of the Northshore LIJ Health System. It is located on the Long Island Jewish Medical Center campus which also includes Long Island Jewish Hospital and Zucker Hillside Hospital. CCMC treats more than 200,000 children per year. The CCMC Quality and Administrative team are focused on improving the patient experience and fostering a culture of safety. Part of the larger strategic goal of becoming a High Reliability Organization, and in an effort to achieve a culture of safety a novel idea of empowering midlevel managers was introduced. This initiative was introduced via the Daily Safety Brief on May 1st, 2012 with the goal was to improve situational awareness. Problem What is the Daily Safety Brief? The Daily Safety Brief is an operational readiness collaboration among leaders and staff concerning events of harm or potential safety risks that facilitates the mitigation of risk and deployment of resources in order to understand what has/ might occur and in doing so minimize risk or harm to patients, families and staff. The process entails a 24-hour look back and looks ahead with a focus on preparation as opposed to urgent response. Goals The goal of the Daily Safety Brief is to improve situational awareness at all levels of the organization and to prevent risks from becoming accepted, routine, business as usual. Concurrently, the call fosters collaboration across all disciplines which in turn aids in the materialization of becoming a High Reliability Organization. Methods Facilitated by the Safety Officer of the Day (SOD) (a physician leader), this minute brief takes place in a centralized location with call-in capability. There is a designated order and list of areas reporting with targeted risk points reported out by each area. Standardized reporting scripts were developed with the goal of targeting areas of greatest risk. The team reviews current status; look back of significant safety risks from the last 24 hours; a look ahead for anticipated issues in the next 24 hours and follow-up on safety critical issues. 1. The call is facilitated by a Senior Safety Doctor of the Day (SDOD) and an Administrator of the Day (AOD). The Senior staff is designated to follow through and provide the following support during and after the call. a. Facilitate the calls keep team on track b. On-line problem solving and follow-up post call c. Start with days since last serious safety event d. Provide any global announcements System Quality Review Journal Page 4

19 e. Prompt reporters by calling on the areas to report f. Once all areas have reported provide any needed wrap up, include a heads up to any individuals/ areas that the SDOD and AOD may be visiting as result of the call and re-list and follow-up items and who is responsible for reporting-out on next call g. Keeps a spectra link phone for the day and responsible for follow-up if any operational issues requiring any Administrative input or assistance with problem solving h. Problem solving occurs after the call and is lead by the SDOD and AOD 2. The Quality records minutes at daily calls and works with SDOD/AOD for response planning. The Quality Department has created and maintains a database of information from calls for analytics and works with all parties regarding changes to reporting structure and metric identification. 3. The Reporters will announce their name and restate the area they will be reporting for. The report bolsters prediction of potential risk and provides pertinent negatives and positives aspects of the report. Each reporter will remain on the entire call to acquire valuable information from the reports of others. 4. Each Department has scripted forms to complete and use as a reporting tool. These forms are collected by Quality daily and entered into a database whereby we can monitor and have data to represent volume, actionable items and improvements. Results Areas of Potential Risk Identified and Mitigated in a timely manner: Participants have stated that the lead time for resolution/ problem solving has been dramatically reduced as they can share issues in real time and are presented with the opportunity to ask for a huddle or call as needed. At risk patients and families are identified and huddles are called following the calls to discuss plans for: 1) similar names/ twins 2) low volume/ high acuity surgical cases 3) children with challenging intravenous access 4) language barriers 5) social concerns (Child Protective Services) Other area highlighted include: Medication shortages and alternative procurement of drugs are identified; Near misses and medications errors are shared and lessons learned are reported. Equipment down-time such as 1) CT Scan/ MRI and 2) Laboratory instrumentation are reported and plans are put in place to ensure no interruption of care. Potential and actual Respiratory Rapid Responses Team Activations are reviewed with an opportunity for all team members to be aware of unstable patients. Patient flow bottlenecks are identified and team approach activated to assist with throughput. Identified high risk / low volume Operative and pre-operative cases and a mitigation plan is put in place. Patients at high risk for central line associated bloodstream infections and catheter associated urinary tract infections are highlighted so we can make sure they have needed resources. System Quality Review Journal Page 5

20 Data collection and outcome data are underway with identification of key metrics for all departments/ units to monitor improvements. The data analysis has proven to be a challenge as we are measuring near misses as well as improved processes of healthcare delivery in real time. Conclusions The Daily Safety Brief has proved to be successful and beneficial to all staff involved. There is greater transparency of day to day operational risks because all key clinical and operational areas are involved. Therefore, interdisciplinary knowledge has lead to proactive risk mitigations. Participation by key areas of Cohen Children s Medical Center, including shared services with Long Island Jewish Medical Center to ensure daily participation in a large complex of both Adult and Pediatric patients has proved challenging. However, participation by the members of the team has been over 95%. We continue to encourage all members of the call to have a transparent discussion with sensitivity not to violate HIPPA. The Daily Safety Brief serves as a model that can be transferable to the nursing unit level for engagement of frontline staff to ensure ownership and accountability while providing opportunities for continuous process improvement. It may also be applicable to other larger service lines that have multiple sites, i.e. Ambulatory practices. One advantage of a dedicated telephone line with a conference call-in link you may allow other people within the System or the staff at the unit level access to the information at any given time. System Quality Review Journal Page 6

21 Poster Presentation Reorganizing the System of Care and Workflow in the Pediatric Ambulatory Chemotherapy and Transfusion Center: A Cost-Effective Analysis Using Simulation and Lean Methodology to Improve Environmental Management and Organizational Quality Kathy Albert, DNP CPHQ; Christopher Pinna, BS MSc; Donna Newman-Beck, RN BSN CPN; Charlotte Smith, RN MSN NE-BC; Lawrence Wolfe, MD; Ruth Masarik Cohen Children's Medical Center of New York Introduction The Pediatric Ambulatory Chemotherapy and Transfusion (PACT) Center is a high-risk, high-volume outpatient setting that provides chemotherapy, blood product transfusions and fluid hydration to pediatric hematology and oncology patients. The PACT provided services for 8,476 patients in 2012, an 8% increase from Further analysis showed that there were numerous deficiencies that needed to be addressed in order to serve the PACT population safely, efficiently, and economically. They were: (a) Patient scheduling and wait times, (b) Billing inconsistencies, (c) Bed utilization, (d) Inventory control, (e) Optimization of PACT real estate and flow, (f) Supply & cost control. The project utilized innovative methodologies previously reserved for manufacturing and industry. Lead by a Six Sigma Master Black Belt and an Industrial Engineer, these methodologies were seamlessly transitioned into positive healthcare process outcomes. Problem PACT patients were experiencing appointment wait times in excess of minutes. This was a direct result of insufficient bed utilization and scheduling. Patient scheduling was non level-loaded, thereby, most patients were seen between the hours of 8am and 12 noon, with the majority between 10am and 12 noon. This caused dissatisfaction among care providers, patients, and families. In addition, PACT storeroom and bedside cart supplies were being ordered without any correlation to par usage, causing increased costs, overstocking, storage challenges, and lack of bedside cart standardization. Goals The goals of the project were: Reduce average patient wait time by 50% (met) Increase bed utilization by 20% (exceeded) Decrease Vincristine chemotherapy start time by 20% (currently 10%) Reduce supply costs by 20% (exceeded) Methods Tools from Lean/Six Sigma methodology were used to identify the process. Process mapping allowed for the identification of key performance segments in which bottlenecks could potentially or actually occur. A data collection System Quality Review Journal Page 7

22 tool was created to obtain baseline process data in the following areas: The average number of patients seen on a daily basis was 33 with an average wait time per patient of minutes. Patient scheduling was non level-loaded, meaning that most patients were seen between the hours of 8am and 12noon, with the majority between 10am and 12noon. Time studies were conducted for 60 days to gather data surrounding the entire PACT process, including scheduling, patient movement, treatment times, and bed utilization (48%) This project took tools and strategies not traditionally used in healthcare and created practice models that are now being adapted hospital-wide. The innovative use of simulation software in healthcare is derived from its use in the aerospace industry for simulating flight scenarios in the training of pilots to manage flight situations from the safety of a simulated cockpit. This same idea is translated to healthcare by using simulation software to model scenarios without the risk of using live patients and staff. Healthcare simulation software is a predictive analytic tool designed specifically for the patient care industry to evaluate, plan, and design/redesign the processes of hospitals. Simulation software was used to uncover process bottlenecks, delays, and opportunities for improvement in PACT. A model was created to identify inefficiencies in PACT and test a variety of scenarios. The animation and graphic output results showed the behavior in PACT under varying circumstances which provided the opportunity to test new ideas for system design or improvement before committing the time and resources necessary to build or alter the actual system. Computer-assisted drawings (CAD) of PACT were used which allowed the creation of a model from existing floor plans. The use of simulation software enabled the testing of new ideas for system design or improvement before committing the time and resources necessary to build or alter the actual system. 5S originated in Japan and was used by Toyota Manufacturing to optimize workspace efficiency and process optimization. The 5S's are "SORT, SET IN ORDER, SHINE, STANDARDIZE, and SUSTAIN". 5S is a system to reduce waste and optimize productivity through maintaining an orderly workplace and using visual cues to achieve more consistent operational results. Implementation of this method "cleans up" and organizes the workplace basically in its existing configuration while reducing dangerous clutter in the hallways. The PACT staff used red, yellow, and green tickets to sort their equipment and supplies. If an item was red-tagged, it signified that the item was to be discarded. A yellow-tagged item meant that the item was still being used but would not be needed in the near future. A green-tagged item was still being used and would be kept. The staff performed this exercise as a team effort since everyone s input was necessary. To provide a place for everything, and everything in its place, PACT used industrial-grade tape to outline item locations. Cabinet contents have specifically outlined and labeled locations for each item. There is a photo of the cabinet interior placed on the corresponding inside of the cabinet door to serve as a blueprint for how the interior should always look. This process serves as a creative way to always maintain order and recognize when an item is missing. Par values are included on the photo for each item. In order to save money spent on patient care supplies, PACT used an innovative system known as KAN BAN. A Kan ban system can dramatically reduce inventory levels and save money. Kan ban aligns inventory levels with actual consumption. A signal is used to indicate more supplies are needed as products are consumed. System Quality Review Journal Page 8

23 In the late 1940s, Toyota started studying supermarkets with the idea of applying store and shelf-stocking techniques to the factory floor. Similarly, in a supermarket, customers obtain the required quantity at the required time, no more and no less. Furthermore, the supermarket stocks only what it expects to sell within a given time frame, thus saving revenue on unneeded stock. PACT adopted the Kan ban system and used blue horizontal plastic bins for each item in their supply closet. At a key point in the bin, a green tape line was placed. Any supplies before the green line indicate an optimal supply level or par. Further along the bin, a red tape line served as the signal to order more supplies. This process reduced over-ordering, waste, and expired supplies. Results As a result of this project, the following outcomes were achieved: Average wait time in PACT decreased to minutes (approximate 50% decrease) Bed utilization in PACT increased from 48% to 63%. This represents a 24% increase in service for PACT patients due to level-loading scheduling and optimization of process from simulation. Bed deficit decreased from 46.3% to 30.1% Chemotherapy start time (specifically Vincristine) was reduced by 10%. The cost of supplies in 13 bedside carts decreased by 35% due to establishing more stringent par levels and implementing "just-in-time" Kan ban ordering. This process decreases spending, excessive waste, and expirations. Billing consistencies were achieved as a result of the creation of a 6-month Hematology account for every PACT patient. The primary diagnosis now remains consistent and the secondary diagnosis indicates the reason for the PACT visit. This directly impacts financial operations by reducing payment denials from providers. As a result of performance of 5S throughout the PACT, including the supply room and bedside carts, supply ordering was suspended for 1 month to utilize surplus overstock and re-examine utilization. Improved staff satisfaction had a direct impact on patient satisfaction. All staff participated in the processes to improve PACT. There is an increased sense of pride and ownership which translates to patient care. The project has sustainability and is audited monthly for compliance with 5S. The scores continue to increase and PACT has achieved the maximum possible score achievable by sustaining the highest requirements for 6 months or more. PACT has become the "gold standard" by which other units and departments within the hospital are seeking to emulate. Conclusions The techniques and methodologies that were utilized throughout this process have tremendous potential for interdepartmental generalizability and transferability. They are: Simulation software 5S Level-loading Kan ban The use of simulation software to maximize healthcare processes is highly transferable to new and pre-existing processes. It is useful in departments that are seeking to optimize staffing, resources, and time management, whether they be outpatient or inpatient units, operating rooms or emergency departments all have underlying processes that can be improved. Another transferable usage is in the opening of a new department such as a pharmacy or laboratory. By simulating the process, it allows for the design of the optimal work flow with the appropriate resources. Simulation System Quality Review Journal Page 9

24 software should be used by all departments looking to improve their outcome because it is more comprehensive (allows for a far greater range of influential factors), is easier to validate (it is both visual and analytic) and the results are faster to obtain. It is the recommendation to use 5S in any environment that has become disorderly and inefficient. When 5S is done in a pre-existing department, it provides a fresh and efficient work environment that staff have pride in maintaining. 5S is also transferable to the opening of a new department because it starts the area off on the right foot for neatness, orderliness, ease of access, and accountability to maintain the area (see addendum). Level-loading can be transferable to all units that operate off of schedules. The ideal units for level-load placement are Ambulatory Services, Surgery, Cancer treatment, Dentistry, and any other out-patient setting. The core concept of level-loading is to allocate necessary resources to accommodate a particular day's schedule while placing patient appointments in appropriate intervals to minimize surges. Depending on the type of patient mix, level-loading determines required skill sets, staffing levels, and necessary equipment. Overstaffing and over-equipping will thus be minimized. The patient experience will also be improved as they will flow from point to point with minimal wait. Kan ban is transferable to any area that wishes to decrease costs and control inventory. This simple visual technique allows orderers to maintain supply par levels and adjust inventory levels as needed without the risk of over stocking and expiration of supplies and equipment. It is imperative that healthcare leaders look to new and innovative ways to leverage costs and stabilize resources. What was unheard of is now the norm. Healthcare must reinvent the use of processes and personnel such as Lean methodology and industrial engineers that had previously been under the auspices of manufacturing and production and utilize them in ways that improve the quality, patient experience and bottom line of healthcare. System Quality Review Journal Page 10

25 Waiting area with patients By mid morning, the waiting area reaches maximum capacity, simulating real life process Simulation Software depicting actual process in PACT When the software program is activated, patients and staff move through the PACT process according to data from the time studies. (Patients enter and exit waiting room and beds). Patients remain in beds for their allotted treatment time. Architectural CAD drawings were used to simulate real floor plan and dimensions. Time studies were conducted to acquire data to feed into software to achieve an accurate process flow. Input data (# of staff, # of patients, time patients arrived) were manipulated to optimize best process. Beds with patients Waiting area with patients 5S of supply cabinet. All items are categorized and labeled. Par levels are indicated for each product. Map on inside door provides visualization of standardized bin and product placement. Map of cabinet Kan ban Supply System Red line indicates a signal to order Green line indicates an optimal supply level PACT capacity prior to level loaded scheduling showed that there was a bed availability deficit between the hours of 10am and 1pm (see red Product map bars). During this time period, 46.3% of patients were scheduled. PACT capacity following level loading scheduling showed that the bed availability deficit was greatly reduced (see red bars). During the same time period, 30.1% of patients were scheduled. System Quality Review Journal Page 11

26 Sustain Current State 5S Score Sort S: Scoring & Progression Set Standardize Shine 5 5S Trending /11 2/25 3/11 3/25 4/8 4/22 5/6 5/20 6/3 System Quality Review Journal Page 12

27 Poster Presentation Reducing Mortality in Sepsis through the Implementation of Early Goal-Directed Therapy Protocol Ram Parekh, MD (Attending, Emergency Medicine); Scott Weingart, MD (Director of Emergency Medicine Critical Care); Martin Warshawsky, MD (Director of Respiratory Intensive Care Unit) Elmhurst Hospital Center Introduction Sepsis is the tenth leading cause of death nationwide accounting for 1.4% of all deaths. Nationally, about 500,000 cases of severe sepsis are initially managed in the Emergency Department (ED), with an average ED length of stay of five (5) hours. These data support the need for early identification and treatment of severe sepsis. In 2010, faculty at the Elmhurst Hospital Department of Emergency Medicine took a leading role, in conjunction with the Greater New York Hospital Association/United Hospital Fund, in developing the STOP (Strengthening Treatment and Outcomes for Patients) Sepsis Collaborative - a quality initiative that supports early recognition and treatment of severe sepsis and septic shock using a protocol-based approach in the ED and the intensive care unit. Problem Over 750,000 cases of severe sepsis are seen in the US, annually, and this number continues to rise as the population continues to live longer. Despite advances in our understanding of sepsis, life-saving therapies have not materialized over the past 30 years. What has been shown to save lives is timely recognition, early antibiotics, and aggressive intravenous fluid therapy. Goals The goal is to reduce morbidity and mortality associated with severe sepsis and septic shock in the Emergency Department through rapid identification of patients with the signs and symptoms of sepsis and the timely treatment using evidenced-based Early Goal Directed Therapy (EGDT) Protocol. This protocol-driven resuscitation strategy centers on a scientific basis for identification of high-risk patients, standardized practice for hemodynamic optimization, and effective use of antibiotics aimed at hemodynamic optimization in the ED, at the time of recognition of sepsis. Methods Multidisciplinary teams were formed, with particularly close teamwork between nurses and physicians. All providers received comprehensive sepsis education and training with web-based training videos available on demand. An easy-to-use severe sepsis screen was incorporated into the routine triage process on all patients presenting to the ED. A primary focus of the initiative was the adaptation and translation of evidence-based therapies to make them feasible in a busy ED. Two treatment protocols were offered to clinicians, one based on non-invasive means to assess fluid status and tissue perfusion, as well as an invasive protocol that utilizes central venous pressure and central venous oxygen saturation to guide therapy. Results Since 2011, Elmhurst ED has seen a total of 309 patients that met the criteria of severe sepsis and septic shock. With an System Quality Review Journal Page 13

28 average time to recognition from patient triage under one hour and average time to completed resuscitation of 3 hours 21 minutes from time of recognition, Elmhurst has consistently outperformed the other 57 hospitals participating in the collaborative (see Figure 1). Furthermore, Elmhurst saw an improvement in 28-day survival from 50% at the beginning of the initiative to 81% survival over the course of 2 years, which outperforms the collaborative average of 72% during the same time frame (see Figure 2). Conclusions Lessons learned include: Implementation of an easy-to-use protocolized approach to severe sepsis and septic shock recognition and treatment led to a 31% absolute reduction in mortality at no additional cost Having the ability to track our progress in real time allows month-to-month sustained improvement in performance Future Direction: Overwhelming success in the ED has been the impetus to develop similar protocols for the pediatric ED, pediatric inpatient, and adult inpatient services and is now serving as the basis for the recent New York State legislation mandating rapid identification and treatment of severe sepsis and septic shock. System Quality Review Journal Page 14

29 Figure 1 Figure 2 System Quality Review Journal Page 15

30 Assisting the Patient to Navigate Safely Throught Healthcare Reform: The Project Red Congestive Heart Failure Initiative Janet Carr, MD; Milton Espinoza RPh; Marlaina Norris, MD MBA Department of Care Management Elmhurst Hospital Center Introduction Hospital admission is a complex process with both physical and psychosocial challenges. At the time of discharge, many patients remain vulnerable, at risk for re-admission. In 2012 hospital reimbursement paradigms captured national media attention as payments transitioned from fee-for-service to pay-for-performance. Under this system hospital readmissions served as a marker patient safety via: a) understandable provider communication, b) culturally competent educational materials c) care coordination d) and increased engagement/ self-monitoring awareness. Projected 2012 penalties from patient readmissions for Elmhurst Hospital. Problem Hospital must address the issue of readmissions. One of the major causes of readmissions is the gaps in transition from inpatient. Care coordination throughout the continuum of care in addition to attention to medication education/access/ reconciliation/compliance may reduce the incidence of readmission. Goals The goals for Project Red are multiple: Decrease Readmissions for CHF by 10% Ensure all Project Red Patients are on CHF protocol and exceptions documented Post Hospital appointments within 10 days Methods TOOLS Breakthrough (LEAN) Creation & Marketing of a Clear Communication Plan Project Red (Re-Engineered Discharge) a Care Coordination & Patient Education Guideline, learned from a NIHsponsored research out of Boston University Medical Center Team StePPs & Journey to Excellence Multidisciplinary Communication Institute for Health Improvement Triple Aim: Better Care. Better Health, Lower Cost METHODOLOGY The overall team of patient safety champions consisted of Nurses, Social Workers, Pharmacists, Cardiology, Hospital Administration and Clerical support. Clinical protocols were discussed during inter-disciplinary rounds, and self-management tools were emphasized for the patients and family. Communication with the patients at 48 hours and for 30 days post admission was critical to reduce readmission. This included follow up appointment reminders and medication reconciliation pre/ post discharge in addition to communication with community PCPs and sub-specialists. Collaboration with Home Health Services led to early medical assessment of potential gaps in patient wellness. Unique to EHC, Care Management existed across the continuum of patient experience, meaning patients were discussed and transferred between the Care Managers in the ED, Inpatient, and Out-patient clinical areas. This served to create a System Quality Review Journal Page 16

31 safety net infrastructure which helped to sustain our patients within the community. In addition the team Pharmacist provided specialty education regarding medication and compliance. Results CMS data is the gold standard for readmission assessment. However, in order to track concurrent interventions, we used the HHC internal database to monitor concurrent utilization activity. Using this method, CY2012 annual CHF readmissions decreased ~26% from CY2011 values. PNA and AMI rates remained stable over this same period, either at or under the reported CMS national benchmark. This estimated predictor of performance was aligned with the more comprehensive Medicare fee-for-service (IPRO) report and the official CMS announcement, which confirmed the EHC had a 44% reduction in readmission rates for CY 2012! These results not only demonstrate improved patient outcomes and satisfaction but also a financial gain for the hospital. Conclusions The use of a "Specialized Team" has been an effective and efficient strategy to initiate culture change. The goals were achieved through commitment to our patients new communication protocols. The next challenge is to incorporate these steps into the general inpatient discharge process. LESSONS LEARNED Patient Advocacy Is the Leader Communication Breaks Down BARRIERS Patient Population ~ are all equal? One size may not fit all considering: Socio-economic status, Geographic location, Education, Ethnicity, Disease burden, Health Literacy, Substance Abuse System Quality Review Journal Page 17

32 System Quality Review Journal Page 18

33 35.0% Elmhurst CHF Readmission Rates (Jan 2011 May 2013) 30.0% 25.0% Readmission Rates 20.0% 15.0% 10.0% Project RED 5.0% 0.0% J 11 F 11 M 11 A M J 11 J 11 A 11 S 11 O 11 N 11 D 11 J 12 F M Elmhurst A 12 M 12 J 12 J 12 A 12 S 12 O 12 N 12 D 12 J 13 F 13 M 13 A 13 M 13 System Quality Review Journal Page 19

34 Hourly Rounding Initiative and Other Practices Contribute to a Low Fall Rate Kerry Sokolohorsky, RN BSN Helen Hayes Hospital Introduction Falls and injury from falls remain a significant patient safety issue in hospitals, despite use of screening tools to identify patients at risk for falls and initiation of falls reductions programs. Over the past several years, Helen Hayes Hospital has demonstrated a significantly lower incidence of falls compared to similar hospitals, as tracked by the National Database of Nursing Quality Indicators (NDNQI). This poster reviews the interdisciplinary interventions that may have contributed to these findings. Problem Falls in older adults are the leading cause of injury, deaths, hospitalizations, and emergency department visits in New York State. Fall injuries are associated with significant morbidity, reduced mobility, decreased functioning, and loss of independence. In the US, hospital fall rates range from 3.31 to 11.5 fall events per 1,000 patient days. Inpatient Rehabilitation Facility patients at Helen Hayes Hospital are at especially high risk for falls, given their admitting diagnoses which include: traumatic brain injury, spinal cord injury, stroke, complicated cardiac or pulmonary disease, amputation, recent joint replacement and multiple fractures. On admission, the majority of patients have significant balance and cognitive deficits, and as they improve in therapy they remain at risk for falls, due to a sense of increased independence and improved function which is not always accompanied by insights into their limitations, especially at night. In fact, when falls rates at Helen Hayes Hospital were analyzed for trends related to time post admission, disability, age, sex, unit, safety risk level, day of admission or whether a medication was given just prior to the fall, no trends were found. For this reason, a hospital wide-multidisciplinary falls prevention program focusing on issues unique to inpatient rehabilitation facilities was initiated and falls rates were tracked over time using the NDNQI. Goals The purpose of this project is to: 1) To demonstrate the low rate of falls in all units of Helen Hayes Hospital, which are consistently lower than comparable hospitals. 2) To illustrate the nursing and inter disciplinary team based practices that resulted in these fall rates. 3) To demonstrate the impact these practices have on nursing satisfaction and the relevant subcategories. Methods The details about all falls are documented on an interdisciplinary incident report by the professional staff member caring for the patient, including nurses and therapists, and signed by the physician who evaluates the patient immediately after the fall. The health care practitioner completing the form discusses the event with their supervisor, who also signs the form. All falls are reviewed the next day at interdisciplinary team huddles, as well as by the patient's attending physician. All falls are entered into NDNQI each month and are unit specific. Areas tracked include age, sex, injury level, safety risk level and time since last assessment. System Quality Review Journal Page 20

35 Falls rates are tracked and discussed during Nursing Quality Improvement meetings, as well as during the hospital's Patient Safety Committee. Falls with significant injury are discussed during multidisciplinary peer review meetings, focusing on areas for process or system improvement, and the conclusions are presented at the Patient Safety Committee meeting. Patient Safety Committee minutes are reviewed by the Medical Executive Committee and Hospital Quality Management Committee. On admission, nurses use a standardized tool to assess the patient's risk for falls. If the patient scores in the high risk category, the patient is given an orange wrist band. This orange band is a reminder to nursing, therapy and other staff that the patient is at increased risk for falls and specific falls reduction procedures are followed. These include requiring a staff member to assist a patient with all ambulation and transfers and to wait with a patient when they are toileting or at a procedure. Therapy staff let nursing staff know when the patient has returned to their room after a session and family members are instructed about these safety procedures. Restraints are not used to prevent falls at Helen Hayes Hospital. One-to-one staff to patient supervision is used for impulsive, agitated or confused patients, and neurologists specializing in stroke or brain injury, as well as psychiatrists, are primarily responsible to order medications to treat cognition or mood. Medical staff members are also experienced in the treatment of elderly patients, including pain management. In August of 2011, hourly rounds by all nursing staff was initiated. The purpose of hourly rounds is to pro actively address patents needs, improve staff workflow, improve patents pain control and increase patient satisfaction. In addition to tracking falls rates, nurses' job satisfaction has also been tracked since All RN staff are asked to complete an annual anonymous RN satisfaction survey administered by National Database of Nursing Quality indicators (NDNQI). Response rate is typically above 75%. Results A multidisciplinary approach to falls management at restraint free Helen Hayes Hospital has resulted in a fall rate that is lower (average 2-4 falls per month) than comparable hospitals (average 6 falls per month). In fact the fall rate at HHH is below the 25th percentile of the fall rate for all other hospitals (Figure 1). In our initial review of falls, we noted that many falls occurred after patients received Ambien at night for sleep. Therefore, an additional step was added to the medication administration record for Ambien, that the bed alarm must be turned on after administration. Because our patients remain at risk after discharge as they receive less supervision, a "Guide to Fall Prevention" brochure was developed. This brochure addresses a multitude of home safety tips, a complete room to room display for easy use and is provided to all patients at discharge. The initiation of hourly rounding and other interdisciplinary team activities appears to also relate to an improved satisfaction of nurses at Helen Hayes Hospital. As illustrated in Figure 2, nurses at Helen Hayes Hospital score higher than nurses in other facilities in overall satisfaction (65% at HHH vs. 55% at other hospitals). The results of this survey has shown that Helen Hayes Hospital nurses scored higher in all work satisfaction T-scores. These T-scores included pay, professional status, autonomy, decision making, RN-MD interactions, RN-RN interactions and tasks. This higher System Quality Review Journal Page 21

36 score is seen in the areas of professional status, autonomy, decision making, pay, RN-MD Interactions, RN-RN Interactions, and tasks. Although many factors are responsible for this higher job satisfaction, compared to other similar hospitals, it is clear that the falls reductions interventions, such as hourly rounding and inter disciplinary analysis of falls, did not adversely affect nurses' job satisfaction. Conclusions Helen Hayes Hospital, a restraint free hospital, has a fall rate that is lower than the fall rate at comparable hospitals. We feel this is in part related to hourly rounding, a multidisciplinary team approach to the evaluation of each fall that occurs, a constant review of circumstances leading to falls and initiation of corrective actions to prevent further falls. This team approach and the use of hourly rounding not only lead to improved patient care in terms of fall reduction but also an improved satisfaction score of nurses. We recommend that all hospitals have active fall review programs, including a multidisciplinary team approach to evaluate each fall. System Quality Review Journal Page 22

37 System Quality Review Journal Page 23

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39 Prospective Study on Inpatient Falls in an Orthopedic Hospital Setting Lisa A Mandl, MD; Wei-Ti Huang; Jaimie Lee; Tina Bailey, RN; Danielle Edwards, DPT; Mayu Sasaki, MPH; Patricia Quinlan, DnSC MPA RN CPHQ; Steven K Magid, MD Hospital for Special Surgery Introduction This study evaluated rates and predictors of falls among adult orthopedic in-patients at a musculoskeletal specialty hospital. Problem The condition studied was inpatient falls that occurs postoperatively in an orthopedic hospital setting. At Hospital for Special Surgery (HSS) a fall is defined to be an assisted or unassisted event in which the patient makes contact with the ground. Minimizing falls in-house is an important safety initiative. Of reported accidents in hospitals, falls are the most frequent. A recent study focusing on postoperative falls on an orthopedic unit calculated 2.5 falls per 1,000 musculoskeletal inpatient days. Patient falls result in morbidity, mortality, and the fear of falling again. Fear of falling can result in the restriction of movement by the patient, resulting in impaired mobility. Falls are also associated with a longer hospital stay and increased costs. Goals The specific aim of this case-control study was to examine risk factors associated with orthopedic inpatient falls in an orthopedic hospital setting. The secondary aim of this study was to determine the incidence and severity of injury that results from a fall. While a two-year retrospective study was recently published on postoperative falls on an orthopedic unit, there are no studies we know of that evaluate orthopedic inpatient falls prospectively. Investigating risk factors associated with patient falls in an orthopedic hospital will result in increased awareness of clinicians and hospital staff with regards to a patient s propensity to fall and will allow staff to initiative effective, evidence-based measures to prevent future falls. This study will also help to create a falls risk assessment specific to orthopedic patients. In addition, in comparing our results to the previous work of other investigators, we should be able to determine which risk factors of falling are universal and which risk factors pertain specifically to orthopedic surgical patients. Methods Researchers prospectively studied falls from 5/2/10-5/1/12. Two controls were matched to every fall on age, postoperative day (POD), type of orthopedic procedure, and each assigned the index time that their case fell. Data were collected via chart review and patient questionnaire. Medical record data for controls was abstracted from last note prior to the index time or first note after. Differences between cases and controls were compared using t-test or chisquare test, as appropriate. A multivariate logistic regression was performed to identify predictors of falls. Results There were 169 falls during the study timeframe. The fall rate was 0.65 of in-patient orthopedic admissions; 1.67 falls/1000 in-patient days. The average age of cases was 68.4 yrs (SD 12.7), 55% were women, mean BMI was 29.4 (SD 6.5), and average POD was 2.9 (SD 2.5). One patient fell twice. 39.5% of falls occurred in total knee replacements (TKR), 23.3% in total hip replacements (THR), 25.8% in spine procedures, 9.6% in lower extremity procedures and 1.8% in upper extremity procedures. 92% of falls occurred in the patient's room. Neither a known history of falls nor System Quality Review Journal Page 25

40 wearing a falls risk bracelet was associated with falling. Fallers were less likely to use a crutch or cane, more likely to use a walker, and more likely to be in a single occupancy room. Cases walked significantly fewer feet and required significantly more physical therapy (PT) ambulation assistance than controls. 31% of falls involved using the bathroom. Of 168 first falls, 28 (17%) resulted in injuries, most of which were minor. 8 falls (4.8%) resulted in 10 serious adverse events (AEs), including 4 dehiscence/return OR, 3 transfer to a higher level of care, 2 dislocations and 1 fracture. There were no deaths or intracranial/epidural bleeds. In a logistic regression controlling for significant univariate predictors (single room occupancy, confusion, being assigned canes/crutches, using a walker or needing physical therapy assistance to ambulate) the only predictors of falls were confusion (OR 2.6; 95% CI ) and using a walker (OR 28.6; 95% CI ). Being in a double occupancy room was borderline protective against falling (OR 0.55; 95% CI ). Among TKR, having a femoral block trended towards being associated with falls (p=0.057). There were no significant predictors of AEs. Conclusions The rate of falls and AEs in this patient population was low. This large series identifies confusion and using a walker as being predictive of falling among orthopedic in-patients. Larger studies are needed to confirm these results, and to inform fall prevention strategies in this rapidly growing group of patients. System Quality Review Journal Page 26

41 Table 1 Comparisons of Patients Who Fell vs. Controls* Characteristic Fall Cases (n=168) Controls (n=317**) P value Sex Female 92 (55%) 179 (56%) 0.72 Distance (feet) able to ambulate with assistive device 48.9 (SD=66.5) 64.4 (SD=86.8) Room Size Double room Single, or Double Single 124 (80%) 31 (20%) 262 (89%) 33 (11%) Chart documented confusion 34 (20%) 29 (9%) <0.001 Assigned a cane or crutches at 162 (96%) 278 (88%) fall/index time Walker used during fall/ index time 142 (85%) 315 (99%) <0.001 Ambulation Assistance by Physical Therapist Max or Moderate Minimal Contact Guard Supervision or Independent Not Tested 24 (15%) 39 (25%) 56 (35%) 13 (8%) 27 (17%) 33 (11%) 97 (31%) 84 (27%) 57 (19%) 37 (12%) Recorded prior history of falling 58 (36%) 82 (26%) 0.09 Patient wearing a yellow risk bracelet 45 (28%) 60 (19%) 0.13 Pre operative urinary issues (incontinence, nocturia, urgency/frequency) 49 (30%) 84 (27%) 0.62 *Controls were assigned index time and date based on the time and date their matched case fell **2:1 controls could not be identified for 14 cases double room = two beds and two patients; a single room =one bed and one patient; double single room = size of a double room with one bed and one patient System Quality Review Journal Page 27

42 Pharmacist Active Involvement in Patient s Continuity of Care After Hospital Discharge Rafael Felippi, PharmD BCPS; Michael Liebl, PharmD BCPS; Janice Finder, RN MSN Houston Methodist Hospital Introduction The period after hospital discharge is a vulnerable time for patients. Medication errors are common as a result of changes in the regimen during hospitalization, suboptimal discharge instructions, and prolonged time to follow-up. This frequently causes increased drug-related problems that can lead to re-hospitalization and increased morbidity and mortality. Problem A recent study suggests that approximately 20% of patients discharged to home from a hospital will experience an adverse event during this transition and that 66%-72% of these events are avoidable or ameliorable with simple instructions provided at discharge. Goals The purpose of this study was to evaluate the role of the pharmacist as one of the key members of the patient s continuity of care after hospital discharge. Methods The setting of this study was in an outpatient clinic that follows up telephonically with patients discharged from Houston Methodist System Hospital. Care Navigator Nurses arranged phone call appointments with pharmacist for patients 2-3 days after discharge who were identified with drug-related problems or at high risk for medication issues. Pharmacy interventions included: Reviewing and educating patients on their current drug regimen; highlighting differences in the patient s current regimen and the discharge medication list; identifying duplicative therapies; discussing symptoms that are possible adverse reactions from medications; recommending cost effective alternatives; and communicating to physicians any significant or concerning findings. Results In a period of 5 weeks, 100 patients were referred to pharmacist. Of those, 86 patients accepted referral and were contacted by pharmacist. The average number of discharge medications per patient was 14 and 94% of contacted patients had at least one pharmacist intervention. There were a total of 160 pharmacist interventions; the most common being non-compliance (25%), followed by incomplete/inaccurate medication list (19%) and unnecessary drug therapy (11%). Conclusions Pharmacists making post-discharge follow-up calls can identify and intervene in many types of drug-related problems and potentially improve patient care while reducing hospital utilization after discharge. System Quality Review Journal Page 28

43 Utilization of Shared Governance to Sustain Continuous Improvement Janet Gilmore, MSN RN CMSRN; Sandra Prevost, MSN RN CPPS; Elizabeth York, MSN RN Houston Methodist Hospital Introduction Retained surgical items is one of the top three safety issues identified by hospital ORs Retained surgical items occur 1 in every 1500 abdominal surgical procedures across the United States Communication between the surgeon, scrub technician and the circulator is key to patient safety within the OR Utilizing checklist and adjuct counting technology can enhance OR safety for our patients Problem The physical and financial effects from a retained surgical item (RSI) may be devastating to both the patient and the surgical team. Conducted assessments which revealed noted variances in practice related to count process Goals To improve patient outcomes by eliminating deviations in the operating room counting process Create a network for the OR staff to communicate with each other and increase awareness of patient safety issues Standardize the counting process of sharps, needles and sponges within the OR suites Utilize ISO 9001 Eight Management Principles for sustained performance improvement Create awareness and accountability for count policies To be the safest hospital in the world To create an environment that encourages reporting unsafe practices or events Methods Created process flow maps of OR count procedure Created swim lanes depicting the roles of circulator, technician, surgeon and radiology Conducted direct observations of the process Tracked Retained Surgical Items (RSI) through our internal review system Tracked RSI through Risk department reviews Results Increased staff awareness and facilitated their proactive involvement to decrease the risk of a RSI error Additional support and involvement from Administration to provide funding for adjunct counting technology Conclusions Adoption of standardized practice of counting process Increased accountability of the team to adhere to policy and procedure Utilized shared governance principles to increase patient safety awareness in other clinical areas Facilitated a partnership with Supply Chain to provide supplies that would create a hard stop to prevent medical errors, e.g. count system and number of sponges provided in a single pack System Quality Review Journal Page 29

44 Volunteer Engagement in Patient Safety Fall Prevention Mary E Woodard, MSN RN CPPS; Pamela D Salyer, PhD RN BC Houston Methodist Hospital Introduction Volunteers enhance the services and complement the care provided by Houston Methodist Hospital s professionals. They represent an important connection to our community and their engagement in Patient Safety Program development and evaluation is a mutually beneficial partnership. Volunteer assistance in monitoring the Fall Prevention Program has the potential to reduce patient falls in problemprone, high-risk areas; reducing injury, containing costs, and identifying areas where staff educational support and/or process improvement may be needed. Volunteer participation in Patient Safety initiatives also contributes to the community engagement requirement of the Affordable Care Act (ACA). Problem Patient falls are second only to medication errors in reported adverse events at Houston Methodist Hospital. Frequent monitoring of compliance with the Fall Prevention Program is necessary, but requires ample resources. With training and oversight, our community volunteers can supplement this essential monitoring function. Goals 1. Increase Fall Prevention Program audits. 2. Decrease incidence of patient falls in identified populations of patients at risk. 3. Increase patient satisfaction scores through volunteer/patient interactions. 4. Enlist volunteers in Patient Safety initiatives in support of the community engagement requirement of the ACA. 5. Increase recruitment and retention of volunteers through partnership and sustainable relationships. Methods The initiative was developed utilizing the Plan- Do-Check-Act methodology. 1. Analyze submitted reports of patient falls to identify high-risk patient populations and their locations. 2. Train participating volunteers in the Fall Prevention Program, HIPAA, use of the audit tool, and interaction with patients. 3. Assign volunteers to target areas to audit compliance with the Fall Prevention Program. 4. Report results at the point of contact to unit management for immediate correction of deficiencies and report back to the Patient Safety Department for summary analysis and reporting. 5. Analyze data over time for improvements in fall prevention and patient satisfaction scores. 6. Interview volunteers quarterly for input into further development of the program and to contribute their stories of patient and staff encounters to the Patient Safety Care Management Performance Improvement Committee and the Quality Committee of the Board of Directors, which both contain members of the community. Results 1. Greater compliance with the Fall Prevention Program. 2. Increased monitoring of patients at risk for falls. System Quality Review Journal Page 30

45 3. Increased community engagement with our volunteers. 4. Increased satisfaction among participating volunteers. 5. An increase in patient satisfaction scores is expected in the next measurement cycle. Conclusions Research has shown that visits from volunteers can positively impact patient satisfactions scores. The addition of some patient safety monitoring activities is not overly burdensome to the volunteers, and these additional "boots on the ground" is a win-win for the volunteers, patients, and the Patient Safety Department. As the program matures, we will explore additional opportunities to engage this under-utilized resource in Patient Safety. System Quality Review Journal Page 31

46 Poster Presentation A Venture in Par Level Savings: Improving Cardiac Catheterization Lab Inventory Utilizing 5S Methodology Charmaine D Shields, MSN RN CVRN II; Andrew Brown, MBA Houston Methodist Hospital Introduction The Houston Methodist Hospital s Department of Cardiology is world-renowned in cardiovascular care and research and has been recognized for its contributions to advances in the practice of cardiology. Consistently ranked in the Top 20 in US News and World Report, The Methodist Hospital has made significant contributions to changing the way that Cardiology is practiced. The Department of Cardiology's mission is to offer patients the most complete and advanced methods for the diagnosis, treatment and prevention of heart disease through teaching, research and patient care (methodisthealth.com, 2010). The Houston Methodist DeBakey Heart and Vascular Center (HMDHVC) provides care to populations from adolescents, adults and elderly. Various procedures are offered in the cath lab such as: heart catheterization, electrophysiology studies and procedures, structural heart, peripheral/ vascular studies and interventions, cardioversion, tilt table studies, etc. One of the goal of HMDHVC is to provide high quality and cost effective patient care. HMDHVC operates with a monthly of supply expense of about $1.5 million and manages approximately $3.1 million dollars worth of inventory on hand. Problem Upon 3 months of monitoring processes around supplies, there appeared to be some gaps in the capture and management of expired products in the Cardiac Catheterization Lab. Goals Our goal was to map out and implement a new process for capturing expired products to ensure a high quality of safety and care and a reduction of expense for unused supplies. Methods Upon reviewing this process, we decided to go with a 5S methodology along with standard gap analysis to develop a solution for this problem. Initially, at the end of each month, our supply personnel would walk through all of the core hallways and through the stock room to collect product and sticker short-dated product one month out for easy identification for the next month. This process collected found an average of $36 thousand worth of expired product per month, about 1/3 of which was at the expense of the department, which equates to almost $1.5 million of accrued waste annually (slides 8, 9, 10). It was discovered through our initial observation that there were areas within the department where supplies were being kept that were not being monitored or reviewed. We decided to implement a 5S approach to rid the department of the clutter and eliminate the chances of expired products getting to patients. The first step in this process was seiri, which was to get into the cath lab rooms and get rid of all supplies in the work space that was not absolutely necessary. We made this a department wide project that involved all cath lab staff to build teamwork and ownership within the department. We then developed PAR areas within each room to perform the seiton (straighten) step of 5S. This gave an easy identification to what items should be held in what locations to discourage hoarding. We then made some process changes to spread ownership of the expired product collection process to System Quality Review Journal Page 32

47 complete the seiso (shine) and seiketsu (systemize) steps. We created a standardized form and time of the month for completion of the process and made everyone accountable for their areas. To complete the last step, shitsuke (sustain) we made it mandatory for the forms to be signed and turned in by the owners of the areas to prevent backsliding. Results We found a significant reduction in wasted expense to the department after implementing the change after three months. The first month, the dollar value increased to approximately $14 thousand dollars in waste as a result of the seiri (clean up) step, but the next two months generated 0 dollars in owned expired products to hit the department (slides 17: process map). An estimated savings of $12 thousand per month or $144 thousand per year was saved with the implementation of this project leading to offering high quality and cost-effective patient care. Owned supplies were closely monitored. Vendors were encouraged to managed consigned products to avoid patient safety issues (i.e: use of expired supplies in a procedure). Unrelated to this project, an eventual contract was coordinated with our largest distributor to take on ownership and management of all of the HMDHVC supplies. This alliance results in hospital and department being expensed for what is actual used and not for any waste in supplies (slide 23). Conclusions The project enabled us to find efficient ways to track what is on our shelves, when to re-order supplies, their actual costs and identify new ways to cut costs. Providing par sheets that are monitored on a monthly basis were recommended to decrease potential waste in supplies. Vendors are encourage to take ownership with their supplies to save hospital expense. Negotiating consignment contracts with vendors was also implemented to help with inventory and control wasting or losing money for wasted products. System Quality Review Journal Page 33

48 Dizon Shields 1 Slide 8 Slide 9 System Quality Review Journal Page 34

49 Dizon Shields 2 Slide 10 Slide 17 System Quality Review Journal Page 35

50 Dizon Shields 3 Slide 23 System Quality Review Journal Page 36

51 Poster Presentation Goal Toward Zero Catheter Associated Urinary Tract Infections (CAUTI) - Eliminating Harm Melvin Stone, MD; Amit Tibb, MD; Christina Coyle, MD; Regina Modica, RN; Swati Raja, BS M(ASCP); Hilda Diongon, RN; Mila Quinones, RN; Carol Sheridan, RN Jacobi Medical Center Introduction Urinary tract infections account for over 30% of healthcare associated infections. The majority of urinary tract infections are due to the foley catheter. At Jacobi Medical Center, we have begun the work of reducing the Catheter Associated Urinary Tract Infections (CAUTI) throughout the facility. In order to reduce CAUTI, we have had to reevaluate the role of the foley catheters in the acute care setting. Problem The staff at Jacobi Medical Center has recognized the significance of CAUTI s on the morbidity of hospitalized patients, and has accepted the call to action to implement meaningful and measurable change. There has been a recent positive impact on the number of patients requiring indwelling foley catheters. This was driven by utilizing interdisciplinary teams to review and to implement evidence-based practices. This began by developing standard indications for insertion of an indwelling catheter; the credentialing of our clinical staff for both the insertion and daily maintenance of the foley catheter, and by identifying which patient s catheters could be removed within 3 days of insertion. Over the past 18 months this has resulted in not only a decrease (of approximately 15% decrease in the number of catheter days across the hospital), but a dramatic decrease in the number of patients harmed by this hospital acquired infection (HAI). In 2012 there were 83 CAUTI infections, current year to date (CYTD) ending August 2013, there have been 21 CAUTI infections. For the first six months of 2013 there are six units out of fifteen that have had Zero CAUTI s, this represents about 40% of our clinical services achieving the loft goal we set as an organization, when we initiated our CAUTI RIE utilizing the Breakthrough process. Both the Infection Prevention team and the Patient Safety Officer acted as co-pilots setting the course, monitoring the progress, and making course adjustments as we drive toward our goal of Zero CAUTI s. The infection prevention specialists became an integral part of the interdisciplinary team, both at daily goal rounds, interdisciplinary rounds and reviewing and infections that did occur to assure that lessons learned and opportunities for immediate changes in practice where rapidly applied back in the clinical practice unit. Goals The overall goal is to reduce the number of patients harmed by CAUTI s. The secondary goal is to enhance and improve intra professional communication focused on eliminating safety risks and harms to patients. The staff has embraced and utilized our TEAM STEPPS strategies and tools to raise concerns (utilizing CUS, situational awareness, the huddle, brief) re: need for foley catheter, when and if to remove a foley, and the # of days a catheter has been in place. Decrease Morbidity, related to Catheter associated infections and harms to patients at Jacobi Medical Center System Quality Review Journal Page 37

52 Demonstrate the impact of decreasing catheter days, has on the incidence/and number of catheter-associated infections Promote interdisciplinary communication and collaboration in reducing this patient harm (CAUTI s) Publically (at the unit level) display results so staff could receive feedback and constructive information re: changes in practice in real team Methods Utilizing the breakthrough methodology conducted a hospital wide RIE in August This consisted of a crossfunctional interdisciplinary team, who set the goal of Zero CAUTI s and who s mission it was to monitor and track progress to plan. The Infection Prevention Staff and the Patient Safety Officer reviewed every CAUTI. A root cause analysis was conducted for each infection. The insertion and maintenance documentation was reviewed at the root cause analysis. The group identified areas for improvement and these finding were shared with all staff. An Interdisciplinary team met to create a list appropriate urinary catheter indications. When a patient no longer met the criteria from the list the foley was discontinued. The Emergency Room updated their criteria for insertion of catheters, resulting in less foleys being inserted in the ER. Nurse and Doctor champions were identified on the units to drive and sustain change. The SICU, MICU, and Surgical Stepdown Unit began identifying patients that could have their catheters removed early. A bladder scanner protocol was developed and used as a tool during the trial of void to avoid unnecessary reinsertion. The Medical Director of Infection Prevention and the Patient Safety Officer met with the Department of Medical Faculty to review quarterly cases, to discuss opportunities for prevention, education of staff in an effort to reach the goal of Zero CAUTI s. The Infection Preventionist distributed posters to each medical floor that displayed the number of days since last CAUTI. CAUTI rates were calculated using device days and patient days as the denominator. Results Data (Results/Outcomes): Six out of 15 units (40%) have reached the Goal of Zero CAUTI s in 2013 There is projected to be an approximate 15% decrease in the total number of catheter days (less are going in, and they re coming out in less days) CYTD, August 2013 there have been 21 CAUTI s, there were 83 in all of 2012 Conclusions Standardizing practice is the first step, review of each case with the interdisciplinary team providing care to the patients in real time provided rich data and opportunities for identification of contributing issues that were amenable to correction. These insights helped our team to adjust our practice and approaches to care and drove this process forward. As the device days began to drop across the organization the denominator became smaller, therefore the rates did not reflect our success. Subsequently, we also looked at the rates differently to capture the decrease in CAUTI's throughout the institution taking into account our decreased catheter days. We used the standard definition using device days (# of infections / # device days*1000), but we also adopted a definition using the number of patient days (# infection / System Quality Review Journal Page 38

53 patient days*10,000) to account for decreasing catheter days. This additional data underscored all the great work the floors were doing in reducing the catheter CAUTIs and catheter days. Awareness was heightened by posting rates in the clinical area with # of CAUTIs, catheter days along with the overall hospital CAUTI rates, thus instilling a sense of ownership at the level of the units. This ongoing teamwork promoted enthusiasm and helped us to sustain our drive toward our Zero Goal. System Quality Review Journal Page 39

54 Impact of a Nutrition Educational Intervention Coupled with Improved Access to Fresh Produce on Fruit and Vegetable Purchase and Consumption in Patients with Type 2 Diabetes E Weinstein, MD; J Galindo, MD; M Fried, MS; L Rucker, MD; N Davis, MD Jacobi Medical Center/ North Bronx Healthcare Network Introduction In 2010 the prevalence of diabetes in New York City (NYC) was estimated to be 9.3% and up to 58% of NYC residents are either overweight or obese. Of all NYC boroughs, the Bronx has the highest rates of obesity and diabetes. 40% of residents in the South Bronx reported it was difficult or impossible to find fresh or affordable produce in their neighborhoods. 96% of Bronx adults eat fewer than the recommended five daily servings of fruits and vegetables (F&V). An inverse relationship between F&V consumption and obesity has been demonstrated in prior studies. Problem The people of Bronx eat an unhealthy diet and as a result have poor health. Standard care of diabetics is not sufficient to change diet. A quality intervention including an educational intervention and a visit to a green market might improve diet. Goals To assess the impact of distributing coupons redeemable at local farmers markets plus an educational intervention on F&V purchase and consumption. Secondarily, we assessed the effect of the intervention on BMI, weight, hemoglobin A1c, LDL-cholesterol and blood pressure. Methods This was a 12-week randomized control trial comparing intervention to standard care. Intervention consisted of 1 hourlong group educational session focused on F&V consumption plus $6 in Health Bucks (vouchers redeemable at NYC green markets). Survey responses assessed F&V purchase and consumption. Secondary outcomes were evaluated through review of electronic medical record. Paired t-tests or chi-square test compared survey responses at baseline and 12 weeks. Results Percentage of participants that reported purchasing fruits and vegetables at a Green Market in NYC in the last 3 months: At 12 weeks there was a statistically significant increase in the number of participants in the intervention arm who reported purchasing from a farmers market. There was a minimal increase of 0.3 servings/day in fresh fruit intake in the intervention arm at 12 weeks. Conclusions Our pilot study suggests that focused education may be needed in addition to improved access to improve purchasing and consumption of fresh produce in the effort to improve outcomes of diabetic patients in urban populations. Studying the impact of bringing fresh produce directly to the community in a variety of ways could help identify which approaches are most effective. System Quality Review Journal Page 40

55 Table 1: Baseline Characteristics Characteristics Intervention (N=44) Control (N=34) p value Age in years (Mean/SD) 55.6 (10.7) 55.4 (11.1) Race/Ethnicity (n/%) Hispanic 15 (34) 23 (67.6) Black 18 (41) 8(23.5) White 2 (4.5) 0 Other or More than one race 9 (20) 3 (8.9) Gender (n/%) 0.79 Male 13 (29.5) 11 (32.4) Female 31 (70.5) 23 (67.6) Marital Status (n/%) 0.62 Married 15(34) 12(35) Divorced or Widowed 15(34) 14(41) Never married 14(32) 8(24) Annual Income (n/%) Less than $20,000 31(70) 20(58) From $ 20,000 to 35,000 6(13.6) 5(14.7) More than $35,000 7(15.9) 9(26.4) Educational Level (n/%) Lower than High school 16(36.3) 22(64.7) High School Graduate or GED 13(29.5) 8(23.5) Some college 9(20.4) 3(8.8) College Graduate 6(13.6) 1(2.9) Clinical characteristics (Mean/SD) Hemoglobin A1C 9.2(2.3) 9.4(2.1) 0.79 Total Cholesterol 175(39) 183(47) 0.40 Low Density Lipoprotein 93(34) 92(35) 0.92 High Density Lipoprotein 50(13) 47(11) 0.39 SBP 135(23) 133(23) 0.89 DBP 73(14) 74(13) 0.82 System Quality Review Journal Page 41

56 Table 2. Change in Secondary Outcomes from baseline to 12 weeks * Outcome Intervention Control p-value A1c (%) (1.8) (1.6) 0.76 Total Cholesterol (mg/dl) -6.1 (38) -18 (50) 0.34 Low Density Lipoprotein -5.1 (21) 0.72 (mg/dl) High Density Lipoprotein 1.7 (9) -0.4 (11) 0.50 (mg/dl) Triglycerides (mg/dl) -18 (64) -83 (245) 0.24 SBP (mmhg) 0.6 (20) 3 (22) 0.69 DBP (mmhg) -2 (13) -1.6 (13) 0.78 *All values are mean (SD) System Quality Review Journal Page 42

57 Figure 1: Randomization 226 participants screened Met inclusion: 147 Unable/refused to consent: randomized participants Intervention group:45 Standard of care group:34 Lost to follow up: 0 Excluded: 1 Lost to follow up: 0 Data Analysis: 78 Figure 2: Percentage of participants that reported purchasing fruits and vegetables System Quality Review Journal Page 43

58 Patient Engagement - Prescribed Group Treatment Carlos J Rodriguez Perez, RDT BCT LCAT (Director of Therapeutic Rehabilitation Department) Kings County Hospital Center Introduction Kings County Hospital Center (KCHC) is a member institution of the New York City Health and Hospital Corporation (HHC) one of the largest municipal health care systems in the country. HHC has 11 facilities operating psychiatric emergency services and inpatient psychiatric care. With 627 beds, KCHC remains on the cutting edge of healthcare and provides a wide range of services, and specialties are offered in all fields of modern medicine. In particular, KCHC has a robust Behavioral Health Service (BHS) with 160 adult and 45 child and adolescent inpatient psychiatric beds. KCHC has adopted Lean/Breakthrough as a philosophy for improving the delivery of healthcare to the community in which it serves. Lean methodology empowers staff to improve services, the patient experience, and the effectiveness of work flows. Behavioral health inpatients are often prescribed therapeutic group programming activities as part of their individual recovery plan. Patients are prescribed these groups based upon the interdisciplinary assessment as well as the patient's goals for treatment. Problem While group programming is an identified effective modality of treatment, BHS has identified several issues with group programming that serve as a reason for action. An assessment of the current state identified that the percentage of prescribed groups that an individual patient attends in less than optimal at approximately 50%. Additionally, BHS identified a reluctance by staff to run groups noting that some groups are delayed or canceled. Current practice revealed that program schedules are posted on each unit and patients are provided with a copy of their schedule. Group treatment is also discussed during morning report, community meetings, treatment planning sessions, and during individual interventions with patients. Goals In formulating project goals, the first step was to identify what the target or ideal state would look like. This target included a culture of accountability. This was defined as staff having an awareness that groups are treatment and are prioritized as such. Groups will run as per scheduled; and cancelled group equate to cancelled treatment which results in the use of the escalation protocol in order to identify the cause for cancellation and act upon it. The target state would also contain a specific standard work for use of prescription sheets which would include a mechanism to monitor attendance as well as standard work for gathering patients for groups. Methods A gap analysis was performed in order to drill down on the top four reasons which lead to the current state and identify the root cause for each. Reason: No standard work for use of prescription sheets. Group programming is viewed as a therapeutic rehabilitation (TR) thing. This thinking may be due to the fact that TR runs the largest number of groups in the System Quality Review Journal Page 44

59 inpatient setting. This results in a silo mentality. Reason: No clear accountability for groups to occur per schedule. Group programming is not prioritized by department leadership. Staff believes that they have other more important things to do than run groups. Groups are not viewed as treatment by all disciplines. This results in varied comfort levels for running groups. Reason: Measurement is inconsistent at best and not often completed. The current process for monitoring attendance is ineffective and cumbersome and is not assigned to anyone. Attendance monitoring is a paper process. This results in no clear easy means of measurement. Reason: Lack of accountability for the monitoring process. There is no clear understanding of what is to be monitored or who is responsible. Lack of clarity in functional job descriptions regarding monitoring as well as differences between the various disciplines who run groups leads to a not my job mentality. This results in no standard work for monitoring. In order to achieve the target state, BHS utilized a solutions approach. If standard work if developed, all staff who run groups will understand their role in the monitoring process. If unit leadership support and monitor the process, accountability will be embedded. If staff and patients are educated on the importance of group programming, enhanced engagement will follow. The first task was to develop a trans-disciplinary standard work. This standard work served to clarify task specific verses disciplinary specific items to be accomplished. The next step is to educate on the standard work in order to hold staff accountable. A group training curriculum was identified with the first module being The ABCs of Running Groups. This module will be offered to existing staff as well as incorporated into the BHS CORE Orientation necessary as part of the on-boarding process required of all staff. Lastly unit leadership are expected to take an active role in monitoring compliance. Results of monitoring whether or not groups take place as scheduled will be an agenda item at unit based meetings. When groups are not held as scheduled, this information is escalated through the chain of command in order to address cause. Results BHS will monitor the results of this project by utilizing two metrics. Groups will be monitored to ensure that they are held according to schedule. Cancellations will be tracked and reported at the unit level and ultimately to the BHS Quality Council on a regular basis. Additionally, patient attendance at prescribed groups will be monitored. Conclusions BHS has initiated the steps outlined in the completion plan and has begun to collect data. The plan will be re-evaluated once there has been sufficient data collected. System Quality Review Journal Page 45

60 Reducing Restrictive Interventions Karen Mohamed, RN MSN ACNS BC; Chinmoy Gulrajani, MD Medical Director Adult Inpatient; Paul O'Keefe DO Medical Director CAPIS; Sally E Riggs, DClinPsy Adult Inpatient Psychologist II; Liliane Rocha, MA MPhil BCBA Director of Behavior Support Team; Anne Paulin, Associate Director Risk Mgt; Annahit Daglyan, PharmD BCPP Assistant Director Kings County Hospital Center Introduction Kings County Hospital Center (KCHC) is a member institution of the New York City Health and Hospital Corporation (HHC) one of the largest municipal health care systems in the country. HHC has 11 facilities operating psychiatric emergency services and inpatient psychiatric care. With 627 beds, KCHC remains on the cutting edge of healthcare and provides a wide range of services, and specialties are offered in all fields of modern medicine. In particular, KCHC has a robust Behavioral Health Service (BHS) with 160 adult and 45 child and adolescent inpatient psychiatric beds. KCHC has adopted Lean/Breakthrough as a philosophy for improving the delivery of healthcare to the community in which it serves. Lean methodology empowers staff to improve services, the patient experience, and the effectiveness of work flows. The Behavioral Health Service (BHS) at KCHC has achieved much success in reducing restrictive interventions such as restraints, STAT IM use, 1:1 observations. However, the thought that a more integrated approach would yield better results still lingered. Problem While there have been many hospital wide initiatives put in place with the intent of reducing the use of restrictive interventions such as restraints, STAT IM use, 1:1 observations; many questions still remain. Is there redundancy of efforts? Are there gaps in interventions? What are the common variances seen? Can the current process be better integrated. The restrictive intervention workgroup was created to establish a "bird s eye view" of the current state and seek to further reduce the usage of Restrictive Interventions. Goals This Workgroup seeks to ensure that the indications for the use of restrictive interventions including the newly adapted Preventing and Managing Crisis Situations (PMCS) techniques is known and universally practiced in an appropriate, safe and consistent manner. The group also seeks the establishment of leadership roles within code situations and the Crisis Management Unit (CMU) process to serve as support to staff. Finally, it is the goal of the Restrictive Intervention Workgroup to have effective and meaningful utilization of the Personal Safety and Support Plan (PSSP) and Individual Behavior Plan (IBP). Methods The Restrictive Intervention Workgroup began by critically reviewing all available information. This included patient level and aggregate data on restraint rates, STAT IM usage, 1:1 usage; as well as the use of CMU and PMCS techniques via video ethnography. The workgroup then began by revisiting the CMU process by conducting problem-solving session to re-conceptualize System Quality Review Journal Page 46

61 and restructure the CMU process. Roles within the CMU process will now be clearly defined and established at the beginning of each shift. Re-education of staff (RNs and MDs) describing PO and IM medication bioequivalence and its onset of action is in progress. A list dos and don ts indicating specific actions for the use of IMs were developed. Restraint policy and guidelines were reviewed with particular emphasis on assessing the indications for use. Lastly, the workgroup identified that, while staff receives PMCS and TeamSTEPPS training as part of orientation and mandatory education, the need for refresher training is apparent. This training will be rolled out in a series of booster classes delivered on the unit with the treatment team rather than removed and in a classroom. The booster classes will be conducted on a rotating basis with each treatment team receiving a module at least quarterly. This will serve to reeducate the staff in de-escalation techniques with the support team with which they respond on the unit. A mechanism to assess the use of de-escalation techniques via observation both in vivo and via video footage was developed. This information will serve to inform the booster training content. Results BHS will continue to monitor the use of restrictive interventions by service and by unit. This data, coupled with the information learned from the observations of CMU and PMCS will be utilized to evaluate the effectiveness of the interventions. Conclusions While interventions aimed at reducing restrictive interventions individually were widely successful, a more integrated approach was desired. The restrictive intervention workgroup is the vehicle that will be utilized to assess, evaluate, implement, and measure all actions aimed at reducing such interventions. As the team has just begun its work, it is anticipated that a reduction will be realized. System Quality Review Journal Page 47

62 Road To Home George Jagatic, LCAT; Suzanne Garrison, CAT; Dana Trottier, CAT Kings County Hospital Center Introduction Kings County Hospital Center (KCHC) is a member institution of the New York City Health and Hospital Corporation (HHC) one of the largest municipal health care systems in the country. HHC has 11 facilities operating psychiatric emergency services and inpatient psychiatric care. With 627 beds, KCHC remains on the cutting edge of healthcare and provides a wide range of services, and specialties are offered in all fields of modern medicine. In particular, KCHC has a robust Behavioral Health Service (BHS) with 160 adult and 45 child and adolescent inpatient psychiatric beds. KCHC has adopted Lean/Breakthrough as a philosophy for improving the delivery of healthcare to the community in which it serves. Lean methodology empowers staff to improve services, the patient experience, and the effectiveness of work flows. Behavioral Health Services has invoked a paradigm shift from a medical model to a patient-centered model working hand-in-hand with patients who are engaged in their own recovery. Patients work with the treatment team to design their own recovery via their individualized recovery plan (IRP). Problem Challenges in communication and resistance between patients and treatment providers can lead to an increased length of stay. Patients need to feel a sense of agency through a better understanding of the recovery system and receive education regarding what it means to be a part of the treatment team. Goals The goals of this project are to increase clear communication and transparency between treatment team members, including the recipient, who is an integral member of the team; foster a more empowered positive experience for patients; and attain a smooth transition back into the community. Additionally the gain of a shorter length of stay should be realized. These goals will be realized by a demonstrating a relationship between the Road to Home intervention and efficacy of treatment. This will be evidenced by qualitative and quantitative data related to groups and treatment teams. Methods The staff on a selected adult inpatient unit identified and implemented a track of group programming titled Road to Home. This track addresses different aspects of treatment that correspond to the different stage of change that the patient may be in and provides patients a robust and appropriate engagement in their own recovery process. The project will look at directly linking specific unit group to the treatment team and the corresponding length of stay for each patient who attends these groups. Quantitative surveys measuring recipients understanding of a group s link to treatment teams are given to recipients after every Road to Home group. Additional quantitative surveys using a Likert scale assessment completed by the recipients measuring efficacy and recipient involvement in treatment teams and groups are given to recipients as a part System Quality Review Journal Page 48

63 of the discharge process. Lastly, clinicians leading Road to Home groups engage in supervision, where qualitative case examples are shared and examined. Patient attending the Road to Home groups should have a greater understanding about the connection between prescribed groups as treatment within the Wellness and Recovery Model, the treatment team system, and recovery planning. Results Data was collected on the unit in which the Road to Home track was implemented and a control unit. Preliminary results reveal that individuals who have participated in Rode to Home report that they feel their participation in groups have helped them to achieve their objective and that their treatment plan helped them to accomplish their goals. This is apparent with the data related to the group objective: I understand how group relates to the objectives that I am currently working on. Individuals who participated in Road to Home felt that they understood the purpose of treatment teams slightly more than individuals who did not participate. Conclusions The preliminary data has demonstrated some positive feedback from patients. Data will continue to be collected and trended over time. Length of stay data will also be analyzed for both sets of patients. Staff education on interventions appropriate for the patient s stage of change will continue. System Quality Review Journal Page 49

64 Primary Nursing as a Behavioral Health Nursing Care Delivery Model Linda Paradiso, RN MSN NPP NEA-BC; Ihsaan Alim, RN MSN Kings County Hospital Center Introduction Kings County Hospital Center (KCHC) is a member institution of the New York City Health and Hospital Corporation (HHC) one of the largest municipal health care systems in the country. HHC has 11 facilities operating psychiatric emergency services and inpatient psychiatric care. In Kings County Hospital, Behavioral Health, the attraction to Primary Nursing is the professional nurses ability to make decisions about their patient s care based on the therapeutic relationship that is developed between the nurse and the patient. This is key in giving optimal care on inpatient psychiatric settings. Continuity of care is another factor that lends to optimal behavioral health nursing care. The patient and the behavioral health care delivery team all benefit from having a single nurse responsible for orchestrating the patients nursing care. Communication to the patient and the treatment team is direct. The nurse can be proactive in meeting the patients needs as well as supporting the treatment team. Problem The Behavioral Health Nursing Department identified the need to provide an evidence based nursing model of care that was person centered. A literature review revealed that there is a lack of an evidence based model of care specifically designed for the inpatient behavioral health setting. It is Kings County s premise that Jean Watson s theoretical framework and the concept of Primary Nursing are compatible and complement each other to the extent of optimum care for psychiatric inpatients. Goals Utilizing a primary nursing model of care is expected to increase both staff satisfaction and patient satisfaction through the benefit of the relationship between nurse caregiver and person in need of care. Methods Success in this project is measured by the National Database of Nursing Quality Indicators (NDNQI) staff satisfaction scores as well as the Press Ganey Patient Satisfaction scores. Use of these two new endeavors is expected to result in higher satisfaction scores. Indicators for nursing satisfaction are (1) Job Enjoyment, (2) Decision Making, (3) Autonomy, (4) Time for Patient Care. Press Ganey Patient Satisfaction survey indictors are (1) RN / Friendliness and Courtesy (2) RN Introduction to Unit, (3) RN Prompt Response, (4) RN Information to Medication Regimen, and (5) Helpfulness of the RN. Results The nursing staff completed their initial NDNQI survey in October 2012 and the results were received March Patient Satisfaction survey through Press Ganey was initiated in 2011 but the first full year of data was obtained in Primary Nursing Watson Model of care was initiated in August Baseline satisfaction results have been obtained. In October 2013 nursing staff will complete the second NDNQI staff satisfaction survey and Press Ganey Patient Satisfaction results are obtained monthly. The year-end survey results for 2013 will be compared to the baseline System Quality Review Journal Page 50

65 results of NewYork-Presbyterian Healthcare System Quality Symposium 2013 Conclusions Success in this project is measured by the National Database of Nursing Quality Indicators (NDNQI), staff satisfaction scores as well as the Press Ganey Patient Satisfaction scores. Use of these two new endeavors is expected to result in higher satisfaction scores. Indicators for nursing satisfaction are: Job Enjoyment, Decision Making, Autonomy, and Time for Patient Care. Press Ganey Patient Satisfaction survey indictors are: RN Friendliness and Courtesy, RN Introduction to Unit, RN Prompt Response, RN Information to Medication Regimen, and Helpfulness of the RN. System Quality Review Journal Page 51

66 At Your Fingertips: Web-based Sepsis Data Collection and Analysis Kevin D Masick, PhD; Marcella De Geronimo, MS; Eric Hamilton, BA; Carol Cross, MBA; Rosemarie Linton, MPH Krasnoff Quality Management Institute - A division of the North Shore-LIJ Health System Introduction Under the direction of CEO Michael Dowling, the 16-hospital North Shore-LIJ Health System partnered with the Institute for Healthcare Improvement (IHI) on a joint venture to reduce sepsis mortality by 50% in 5 years. To accomplish this goal, the analytic group of the Krasnoff Quality Management Institute developed and implemented a patient level database to capture critical clinical information related to sepsis, severe sepsis, and septic shock to improve data collection and analysis. Prior to the initiative, relevant clinical information was in a variety of disparate data sources: Electronic health record, paper medical record, flow sheets, laboratory information system, pharmacy, etc. Standardized data definitions were created and continuous training initiatives were implemented on a monthly basis to ensure data integrity and quality and to clarify questions to ensure accurate data abstraction. This educational process has improved and standardized data capture. Having clinical information about sepsis in one online database has enhanced the efficiency of developing reports and analyzing data from all system hospitals. Problem Sepsis, severe sepsis, and septic shock has been the leading cause of death in the North Shore-LIJ Health System for over 5 years. Currently, the North Shore-LIJ Health System consists of 16 hospitals at varying implementation levels of an electronic health record. As a result, all hospitals did not have access to the same clinical information in a standardized format. This creates a problem for standardizing data collection and makes it difficult to evaluate change and improve processes. The Krasnoff Quality Management Institute partnered with clinicians to develop a patient level database that would capture all the critical clinical information needed in a standardized online format. Without a standardized database to capture clinical information pertaining to sepsis, all hospitals would not have the ability to effectively monitor and track their improvement efforts towards reducing sepsis mortality by 50% nor be able to compare best practices. Goals To increase sepsis recognition and identification as well as provide real time feedback for process improvement, the initiative had multiple goals. First, to develop a standardized database that was clinically relevant and would allow abstractors the ability to ensure the integrity of the data being collected. Second, it was important to seamlessly integrate this information to allow for an efficient and effective way to analyze the clinical data. Third, to ensure data that was easily accessible and available to clinicians in a timely manner. Fourth, to increase data abstraction accountability through the development of quality control reports. Fifth, to create a seamless transition between data abstraction and submission to third party organizations for additional data analysis. Methods Sepsis, severe sepsis, and septic shock has been the leading cause of death in the North Shore-LIJ Health System for over 5 years. Currently, the North Shore-LIJ Health System consists of 16 hospitals at varying implementation levels of an electronic health record. As a result, all hospitals did not have access to the same clinical information in a standardized format. This creates a problem for standardizing data collection and makes it difficult to evaluate change System Quality Review Journal Page 52

67 and improve processes. The Krasnoff Quality Management Institute partnered with clinicians to develop a patient level database that would capture all the critical clinical information needed in a standardized online format. Without a standardized database to capture clinical information pertaining to sepsis, all hospitals would not have the ability to effectively monitor and track their improvement efforts towards reducing sepsis mortality by 50% nor be able to compare best practices. Results Measures were created and defined for blood cultures prior to antibiotics, serum lactate turnaround time, antibiotics within 180 minutes, and fluid bolus administration. These measures were calculated as percent compliance and average minutes, so that improvement can be tracked over time. These metrics were created for sepsis and severe sepsis/septic shock patient s hospital wide and also to track improvement for severe sepsis/septic shock patients in the emergency department and the inpatient floors. Metrics are displayed monthly on control charts, run charts, and histograms, looking at percent compliance for meeting the metric and the average time to complete the metric. For example, hospitals not meeting the 180 minute antibiotic measure have used the percent compliance report to examine trends in data and the average times report to identify opportunities. End users have the ability to drill down to the patient level based on selecting a range of minutes to further examine opportunities for improvement in the process. Hospitals are using this data to prioritize improvement efforts, monitor their PDSA cycles and evaluate whether improvements are effective. Over 160 clinicians and administrators currently have access to this database and 18 reports that can be run in real time to track outcome measures, identify sepsis patients through billing, and quality control their data. As an example, one hospital noticed that their percent compliance for blood cultures before antibiotics began to drop. Our reports and real time feedback increased awareness that led to a safety alert and triggered the next step in process improvement through examining their current process for collecting blood cultures. Additionally, our standardized database is used to generate electronic upload files that are submitted to IHI, GNYHA, Dartmouth High Value Health Care Collaborative and the NYS DOH once the sepsis guidelines have been approved. Clinicians also have the ability to extract pertinent clinical indicators in an aggregate manner to evaluate existing processes and identify improvements. Conclusions The successful development of this web-based sepsis database and its adoption and acceptance by users who were somewhat uncomfortable using data to represent care management has transformed the identification of gaps in care and best practices. Clinicians are able to analyze trends, quality control their data, accurately capture the coded sepsis patients, identify gaps in care for improvement, and extract and upload indicators to third party organizations. The data collected are being used to implement new areas of improvement and open up lines of communication between clinicians and administrators to begin to reduce sepsis mortality rates by early recognition of problems. System Quality Review Journal Page 53

68 Quiet Time: A Bright Spot Spreads Tina Sokolik, BSN MSN Lawrence Hospital Center Introduction This 31-bed telemetry unit that is typically quite busy with a high turnover (sometimes 30% per day), a high acuity level and a high decibel level, was the noisiest unit in the hospital. Problem For this unit, which provides care almost exclusively to cardiac patients, it was particularly important to create a calming, healing environment to promote recovery. In April 2013, the Shared Governance Committee of 3 North decided to initiate a "quiet time," an hour each day to decrease activity, lower lighting and minimize noise in order to promote a time of rest. Goals The goals of quiet time are simple: To create a calming and healing environment for patients. To improve patient satisfaction scores with respect to the quietness of the unit. To improve staff satisfaction by creating a time to re-focus and catch up on work. Methods Quiet time was the brainchild of the Shared Governance Council of 3 North. Staff nurses chose a time that would work well by not interfering to a great extent with tasks to be accomplished, meals, testing schedules, etc. That time would be 2:00-3:00 every day. A letter was provided to each 3 North patient explaining the practice of quiet time. It was very well received by patients and their family members. An was sent to the Hospital community explaining quiet time and asking all members of the staff to minimize their visits to the unit at this time and to respect the quiet when they did need to come. So, at 2:00 each afternoon, the Nurse Manager announced the commencement of quiet time. Lights were lowered, doors were closed and the quiet began. Although it was not an immediate success among staff - some thought it silly or unworkable - patients eagerly looked forward to quiet time. This was their time to relax, nap and step back from the busy hospital routine. Results With the practice of quiet time, the many alarms going off on the unit began to seem much louder. Staff began to assess alarms for necessity, volume and individualized parameters. With support from the cardiology staff, alarm parameters are now set to individualized thresholds. The number of nuisance alarms and unnecessarily loud alarms has diminished significantly. Nurses are now attuned to alarms since they know that the calibration is such that an alarm that does sound needs immediate attention. Even those staff who resisted quiet time in the beginning found that this was a time to re-focus and catch up. The System Quality Review Journal Page 54

69 number of call bells decreased as patients relaxed and took their naps. One patient asked the nurse when "happy hour" would be! In fact, quiet time was so successful that the noise level for the unit declined throughout the day. Staff satisfaction has improved. Patient satisfaction with the noise levels on the unit has improved from 65.5 to 79.2 from September 2012 to the present (see Attachment 1). Mean patient satisfaction has also improved from 86.0 to 87.3 for the same time frame (see Attachment 1). Conclusions Quiet time has improved patient satisfaction, promoted a quieter atmosphere throughout the day and contributed to the safety of clinical alarms. Its success is now being emulated throughout the hospital as one by one, the other units begin their own version of quiet time. As the sign on the 3 North wall says, "A calm quiet environment is a healing environment." System Quality Review Journal Page 55

70 Mean Trends Inpatient - 3 NORTH Lawrence Hospital Question - Noise level in and around room 3 NORTH Displayed by Discharged Date Mean Trends Inpatient - 3 NORTH Lawrence Hospital Overall 3 NORTH Displayed by Discharged Date System Quality Review Journal Page 56

71 Map to Achieve 100% Compliance in DVT Risk Assessment and Prophylaxis for the Hospitalized Patient Nejat Zeyneloglu, MD; Keziah NarayanaJaya, R-PAC; Jean Versace, RN BS; Al Caligiuri R-PAC MBA; Kenneth Ong, MD MPH; Karen Nefores RN BSN MBA; Regina Langer, BS PharmD; Helena Hizon, RN; Nancy Moybed, RN MS; Todd Kerwin, MD New York Hospital Queens Introduction Hospitalized patients at high-risk for Venous Thromboembolism (VTE) may develop an asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is suspected. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE. The estimated annual incidence of DVT and PE, known collectively as VTE, is approximately 900,000. Our Inpatient rate of potentially preventable hospital acquired VTE was initially as high as 50%. This was very concerning to us since it meant that our current process for VTE prophylaxis was not effective enough to keep all of our patients safe. Problem Non-standardized DVT risk assessment and prophylaxis Poor documentation of DVT risk assessment and prophylaxis We started a preview quarter for the VTE measure set in 4Q12 for the CMS Inpatient Quality reporting requirement that started in January We noticed that our results were extremely poor, rates as low as 48% compliance. We realized that the process for DVT prophylaxis had been in place in our facility for a while even prior to the implementation of electronic health record. Once we actually started looking at the data for VTE prophylaxis, we realized that the process was not standardized and that our documentation was not optimum. In many cases even though the care was within standards, the supporting documentation was not acceptable by the regulatory bodies. Our performance worsened once our facility went live hospital-wide with the electronic health record in February Goals To simplify and standardize the DVT risk assessment and prophylaxis by revising the order set Eliminate practice variability Increase CMS core measure compliance for the VTE measure set Provide the best evidence based care aligned with the current ACCP guidelines Methods We organized a multidisciplinary committee including clinical pharmacy, physician leadership from the department of medicine, quality management leadership and coordinators, leadership from Information technology, and nursing. After we recognized our problems we developed PDSA cycles and implemented small tests of change. We first changed the risk assessment from the Caprini risk assessment tool (21 questions) to the Padua VTE Prediction tool (12 questions) to make it more user friendly. The Padua VTE prediction tool was recently published in CHEST, February 2012 and was proven to effectively measure VTE risk. The electronic health record automatically calculated the risk score to guide the provider to order either pharmacological or mechanical prophylaxis. If the risk score is low the System Quality Review Journal Page 57

72 provider is guided to order early ambulation and conversely, if the patient is at high risk, the practitioner is directed to provide prophylaxis.the order set also allowed providers to document contraindications for mechanical or pharmacological prophylaxis, or document that the patient is already therapeutically anticoagulated and will continue during the hospitalization. The DVT order set was preselected for all medicine admission order sets to increase compliance. After we launched these changes, a global education was done to teach the staff about the revised DVT prophylaxis process in June We also developed a feedback mechanism for all fallouts that is referred to the supervisors for one on one education. A concurrent review process was instituted for all medicine admissions to help increase the compliance while simultaneously allowing for education on the floors. Results We have seen much improvement after implementation of the new changes, raising the awareness, and continuous monitoring. We have achieved 88% compliance for DVT prophylaxis in June In addition, the other VTE measures have also demonstrated a sustained improvement. We anticipate a continued upward trend of compliance for the entire measure set. The goal is to sustain perfection. Conclusions In conclusion we can see that updating the DVT prophylaxis and allowing the electronic documentation to be more user friendly allowed for the upward trend in our data. Although, there is still room for improvement, we foresee DVT prophylaxis continually improving. This was a true use of our clinical decision support to improve our hospital performance in the VTE measures, specifically VTE-1: VTE prophylaxis by hospital day two. As a result of our efforts for DVT prophylaxis, it will also impact our results for preventable hospital-acquired VTE and keeping our patients safe (VTE-6) while hospitalized. In the future, as the technology advances within our electronic health record, we would like to further automate the process by limiting the duplicate data entry. The goal would be to auto-populate the risk assessment once the information is filled out in other documentation by the practitioner. In addition once there is a completed risk assessment, the EMR can automatically recommend the appropriate prophylaxis for the practitioner to sign. System Quality Review Journal Page 58

73 100% DVT Prophylaxis Compliance 90% 88% 80% 79% 74% 70% 69% 70% 63% 63% 64% 60% 50% 49% 40% 30% 20% 10% 0% Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 System Quality Review Journal Page 59

74 Stroke Center Check List to Optimize Care and Resource Use and to Reduce Practice Variability Nejat Zeyneloglu, MD; Roxana Lazarescu, MD; Patrick Wang, MD; Samar Hameed, MD; Sheela Mehra, MD; Lotus Ahmed, MD New York Hospital Queens Introduction As a designated stroke center, NYHQ takes care of more than 1,000 stroke patients annually. Stoke care requires a multidisciplinary team approach. Utilization of our valuable resources such as telemetry beds and monitors and optimizing the length of stay to enable to care of this large volume has been very challenging. Patients spend excessive time in the Emergency Room and often are sent to other telemetry units, rather than the designated stroke service where all staff and doctors provide stroke centered care. Problem Prior to the project we faced two significant problems: Over utilization of telemetry monitors in the stroke unit causes admissions of stroke patients to other units without staff trained or experienced in acute stroke care and not obtaining physical therapy evaluations in a timely manner delays the plan of care for stroke patients. Goals We aimed to minimize the over utilization of telemetry monitors and initiate physical therapy evaluation for stroke cases in the first 24 hours of admission by using a checklist. Our ultimate goal was to reduce practice variability. Methods Routine aspects of complex care can easily be overlooked during a busy work day. However the consequences of these minor missed details can affect the plan of care for that patient or other patients. We developed a checklist that focuses on the simple aspects of complex care that can easily be overlooked. Every teaching attending reviewed the telemetry findings and determined the need for continued telemetry monitoring every day on every stroke patient. If there was no longer an indication, a "discontinuation order" was placed at the bedside and the nurse removed the monitor during rounds. The attending marked each patient on the list as "continue to use tele, discontinue tele or no indication for tele." By following the same daily process we also confirmed the physical therapy orders and reviewed the therapist's findings and recommendations. If a need was identified and there was no order, the team placed an order while the nurse called the physical therapy service simultaneously. Everyday all checklists were reviewed at the end of rounds to ensure completion and continuity. Results As a result of this new process we are able to discontinue unnecessary telemetry monitors everyday and this allows us to have available monitors for new patients at all times. No patient was transferred to another unit due to lack of monitors. We also made a minor impact on the length of stay for stroke patients by making sure that they are reviewed by the physical therapist early in the admission. To be able to assess the effectiveness our process we looked at 26 random checklists in July and August 2013 that were completed on the stroke teaching service. 971 patients were screened using the checklist, 23% of these patients had telemonitoring during rounds and 34% of those telemonitors were discontinued by using the checklist. During this time System Quality Review Journal Page 60

75 80% of stroke cases were placed on the designated stroke teaching service compared to 40% the same time frame prior to checklist implementation. The remaining 20% were placed in other areas of the hospital due to lack of available beds but not telemonitors. Also as a result of the checklist none of the discharges were delayed due to lack of physical therapy evaluation. There was a very minor improvement in the median LOS however it is not clear if this could be attributed to the use of checklist. Conclusions Checklists can be utilized during teaching rounds in the context of great practice variability due to periodically rotating trainees. They can be good teaching tools as they help providers standardize patient care and integrate established best practice guidelines. There is a lot of evidence about the effectiveness of checklists in high risk areas to improve the quality of care such as ICUs or procedures however checklists are not been utilized as much in routine general practice. As our medicine practice is constantly improving with evolving electronic health records we are hoping to develop disease specific checklists that could assist providers to deliver the best care possible. System Quality Review Journal Page 61

76 Poster Presentation Stroke and the Electronic Health Record: Improving Quality and Reporting Ken Ong, MD MPH; Bebe Z Rahamatalli, RPA-C MPAS; Jean Versace, RN BS; Edward Chai, MD; Anna Delios, MD; Helena Hizon, RN MS; Alfred Caligiuri, PA MBA; Karen J Nefores, RN BSN MBA New York Hospital Queens Introduction Electronic health records can enhance clinical decision support and improve the capture and reporting of quality measures. In January 2013, CMS added stroke to the IQR Core Measures. In January 2014, hospitals may submit electronically one quarter's data for 16 quality measures from four measure sets collected from certified electronic health record (EHR) technology for Fiscal Year 2016 Inpatient Quality Report payment determination. Problem New York Hospital Queens transitioned from the hybrid paper and electronic clinical documentation to fully electronic clinical documentation in February This case study describes an initiative to improve stroke measure performance and data capture with stroke specific electronic order sets and documentation combined with staff education. Goals Develop clinical decision support, documentation, and analytics to enable the capture and reporting of stroke clinical quality measures for performance improvement. Methods In June 2012, a disease specific discharge section was added to the MD summary of care discharge note. If a patient was not on comfort measures, branching logic was used to make subsequent questions about core measures "significant" observations. Monthly meeting with Quality Coordinators and Nursing Performance Improvement started. A Stroke Coordinator position was created in January 2013 and an additional neurologist was hired to champion the stroke service in February In February 2013, a quality management coordinator began concurrent chart reviews and clinician interaction on the Stroke unit on weekdays. Focused stroke education was given to leadership and individual staff during nursing leadership meetings, housestaff and hospitalists at noon conferences, P.A. meetings, monthly ED staff meetings, and ED Observation meetings. In March 2013 the dysphagia screen template in the ED "Nursing Physical Assessment Note" was expanded in scope to include "Stroke/TIA symptoms" rather than only "Stroke" patients. The dysphagia screen was performed on those with suspected stroke and not just those with confirmed diagnosis. The MD stroke progress notes and initial stroke team evaluation notes were modified to better capture the time measures. Originally, midnight would default as the time given for "last known well and discovery of symptoms" if the provider entered the date but forgot to enter the time. The default value was changed to "null." In April 2013, the Modified Rankin scale was added to nursing discharge note. The Ischemic Stroke/ TIA order set was modified with the following: added vital signs monitoring parameters, criteria for prescribing anti-hypertensive System Quality Review Journal Page 62

77 medication, added stroke education booklet order item, removed "NPO except meds," added insulin protocol, omission orders for anti-thrombotic medication and statins, added new MRI stroke protocols with or without contrast, criteria for ordering echocardiograms (i.e., no need to order if taken within 6 months and no new indication for re-ordering), urine toxicology selected by default, and VTE prophylaxis order set selected by default. In addition, the neurologist & stroke team physician assistants (Pas) devoted one weekly morning report to review cases. [See screenshots of the automatically calculated NIH Stroke Scale and the branching logic for core measures in the physician's Summary of Care note.] In May 2013, the VTE prophylaxis order set was updated for the VTE core measure and presented positive impact on stroke VTE measures, i.e., "no VTE prophylaxis indicated" was added as omission documentation in patients with early ambulation selected as prophylaxis. During this month, educational posters with guidelines indicating potential acute patients, assessment of these patients and criteria for tissue plasminogen activator (tpa) and post tpa monitoring were placed in the ED triage and trauma room. In July 2013, new branching logic was added to the initial and progress stroke notes to capture the differing times for last known well required by Meaningful Use (MU) and the New York State Department of Health (NYS DOH), i.e., within 2 hours for MU and 6 hours for NYS DOH. New Stroke Task Force started its monthly meetings. In August 2013, as per a Stroke Task Force recommendation, the data element to record patient education for stroke was moved from the MD Summary of Care Discharge Transfer Note to nursing discharge documentation. In addition, documentation remains in the Stroke Team PA note to record patient education. Results The compliance the 4 months after the intervention compared 4 months prior improved for 4 stroke measures: Modified Rankin Scale at Discharge (155%), VTE Prophylaxis (36%), Dysphagia Screen (24%), and Stroke Education (13%). There was no significant improvement for 5 stroke measures: Door To IV rt-pa in 60 Min (Historic Quality), Early Antithrombotics by end of hospital day 2, Antithrombotics Prescribed at Discharge, Anticoagulation for A. Fib/A. Flutter, and LDL 100 or ND - Statin. Conclusions The modified Rankin scale was not performed by the staff prior to mid April Scores in 2012 are reported because of the default score in GWTG of six expired patients. Estimated scores based on documentation were reported from January to Mid-April The documentation template was key to adhering to this measure. Nursing education began, but there was a need for reminders in the medical record to ensure staff compliance. This template works well and requires only reinforcement. Changes in documentation for the VTE prophylaxis measure did not change prescribing practice. Education has always been focused on administering prophylaxis by hospital day two. The measure definition has changed in that prophylaxis must be administered by day two of admission. This may allow extra time in a few cases but this was not emphasized to the staff. There has been a modification to the EHR and focused education for the nursing staff to ensure compliance with utilization and documentation of sequential compression sleeves when there is an order for mechanical VTE prophylaxis. Improvement in this measure can be attributed significantly to both modifications to the System Quality Review Journal Page 63

78 electronic health records as well as performance improvement concurrent review. This measure requires occasional reinforcement and education for new staff members. The results of dysphagia screen can be attributed to performance improvement driven by change in the documentation template and ongoing education. There was a misconception that a dysphagia screen must be performed only when there is a stroke team activation and confirmed stroke diagnosis. It was clarified that all patients with a suspected stroke must also have a dysphagia screen prior to any oral intake. This measure is discussed in nursing huddles daily at each shift change in the emergency department. Performance is on a positive trend but ongoing reinforcement and education is vital for this measure. Data is currently being evaluated for other trends to better target educational opportunities and performance improvement. Concurrent review improved stroke education measure results. Concurrent review provides opportunities to educate the nursing staff on improving their documentation of the patient education they provide. In addition, a nursing order to give the Stroke Education Booklet was added to the stroke order set. Stroke team PAs also provide education to patients and document on a specific stroke team note. Performance in this measure also depends on the rate of patient capture by the PAs. With the addition of the patient education record to the nursing discharge note, and a new electronic referral system for the PAs, there will be continued improvement in this measure. Improving tpa administration time has been an ongoing struggle. This measure is very complex and requires many team members to work quickly and efficiently while documenting specific times on the stroke call template within the EHR. The stroke must be recognized rapidly, the entire stroke team must be mobilized in order to obtain a history and physical, vital signs, CT scan and labs all in a timely manner. The team must work efficiently to gather all of this data as part of a crucial decision-making process. The documentation template in the EHR has helped tremendously in capturing documentation of delays in tpa administration or reasons for not administering tpa. It has also helped in reviewing failed cases for performance improvement opportunities. However, it does not and cannot fix all the failures within the system. Guidelines have been posted in the ED triage and trauma areas but the effect is yet to be evaluated. Early antithrombotic by hospital day two requires a practitioner to first suspect a stroke on admission, order the medication via an appropriate route, and rely on the nurse to administer the medication. Performance is usually good because practitioners are usually aware that these patients must be treated with antithrombotic therapy. The challenges have been in the few cases that have contraindications and require documentation to reflect these, or patients who are unable to swallow that require medications via alternative route to oral formulations. Order set revision included omission reason for not administering these medications. However, compliance with order set utilization remains a challenge. In previous years, compliance had been about 30%. In May and June of this year, after revision and education, it was 48% and 53%, respectively. There is also education to promote utilization of Aspirin suppositories in patients who are unable to swallow. This is reflected within the order set. More data and time to follow trends are needed to evaluate the effect of these changes. The discharge measures which include antithrombotics at discharge, anticoagulation for A.Fib/A.Flutter and statin therapy usually have good performance since practitioners usually have a good understanding of the appropriate therapy for stroke patients. Few cases present challenges due to documentation. The disease specific discharge instructions were designed to capture these cases while serving as a reminder to prescribe the appropriate medications. Unfortunately, medication reconciliation in the EMR has presented significant challenges and therefore, we have found System Quality Review Journal Page 64

79 discrepancies in the discharge medication list and the disease specific discharge instruction. Concurrent reviews have helped to capture potential failures prior to discharge. More data is needed to evaluate trends but the suspicion is that the system of medication reconciliation needs revision. The CMS FY2014 inpatient payment rule seeks to reduce providers reporting burden in both the EHR Incentive Program and the Hospital Inpatient Quality Reporting (IQR) Program. Meaningful Use of the EHR envisions sequential advancement from data capture and sharing, advanced clinical processes, and improved outcomes. As a literature review by Buntin et al. confirms, the electronic health record can improve patient safety, efficiency and effectiveness of care, and numerous other benefits to health. Guideline-based computerized clinical decision support has increased compliance for stroke prevention in atrial fibrillation. Electronic medical record associated clinical decision support has also increased dysphagia screening in acute stroke. Our study demonstrates the synergy of using the electronic health record with traditional performance improvement in stroke quality measures. System Quality Review Journal Page 65

80 Interventions: June 2012 Core Measure 'significant' information added to Physician Summary of Care Note February 2013 Concurrent reviews February 2013 Focused education to staff March 2013 Requiring completion of Core Measure information in the Physician Summary of Care Note March 2013 Dysphagia screen template modified with staff education April 2013 Ischemic stroke/tia order set revision May 2013 VTE prophylaxis order set revision May 2013 ED posters & education Measures That Showed Improvement Measure November 12 December 12 January 13 February 13 March 13 April 13 May 13 June 13 4 Months Pre 4 Months Post Change Modified Rankin Scale at Discharge Num Modified Rankin Scale at Discharge Deno Modified Rankin Scale at Discharge Perce 18% 19% 38% 11% 23% 44% 72% 77% 21% 52% 155% VTE Prophylaxis Numerator VTE Prophylaxis Denominator VTE Prophylaxis Percent 67% 74% 59% 73% 91% 93% 91% 100% 69% 93% 36% Dysphagia Screen Numerator Dysphagia Screen Denominator Dysphagia Screen Percent 53% 38% 53% 41% 39% 58% 63% 65% 46% 56% 24% Stroke Education Numerator Stroke Education Denominator Stroke Education Percent 90% 79% 100% 83% 95% 100% 96% 100% 87% 98% 13% Measure November 12 December 12 January 13 February 13 March 13 April 13 May 13 June 13 4 Months Pre 4 Months Post Change Modified Rankin Scale at Discharge 18% 19% 38% 11% 23% 44% 72% 77% 21% 52% 155% VTE Prophylaxis 67% 74% 59% 73% 91% 93% 91% 100% 69% 93% 36% Dysphagia Screen 53% 38% 53% 41% 39% 58% 63% 65% 46% 56% 24% Stroke Education 90% 79% 100% 83% 95% 100% 96% 100% 87% 98% 13% 120% 100% 80% 60% 40% 20% 0% November 12 December 12 January 13 February 13 March 13 April 13 May 13 June 13 Modified Rankin Scale at Discharge VTE Prophylaxis Dysphagia Screen Stroke Education Measure 4 Months Pre 4 Months Post Modified Rankin Scale at Discharge Perce 21% 52% VTE Prophylaxis Percent 69% 93% Dysphagia Screen Percent 46% 56% Stroke Education Percent 87% 98% 120% 100% 80% 60% 40% 20% 0% 4 Months Pre 4 Months Post System Quality Review Journal Page 66

81 Measures That Did Not Show Improvement Measure November 12 December 12 January 13 February 13 March 13 April 13 May 13 June 13 4 Months Pre 4 Months Post Change Door To IV rt PA in 60 Min (Historic Quali Door To IV rt PA in 60 Min (Historic Quali Door To IV rt PA in 60 Min (Historic Quali 20% 14% 13% 43% 33% 47% 86% 33% 22% 54% 141% Early Antithrombotics by end of hospital d Early Antithrombotics by end of hospital d Early Antithrombotics by end of hospital d 94% 94% 84% 97% 93% 97% 91% 100% 93% 95% 2% Antithrombotics Prescribed at Discharge Antithrombotics Prescribed at Discharge Antithrombotics Prescribed at Discharge 98% 100% 97% 95% 100% 97% 96% 98% 98% 97% 0% Anticoag for AFib/Aflutter Numerator Anticoag for AFib/Aflutter Denominator Anticoag for AFib/Aflutter Percent 100% 86% 100% 88% 100% 86% 100% 100% 92% 97% 5% LDL 100 or ND Statin Numerator LDL 100 or ND Statin Denominator LDL 100 or ND Statin Percent 98% 100% 91% 86% 98% 94% 90% 91% 94% 93% 1% Measure November 12 December 12 January 13 February 13 March 13 April 13 May 13 June 13 4 Months Pre 4 Months Post Change Door To IV rt PA in 60 Min (Historic Quali 20% 14% 13% 43% 33% 47% 86% 33% 22% 54% 141% Early Antithrombotics by end of hospital d 94% 94% 84% 97% 93% 97% 91% 100% 93% 95% 2% Antithrombotics Prescribed at Discharge 98% 100% 97% 95% 100% 97% 96% 98% 98% 97% 0% Anticoag for AFib/Aflutter Percent 100% 86% 100% 88% 100% 86% 100% 100% 92% 97% 5% LDL 100 or ND Statin Percent 98% 100% 91% 86% 98% 94% 90% 91% 94% 93% 1% 120% 100% 80% 60% 40% 20% 0% Door To IV rt PA in 60 Min (Historic Quality) Percent Early Antithrombotics by end of hospital day 2 Percent Antithrombotics Prescribed at Discharge Percent System Quality Review Journal Page 67

82 MD Summary of Care Discharge Transfer Note : Stroke Questions Branching Logic (* = Required) *Patient with comfort measures ONLY documented o o Yes (alert triggered): CMS Definition: Comfort Measures ONLY refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort. It includes attention to the psychological and spiritual needs of the patient and support for both the dying patient and the patient's family. Comfort Measures ONLY is commonly referred to as "Comfort Care" by the general public. It is not equivalent to a physician's order to withhold emergency resuscitative measures such as Do Not Resuscitate (DNR). No o *Patient with one or more of the following [check all that apply]: Acute MI, Heart Failure, Acute Stroke/TIA, Acute Venous Thromboembolism, None. If Acute Stroke/TIA selected *Patient prescribed a Statin? o Yes o No : *Omission reason for Statins: Rhabdomyolysis; Inflammatory disease of the liver; Hepatic failure; Statin not tolerated; Medication refused; Patient noncompliance general; Hypoglycemia; Conduction disorder of the heart; Medical contraindication; Statin contraindicated; Lipid lowering drug adverse reaction; Patient non compliant refused intervention/support; Refusal of treatment by patient; administration of med not done due to contraindication; Surgical contraindication *Does patient have A. Fib/A. Flutter? o Yes System Quality Review Journal Page 68

83 o No *Patient prescribed an anticoagulant for A. Fib/ A. Flutter? o Yes o * No : *Patient prescribed an Antiplatelet/Anticoagulant? o Yes o No : o o Warfarin therapy started Other reasons for no Anticoagulation: Bleeding risk, Complications r/t AC; Risk of falls; Other *Omission reason for Antiplatelet/Anticoagulant: Administration of med not done due to contraindication; Anterior cerebral circulation hemorrhagic infarction; Anticoagulation not tolerated; Bleeding; Blood coagulation disorder; Blood coagulation disorder due to live disease; Hemorrhagic cerebral infarction; Medication refused; Patient noncompliance general; Patient non compliant refused intervention/support; Platelet count below reference range; Posterior cerebral circulation hemorrhagic infarction; Refusal of treatment by patient; Renal impairment *Patient enrolled in Clinical Trial o Yes o No *Patient admitted for Elective Carotid Intervention o Yes o No System Quality Review Journal Page 69

84 NIH Stroke Scale: After all parameters are completed the score is automatically calculated System Quality Review Journal Page 70

85 Improved Clinical Documentation: Ensuring Effective Medical Records to Support High-Quality Care Lucia Lagan-Rinando, RN BSN; Karen Nefores, RN BSN MBA New York Hospital Queens Introduction The Clinical Documentation Improvement (CDI) process was initiated at NYHQ in November, It began as a concurrent review of the medical record and in 2007, changed to a retrospective review. In 2011, administration opted to engage FTI Consulting to conduct an evaluation and assessment of the CDI program and subsequently contracted with FTI to enhance the CDI program. Problem Issues identified: Focus on coding validation rather than documentation improvement Need for additional staff Retrospective query process, not concurrent, without standardized template Lack of automated software measurement tools to track productivity, benchmarks or metrics Need for increased organizational prioritization with senior leadership support Need for development of physician advisors for program support Need for comprehensive physician education program Need for annual DRG Validation process, coder audits and competencies. Need for coder query training and guidelines Need for Case Mix Index (CMI) statistical analysis and comparison data to establish baseline statistics Goals To produce clinical documentation that supports high clinical quality, appropriate code selection, valid patient acuity, and improved case mix index, which results in appropriate reimbursement for the inpatient care provided. To establish consistent concurrent and retrospective strategies that clarify all aspects of the documentation prior to billing. To meet/change staff requirements for both CDS and coding staff. To formalized and standardize the query process To identify/appoint physician advisors to support medical staff education and CDI staff effectively To effectively use the computerized worksheets and queries To improve CMI Methods 1) Clinical Documentation Specialists Formal educational process to clarify roles and responsibilities of the CDI process completed Development and implementation of concurrent record review utilizing FTI software and computerized worksheets and queries Hired, oriented and educated new Clinical Documentation specialists and coders Development of documentation templates and query templates to assist in updating work flow process System Quality Review Journal Page 71

86 2) Medical/Surgical Staff Physician advisors educated in coding, documentation, DRG's and severity Physician advisors serve as a resource for the clinical documentation team Formal educational schedule initiated, of medical/surgical staff on all aspects of Clinical Documentation 3) Coding HIM hired, oriented and educated new coders, both contracted and staff, in CDCI process flow, strategies and the query process 4) Measurement of effectiveness Implementation of performance and outcome metrics to monitor and manage program effectiveness Use and interpretation of monthly ProTrend reports for outcome measurement Results Surgical MCC Capture Rate Improved by 25% from baseline period (12/ /2012) to current performance (12/2012-6/2013). Medical MCC Capture Rate Improved by 36% from baseline period (12/ /2012) to current performance (12/2012-6/2013). Potential Financial Impact of Medical CMI Potential financial impact of medical CMI for 12/ /2012 was $1,075,406 Potential financial impact of medical CMI for 12/2012-6/2013 is $6,206,457 Total Potential Financial Impact Total potential financial impact for 12/ /2012 was $564,062 Total potential financial impact for 12/2012-6/2013 is $7,481,675 * Potential Financial Outcomes are based on the difference as compared to pre-implementation year, Conclusions Clinical Documentation Improvement requires a multidisciplinary team approach in order to be successful. The addition and training of Clinical Documentation Specialists, hiring of a new contracted coding company, initiation of a coding validation staff, identification and implementation of physician advisors, and the formalized schedule of physician education, has had a tremendously positive effect on performance. System Quality Review Journal Page 72

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89 SPRINT - A Call to Action for Resident Led Performance Improvement Armando E Castro, MD FACS; Anita Ayrandjian Volpe, DNP APRN; Pierre F Saldinger, MD FACS New York Hospital Queens Introduction ACGME core competencies require surgical residents to participate in performance improvement activities and demonstrate leadership skills. In order to accomplish these initiatives as well as meeting the core competencies, the idea of SPRINT Surgical Performance improvement ResIdeNt Team was developed. Teams consist of a chief surgical resident, and a junior resident or intern, an attending surgeon, the Director of Perioperative Patient Safety and Quality, and multidisciplinary members related to the focus of the initiative. The teams develop, educate, implement, revise, and monitor the work of the initiative. Problem The goal of every surgical residency program is to meet the designated core competencies mandated by the ACGME. The dilemma for each program is to integrate resident education, clinical leadership development, and performance improvement in a meaningful, effective manner. Traditionally, faculty and voluntary staff have been prevailed upon to assist with performance improvement activities. Our approach is to enlist the assistance and leadership of the surgical residents to develop and lead performance improvement initiatives and utilize faculty and attending staff to assist with the initiative. This approach provides a foundation based upon viewing clinical activities in a dual manner clinical issues and systems process issues, thus achieving on-going, proactive performance improvement. Due to the increasing focus on quality and outcomes, the role of proactive performance improvement continues to grow. Surgical residents will be entering a new setting in which they will be expected to meet the demands of this new changing environment. In addition, financial constraints and limited staffing impacts the ability of a facility to maintain a large performance improvement staff. The surgical residency program offers a resource to the facility to assist with and drive performance improvement. The integration of the residents in performance improvement initiatives at the ground level meets the needs of both the resident and the facility, as performance improvement activities are implemented. The end result is a mutually collaborative relationship in which both parties benefit for the long term. Goals To introduce and integrate surgical residents in performance improvement in a multi-disciplinary collaborative setting. Methods SPRINT teams were developed to address areas in need of improvement based upon the ACS NSQIP SAR. The goal for each team is to evidence-based, best practice and consistency in the delivery of care. The measure of success is to improve performance and achieve more favorable surgical outcomes as reflected in the ACS NSQIP SAR. Additional goals include the integration of surgical residents and multidisciplinary frontline staff in participating in System Quality Review Journal Page 75

90 performance improvement. Opportunities were identified for the incorporation of the surgical resident in the multiple performance improvement activities of the department of surgery. These activities include participation in the various perioperative performance improvement committees. These committees range from surgical in-patient to overarching perioperative services performance improvement. In addition, the department reviews all surgical mortalities and a resident participates in the review in collaboration with the Director of Perioperative Patient Safety and Quality. It is the responsibility of the resident representative to disseminate the information discussed at the committee meetings to their colleagues during the Resident Caucus. To encourage and nurture resident borne initiatives we have developed and implemented a Chief Resident PI-NSQIP Council in which process defects and performance improvement opportunities are discussed. Issues and opportunities are further discussed with the Director of Perioperative Patient Safety and Quality and the General Surgery Program Director. Presentations at Morbidity and Mortality Conference carry set guidelines for presentation with stated objectives for both the learner and the presenter. Each presenter meets to discuss the case with the attending surgeon and the Director of Perioperative Patient Safety and Quality. During the discussion with AV, the case is reviewed for NSQIP pre, intra, and postoperative variables as well as identifying opportunities for improvement in care and or system process issues. NSQIP variables are presented during conference in order to establish a common language for discussion as well as documentation. Assignment of residents to the various activities has been linked to team assignment thus ensuring rotation of the role throughout the year. Each resident is responsible for providing mentorship regarding role responsibilities to the incoming resident. Guidelines for participation in performance improvement teams have been developed and shared with residents. The end goal for the resident is the requirement for submission of the project for presentation and submission to the ACS NSQIP for annual conference. Results To date, four initiatives have been developed which are being resident led. There has been an increase in the identification and reporting of occurrences. This produces concurrent, proactive performance improvement. Feedback and outcomes indicate the success and feasibility of integrating surgical resident education and performance improvement. Conclusions The combination of surgical education and performance improvement is not only desirable, but necessary for effective conduct of performance improvement in a teaching hospital. System Quality Review Journal Page 76

91 Performance of a Lab Alert Query Integrated into the Electronic Medical Record to Actively Inform Emergency Department Providers of Pending Lab Tests at the Time of ED Discharge David Barlas, MD; Al Caligiuri, PA-C MBA New York Hospital Queens Introduction In a typical Emergency Department, many patients with diverse conditions are simultaneously being managed, many of whom require urgent diagnosis and therapy. Losing situational awareness is a frequent threat to patient safety in this environment and can result from multitasking, information overload, new patients, and interruptions from telephone calls. A notable consequence can be overlooking clinically important information which may lead to unexpected morbidity and mortality. A recent case in New York City in which a previously healthy boy with a sore throat and flu-like symptoms was discharged home from an ED with a life threatening infection highlights the importance of this issue; had this patient s ED physician realized that his abnormal blood tests were incomplete at the time of discharge, a poor outcome may have been averted because these tests eventually proved to be very abnormal when they became final, unbeknownst to the ED physician. Problem ED physicians frequently have to think and act quickly, and making sure that all tests that have been ordered have been completely resulted and checked may not always occur because of the nature of the practice environment and the incessant need to multitask and maintain situational awareness. Utilizing a computerized medical record that interfaces with the clinical laboratory would enable a logic module to be developed that could alert the ED staff when specific laboratory tests have been ordered but remain pending at the time of ED discharge, replacing the human factor with a computer program to perform this mundane yet important task. Goals The goal of this project is to develop a medical logic module (MLM) that is triggered by an ED discharge order and contemporaneously queries the laboratory results for the presence of those that are not reported as final. The purpose is to alert the staff and to prevent premature discharge of patients from the ED who have pending laboratory results that, when finalized, may change management. Methods This enhancement was made at New York Hospital Queens, an urban tertiary care teaching institution with a 75 bed ED hosting 125,000 annual visits. The institution utilizes the Allscripts v5.5 integrated EMR platform. An MLM was created within this environment by the IT Department as follows: Upon placement of an ED Discharge order, the visit will be queried for the following lab results: 'CBC', 'CBC with Automated Diff', 'CBC with Manual Diff', 'Basic Metabolic Panel', 'Comprehensive Metabolic Panel, Lactic Acid, Troponin T Quant.',and Troponin I Quant'. If any of these orders are pending or in-process, conditions will have been met to trigger an alert message which will identify these orders alongside others which may already be final. The alert will request acknowledgement and have a text area for explanatory comments by the ordering provider. After acknowledgement, System Quality Review Journal Page 77

92 the provider will retain the option to continue as usual and complete the ED discharge order or to abort the operation. The medical records of patients with this alert were reviewed to determine if patients were admitted during the index encounter or shortly thereafter, and if there were any quality assurance (QA) referrals. Results The MLM went live on March 19, From this date until July 31, 2013 there were ED patient encounters and the alert was triggered 1,007 times (2.0%). These alerts were acknowledged and the clinical care proceeded as previously planned in virtually all cases, including planned discharge from the ED. Some reasons given in the text area were clinically insignificant, will follow, AMA, and ok. No cases of reversal of the decision to discharge were found. Of these 1,007 cases, chart and QA file review revealed 7 cases (0.7% of alerts) in which the alert highlighted important information. Conclusions The MLM performed as intended by bringing incomplete lab test results to the providers attention at the time of ED discharge. About 1 in 50 patients triggered the alert, and all were discharged. Making the MLM a hard-stop until all labs were resulted would allow clinicians to have more complete data available to them but may delay the discharge of approximately 1 in 50 patients from our ED, or about 6-8 patients a day. In order to continue this patient safety enhancement and improve its efficacy, an appropriate balance should be sought between patient safety and ED throughput which may be achievable through 1) more rapid lab turnaround, especially with CBC and differential testing, and 2) provider education and feedback regarding the outcome of patients with these alerts. System Quality Review Journal Page 78

93 First Year Experience of a Hospital-based Out-Patient Antimicrobial Parenteral Therapy Unit Joanna Kopacz, MD [1]; Javeria Shakil, MD [1]; Nauman Piracha, MD [1]; Deborah Figueroa, PharmD [2]; Caroline Keane, ANP [3]; Ruth Hopkins, RN [4]; Alexander Melchert [2]; Michaelle Williams, RN [4]; Marcia Levine, RN [4]; Stephen Rimar, MD [5]; Sorana Segal-Maurer, MD [1] [1] The Dr. James J. Rahal Jr. Infectious Disease Division; [2] Pharmacy; [3] Case Management; [4] Nursing; [5] Administration New York Hospital Queens Introduction Hospital-based outpatient parenteral antibiotic treatment (HB-OPAT) can avoid hospitalization, optimize early discharge, and facilitate access to hospital services. We report our first-year OPAT experience. Problem Increased hospital acquired infections, length of stay and increased re-admissions. Goals HB-OPAT can to improve rate of readmissions, decrease hospitalization rates, as well as improve patients' safety and satisfaction. Methods Retrospective review of patients treated in a 535-bed university-affiliated community HB-OPAT unit including demographics, referral source, diagnosis, treatment, intravenous (IV) access, adverse events (A/E), and outcome. Results Of 318 patients, median age 60 years (range 19-94), 207 (64%) male, 244 (73%) in-patient referrals, 196 (63%) commercially insured. One-half patients had peripheral IV (PIV) access (142), 42% peripherally-inserted central catheters (PICC) (others with chemoports or midlines). Infections included: 117 complicated skin and soft tissue (37%), 82 urologic (26%), 34 orthopedic (11%), 27 septicemia and/or endocarditis (9%), 22 gastrointestinal (7%), 11 pneumonia (3%), 7 others (2%). Non-infection diagnoses in 18 patients included: thrombosis, dehydration, anemia, steroid administration, etc. Two-thirds of urologic infections were due to pyelonephritis and post-prostate biopsy septicemia. Six patients with MDR E coli rectal colonization received pre-prostate biopsy IV antibiotics. One-quarter patients had microbiologic diagnoses (56% gram-positive organisms, 44% with concurrent bacteremia). Most gramnegative infections were due to MDR E coli. Most patients (145, 43%) received daptomycin (D) (median dose 8 mg/kg/day), 106 ertapenem (Ert), and 68 ceftriaxone (CTX). Ten of 318 patients failed clinically and 9 had non-opat related re-hospitalization. Adverse events in 14 patients included: 8 CPK elevation (D-related, 4 required discontinuation and 4 dose reduction, all resolved), 3 rash (2 CTX, 1 Ert), 1 pancytopenia (CTX), 1 seizure (Ert). No catheter-related infections occurred. Use HB-OPAT led to $824,569 antibiotic cost savings and $1,701,987 new hospital revenue in the first year. Conclusions Over 90% OPAT patients successfully completed treatment with few adverse events. Over 25% of infections were urologic and most due to MDR E. coli. Case Management and Antibiotic Stewardship Program were instrumental identifying OPAT-appropriate patients and facilitating clinician buy-in. Dedicated Infectious Diseases clinicians and System Quality Review Journal Page 79

94 skilled OPAT nurses optimized patient outcome. Further data collected on length of say and re-admission rates. System Quality Review Journal Page 80

95 Poster Presentation Evaluation of Patients with a Chief Complaint of Syncope in an Observation Unit: A Quality Assurance Assessment William Apterbach, MD; Johnathon LeBaron, DO; Greta Apterbach, PhD New York Hospital Queens Introduction Syncope is defined as a sudden loss of consciousness associated with the inability to maintain postural tone, followed by spontaneous recovery [1,4]. The cause of a syncopal episode can range from the benign to the life threatening [1,4,6,7]. Benign causes can include vasovagal, situational, carotid sinus hypersensitivity, orthostatic, or an adverse reaction to medication. Life threatening causes can be cardiovascular or neurologic in origin including trauma, cardiac ischemia, arrhythmias, structural abnormalities, pulmonary emboli, and ischemic and hemorrhagic cerebral vascular attacks (CVA). While some of the life threatening causes are immediately evident, others, such as an arrhythmia may not be and have been associated with high risk adverse outcomes [8,9,10]. It is often difficult to determine the exact etiology of syncope in the Emergency Department (ED) [1]. Consequently, 39% of patients seen for a syncopal event will have an unknown etiology at time of discharge. Despite an adequate evaluation in the ED, patients with an unknown etiology of syncope may have an undetected cardiac or life threatening cause for their symptoms and be at risk for an adverse outcome [8,9,10]. Due to the possibility of an adverse outcome, patients deemed to be at risk are often admitted into the hospital and evaluated in the inpatient setting [11]. On average, 3% of patients per year will present to the ED with the complaint of having experienced a syncopal episode. This chief complaint accounts for an average of 6% of hospital admissions with an estimated cost of $2.4 billion annually and an average cost of $5,400 per patient [3,5]. According to the American College for Emergency Physicians (ACEP) guidelines, initial diagnostic testing of syncope includes a thorough history, physical exam, and electrocardiogram (ECG) [2]. While these tests are often low yield in the diagnosis of syncope, they are used as an initial screen for cardiac causes. Other testing can include evaluation for orthostatic hypotension, computed tomography (CT) of the head, electroencephalograph (EEG), complete blood count (CBC), serial cardiac enzymes, magnetic resonance imaging (MRI), echocardiogram, and an electrophysiologic study (EPS) of the heart. Not every patient needs these additional tests. These additional tests can be expensive and time consuming. However, it is often believed, until a life threatening cause of syncope is ruled out, the patient may be at high risk of an adverse outcome. This belief underlies the compulsion to perform additional diagnostic testing and admission in certain patients. To decrease unnecessary admissions different rules have been created to risk stratify patients presenting with syncope [8,9]. With a sensitivity of 96%, the San Francisco rule states that if a patient has any of the following: abnormal ECG, complaint of dyspnea, hematocrit less than 30%, systolic blood pressure less than 90mmHg, or history of congestive heart failure (CHF), then the patient had an increased risk of adverse outcome in the following 7 days. The Osservatorio Epidemiologico sulla Syncope nel Lazio (OESIL) score uses the presence of age greater than 65 years old, history of cardiovascular disease, syncope without prodrome, and abnormal EKG to stratify patients into different System Quality Review Journal Page 81

96 levels of risk for adverse outcome within 12 months of the syncopal episode. However, subsequent studies have failed to replicate the sensitivity of the San Francisco rule or the clinical outcomes associated with the OESIL score [12,13]. Differences in patient populations and disease prevalence are thought to contribute to the discrepancies between internal and external validation of the clinical rules. Newer approaches that have been created to rule out life threatening causes in the diagnosis syncope include examining the patient on an outpatient basis in a clinic, admitting the patient but expediting their workup in a dedicated unit, and evaluating the patient on an extended basis in the emergency department [14]. Managing syncope in an affiliated clinic was shown to be effective in correctly identifying and admitting the high risk syncope patients but often yielded too many admissions to the hospital [15]. In-hospital syncope units, were shown to order fewer tests and arrive at a final diagnosis more frequently than hospitals without a syncope unit [16]. However, these patients are still evaluated on an inpatient basis which does not cut down on admission rate. The Syncope Evaluation in the Emergency Department Study (SEEDS) evaluated a protocol driven approach to thoroughly evaluating syncope in the ED [17]. This approach led to fewer admissions and greater likelihood of diagnosis at time of discharge from the ED. It is important to note this method was resource intensive, including staffing by a full time ED physician and nurse, access to an outpatient syncope center in case the patient needed further evaluation, and reliable follow-up available to the patient. An Emergency Department Observation Unit (EDOU) is another approach to the evaluation and management of syncope [3]. Observation Units evaluate a wide range of patients and conditions on an outpatient basis while within the confines of the hospital. The unit is meant to care for patients who require short term therapy or need diagnostic workup of a potentially critical disease or complaint. Various types of Observation Units are found in approximately one-third of all emergency departments in the United States [18]. Patients transferred to an EDOU have strict inclusion and exclusion criteria and follow a protocol driven evaluation to rapidly assess, treat, and provide the physician with an appropriate disposition for the patient. The chief complaint of syncope makes up an estimated 11.2% of all patients transferred to an EDOU [19]. Despite the large number of observation units and the number of syncope patients treated, little research has been done regarding their effectiveness in the management of syncope. Problem Given the many different causes of syncope, some etiologies may carry a worse prognosis than others [1]. The initial tests involved in the clinical evaluation of syncope often have a fairly low yield for determining the exact cause of the syncopal event. Therefore, further testing may be indicated in order to rule out potential life threatening causes of syncope [2]. An Emergency department observation unit (EDOU) is able to rapidly perform further diagnostic testing in a safe and monitored environment [3]. The development of dedicated Observation Units is in its infancy and the role of an EDOU in the management of syncope has not been well studied. Goals The purpose of this assessment of quality assurance is to 1) determine the demographic and clinical background of the patients evaluated for syncope in the EDOU and 2) determine which, if any, of these characteristics best predicts whether a patient is appropriate for EDOU level of care versus direct admission Methods The data from this quality assurance assessment was based on 171 patients who were placed in the EDOU following presentation to the emergency department with the chief complaint of syncope. All patients presented between March 2013 and July Clinical data included in this quality assurance assessment was obtained as part of routine patient care. All data was obtained via review of computerized medical records for this de-identified retrospective analysis. System Quality Review Journal Page 82

97 Each patient file was reviewed by two different evaluators to ensure data accuracy. The observation unit is a protocol driven, stand-alone unit within the hospital in which patients presenting to the ED may be transferred, after meeting certain inclusion/exclusion criteria, for expedited and focused assessment of specific chief complaints. Participants were assigned to two different groups based on whether they were admitted to the hospital during their evaluation in the EDOU (admitted group) or discharged home from the EDOU (not admitted group). Only the patients who presented to the emergency department secondary to a syncopal episode and were placed in the observation unit were included. Descriptive statistics were computed for study variables to ensure that all data values were within expected ranges and to eliminate any data errors that may have occurred. SPSS version 21 was used to conduct statistical analyses. Chisquare and independent sample t-test were used to determine significant differences between groups. Results The sample consisted of 171 patients who were placed in the observation unit secondary to a syncopal episode. Of those patient 142 patients were discharged while 29 were admitted to the hospital following observation. There were no significant differences between groups based on age (t[169]=-0.46, p=0.756), gender (χ2[1, N=171]=0.57, p=0.449) or race/ethnicity (χ2[6, N=171]=7.12, p=0.310). Table 1 displays sample characteristics for the overall sample and each group. In the total sample, participants had an average of 2.3 diagnoses (SD=1.6) in their past medical history problem list. Table 2 displays past medical history diagnoses. There was no significant difference in the average number of diagnoses for patients who were admitted (M=2.2, SD=1.6, N=29) and those discharged home (M=2.8, SD=1.6, N=29), t(169)=-1.96, p= However, patients who were admitted to the hospital when compared to those discharged had significantly higher rates of reported medical history of syncope (27.6% vs. 11.3%), χ2(1, N=171)=5.32, p=0.021 and diabetes mellitus (19.7% vs. 37.9%), χ2(1, N=171)=4.54, p= Additionally, initial cardiac enzymes were positive for eight percent of the patients placed in the observation unit. There was a significant difference in rate of initial cardiac enzymes with positive results for 20.7% of those admitted and 5.7% of those discharged, χ2(1, N=170)=7.18, p= Conclusions Using an EDOU for the evaluation of a patient who experienced a syncopal episode can be a safe, rapid, and cost effective alternative when compared to traditional admission or discharge home with outpatient follow up. However, a segment of patients who experience syncope will likely require standard in-patient admission for evaluation because of a need for testing beyond the scope of an EDOU or because they have potentially life threatening cause of their symptoms. While prior studies and decision tools sought to provide a reference regarding patients would be safe to discharge home versus admit, the current use of Observation Units provides a third option. The demographics of the patients evaluated in this quality assurance assessment during the five month period are representative of the general patient population of the study site. Use of either the San Francisco Syncope rule or OESIL did not predict those patients needing admission as an in-patient versus keeping an observation status. However, it is important to note that these decision tools are not meant for this type of stratification. With the exception of cardiac enzyme testing, no objective lab data, ECG finding, nor diagnostic testing, obtainable in the initial ED evaluation predicted the need for inpatient evaluation versus EDOU evaluation. Of all the variables assessed, the only statistically significant independent predictors of inpatient evaluation are positive initial cardiac enzyme testing, previous episodes of syncope, and a past medical history that includes diabetes mellitus System Quality Review Journal Page 83

98 (DM). These factors are easily obtainable in the ED during the initial evaluation and can be used to direct the appropriate level of care. It is possible that these factors are related in that the autonomic dysfunction caused by DM may create problems in the perception of a cardiac insult or the autoregulation of blood pressure and predispose a patient towards having repeated syncopal episodes. These factors may be used to address and modify the inclusion and exclusion criteria for transfer to an EDOU. After initial evaluation, a finding of positive cardiac enzymes or a history of DM or previous syncope may be deemed grounds for exclusion from the EDOU. This preselection of candidates deemed appropriate for and observation unit level of care is what helps expedite evaluate and allocate resources appropriately thereby maintaining patient safety and appropriate reimbursement. This quality assurance assessment was limited by the retrospective analysis of data. However, it does address the assessment goals. Applying the data learned from this assessment can help guide the appropriate care and ED disposition of patients thereby improving patient safety, patient flow, and hospital reimbursement. Future work is already planned to address other potential predictors of inpatient evaluation and compare the admitted syncope population with the general admitted population of the hospital. References 1) Kapoor, W. (2002). Current Evaluation and Management of Syncope. Circulation, 106, Retrieved from 2) Huff, J. S. MD, Decker, W. W. MD, Quinn, J. V. MD, Perron, A. D. MD, Napoli, A. M. MD, Peeters, S. MD, Jagoda, A. S. MD. (2007). Clinical Policy: Critical Issue in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope. Annals of Emergency Medicine, 9 (4), Retrieved from 3) Graff, G. L. (2011). Observation Medicine the Healthcare System's Tincture of Time. Retrieved from 4) Soteriades, E. S. MD, Evans, J. C. D.Sc, Larson, M. G. Sc.D, Chen, M. H. MD, Chen, L. MD, Benjamin, E. J. MD, Levy, D. MD. (2002). Incidence and Prognosis of Syncope. New England Journal of Medicine, 347 (12), Retrieved from NEJM.org. 5) Savage, D. D. MD, Corwin, L. MD, McGee, D. L. PhD, Kannel, W. B. MD, Wolf, P.A. MD. (1985). Epidemiologic Features of Isolated Syncope: The Framingham Study. Stroke, 16 (4), Retrieved from 6) Ouyang, H. MD, Quinn, J. MD. (2010). Diagnosis and Evaluation of Syncope in the Emergency Department. Emergency Medicine Clinics of North America, 28, Retrieved from emed.theclinics.com. 7) Kosiak Jr., D. J. MD, Decker, W. W. MD. (2004). Syncope: An ED approach to Risk Stratification. Emergency Medicine Practice, 6 (1), Retrieved from 8) Quinn, J. V. MD, Stiell, I. G. MD, McDermott, D. A. MD, Sellers, K. L. RN, Kohn, M. A. MD, Wells, G. A. PhD. (2004). Derivation of the San Francisco Syncope Rule to Predict Patients With Short-Term Serious Outcomes. Annals of Emergency Medicine, 43 (2), Retrieved from 9) Colivicchi, F., Ammirati, F., Melina, D., Guido, V., Imperoli, G., Santini, M. (2003). Development and Prospective Validation of a Risk Stratification System for Patients with Syncope in the Emergency Department: the OESIL Risk Score. European Heart Journal, 24, Retrieved from System Quality Review Journal Page 84

99 10) Ungar, A., Del Rosso, A., Giada, F., Bartoletti, A., Furlan, R., Quartieri, F., Lagi, A., Morrione, A., Mussi, C., Lunati, M., De Marchi, G., De Santo, T., Marchionni, N., Brignole, M. (2010). Early and Late Outcome of Treated Patients Referred for Syncope to Emergency Departments: the EGSYS 2 Follow-up Study. European Heart Journal, 31, Retrieved from 11) Sun, B. C. MD, Emond, J. A. MS, Camargo Jr, C. A. MD. (2005). Direct Medical Costs of Syncope Related Hospitalizations in the United States. The American Journal of Cardiology, 95, ) Serrano, L. A. MD, Hess, E. P. MD, Bellojio, M. F. MD, Murad, M. H. MD, Montori, V. MD. Erwi, P. J. MLS, Decker, W. W. MD. (2010). Accuracy and Quality of Clinical Decision Rules for Syncope in the Emergency Department: A Systematic Review and Meta-analysis. Annals of Emergency Medicine, 56 (4), Retrieved from ACEP.org. 13) Birnbaum, A. MD, Esses, D. MD, Bijur, P., PhD, Wollowitz, A. MD, Gallagher, E. J. MD. (2008). Failure to Validate the San Francisco Syncope Rule in an Independent Emergency Department Population. Annals of Emergency Medicine, 52 (2), Retrieved from 14) Vigar-Syed, M. MBBS, Bradley, D. J. MD. Shen, W. K. MD. (2013). Syncope Units Impact on Patient Care and Health Related Costs. Clinical Cardiology, 31, Retrieved from 15) McCarthy, F., McMahon, C. G, Geary, U., Plunkett, P. K., Kenny, R. A., Cunningham, C. J. (2009). Management of Syncope in the Emergency Department: a Single Hospital Observational Case Series Based on the Application of European of Society of Cardiology Guidelines. Europace, 11, Retrieved from 16) Brignole, M., Disertori, M. Menozzi, C., Raviele, A., Alboni, PE., Pitzalis, M. V., Delise, P., Puggioni, E., Del Greco, M., Malavasi, V., Lunati, M., Pepe, M., Fabrizi, D. (2003). Management of Syncope Referred Urgently to General Hospitals with and without Syncope Units. Europace. 5, Retrieved from 17) Shen, W. K., Decker, W. W., Smars, P. A., Goyal, D. G., Walker, A. E., Hodge, D. O., Trusty, J. M., Brekke, K. M., Jahangir, A., Brady, P. A., Munger, T. M., Gersh, B. J., Hammill, S. C., Frye, R. L. (2004). Syncope Evaluation in the Emergency Department Study (SEEDS): A multidisciplinary Approach to Syncope Management. Circulation, 110, Retrieved from 18) Wiler, J. L. MD, Ross, M. A. MD, Ginde, A. A. MD. (2011). National Study of Emergency Observation Services. Academic Emergency Medicine, 18, Retrieved from 19) American College of Emergency Physicians. (2011). State of the Art: Observation Units in the Emergency Department. Retrieved from System Quality Review Journal Page 85

100 Table 1. Sample Characteristics (N = 171) M (SD) of Participants Total Not Admitted Admitted Age 70.6 (16.7) 70.3 (16.9) 71.9 (16.3) Temperature 98.0 (0.6) 98.1 (0.6) 2.8 (1.6) Heart Rate 75.7 (16.0) 75.7 (15.8) 75.9 (16.8) Systolic Blood Pressure (24.9) (25.0) (24.9) Diastolic Blood Pressure 73.0 (15.9) 72.6 (15.8) 74.8 (16.8) Respiratory Rate 17.3 (2.1) 17.3 (2.2( 16.9 (1.5) O 2 Saturation 97.9 (2.1) 98.0 (2.1) 97.1 (1.9) Initial HGB 12.7 (1.6) 12.7 (1.6) 12.6 (1.5) Initial HCT 38.4 (4.4) 38.4 (4.4) 38.4 (4.1) Comorbidity 2.3 (1.6) 2.2 (1.6) 2.8 (1.6) Consultation 1.1 (0.8) 1.0 (0.8) 1.6 (0.7) Diagnostic Testing 1.7 (1.2) 1.5 (1.2) 2.6 (1.0) No (%) of Participants Total Not Admitted Admitted Gender Men 66 (38.6) 53 (37.3) 13 (44.8) Women 105 (61.4) 89 (62.7) 16 (55.2) Race/Ethnicity Asian 23 (13.5) 21 (14.8) 2 (6.9) Black 21 (12.3) 16 (11.3) 5 (17.2) Hispanic 24 (14.0) 18 (12.7) 6 (20.7) Indian 2 (1.2) 1 (0.7) 1 (3.4) White 88 (51.5) 73 (51.4) 15 (51.7) Other 11 (6.4) 11 (7.7) 0 Unknown 2 (1.2) 2 (1.4) 0 Orthostatic hypotension Negative 91 (53.2) 79 (55.6) 12 (41.4) Positive 19 (11.1) 13 (9.2) 6 (37.9) Null 61 (35.7) 50 (35.2) 11 (20.7) ECG Abnormal 27 (15.8) 22 (15.5) 5 (17.2) Arrhythmia 9 (5.3) 6 (4.2) 3 (10.3) NSR 133 (77.8) 112 (78.9) 21 (72.4) Null * 2 (1.2) 2 (1.4) 0 Consultation Cardiology 106 (62.0) 84 (59.2) 22 (75.9) Neurology 75 (43.9) 58 (40.8) 17 (586) Diagnostic Testing CT 127 (74.3) 102 (71.8) 25 (86.2) EEG 44 (25.7) 31 (21.8) 13 (44.8) MRI 19 (11.1) 12 (8.5) 7 (24.1) Stress Test 9 (5.3) 5 (3.5) 4 (13.8) Carotid Scan 23 (13.5) 22 (15.5) 1 (3.4) Echo 59 (34.5) 39 (27.5) 20 (69.0) Catheterization 5 (2.9) 1 (0.7) 4 (13.8) Tilt Table 1 (0.6) 0 1 (3.4) Note. Statistical analyses showed no significant differences (p >.05) between groups for all listed variables; Null = not reported or no value available. System Quality Review Journal Page 86

101 Table 2. Past medical history diagnoses for entire sample and between two groups. Medical Diagnosis % in Total Sample (N = 171) % in Not Admitted (N = 142) % in Admitted (N = 29) Significance p value Comorbid Conditions Syncope 24 (14.0) 16 (11.3) 8 (27.6).021 Hypertension 123 (71.9) 100 (70.4) 23 (79.3).332 Hyperlipidemia 69 (40.4) 54 (38.0) 15 (51.7).171 Coronary Artery Disease 35 (20.5) 28 (19.7) 7 (24.1).591 Congestive Heart Failure 14 (8.2) 11 (7.7) 3 (10.3).642 Diabetes Mellitus 39 (22.8) 28 (19.7) 11 (37.9).033 Arrhythmia 15 (8.8) 13 (9.2) 2 (6.9).695 CVA/TIA 14 (8.2) 11 (7.7) 3 (10.3).642 Anemia 7 (4.1) 6 (4.2) 1 (3.4).847 Ambulation Difficulty 12 (7.0) 8 (5.6) 4 (13.8).117 Benign Prostatic Hypertrophy 12 (7.0) 8 (5.6) 4 (13.8).117 COPD 5 (2.9) 4 (2.8) 1 (3.4).854 Renal Impairment 10 (5.8) 7 (4.9) 3 (10.3).257 Cancer 9 (5.3) 7 (4.9) 2 (6.9).666 Dementia 21 (12.3) 19 (13.4) 2 (6.9).332 Alcohol Intoxication 2 (1.2) 2 (1.4) Note. Bolded values reflect statistical significance between admitted and not admitted groups at p <.05 System Quality Review Journal Page 87

102 Medication Reconciliation Process Improvement and Redesign Susan Denn, PA-C MPAS; Valantina Soni, PA-C MPAS; Patricia Roccisano, PA-C MPAS; Anna Kula, PA-C; Wehbeh Wehbeh, MD New York Hospital Queens Introduction Admitted patients usually have new medication started at the hospital or their medications could be changed. When a patient is transferred or discharged their medication list at discharge might omit medications, duplicate preexisting medications, or include wrong dosages. Medication reconciliation is the process of reviewing the patient's complete medications at admission, transfer and discharge to prevent such dangerous errors. Problem Medication reconciliation is paramount to patient safety and remains a challenge for health care practitioners. Electronic medical record (EMR) add to this challenge. We wanted to test if a prospective process redesign aimed at daily auditing patient charts, under the physician assistant (PA) service, would improve compliance with medication reconciliation and decrease medication errors. Goals This process redesign goal was to improve patient safety by appropriately reconcile their medication lists. Methods A pre intervention three month period from January2013 to march 2013 was followed by a post intervention period from July 2013 to September Charts were audited on a daily basis for medication reconciliation errors. Errors were corrected and results were documented. The errors included duplicate medications, failures to start new medications, failures to discontinue inactive medications, failure to add active medications, failures to switch medications to oral rote, failure to update the medication list, failures to include outpatient medications, failure to document the correct dosages or frequencies, and failure to list the medications in prescription writer. The intervention period started after March and is continuing. It included a redesign of the process of medication reconciliation whereby a senior PA conducted a daily review of a sample of patients on the PA service looking at medication reconciliation from the time of admission through discharge. When a medication reconciliation error was noted, the responsible physician assistant was contacted, corrected and individually educated. This individualized education included an explanation on the importance of medication reconciliation, its impact on patient safety and explanation of how to better do the reconciliation. Any questions that the physician assistant had regarding the process or EMR issues were addressed by the senior PA. The review was done before the patient left and allowed errors to be corrected. The physician assistants knew that their charts were being audited. Results A pre intervention evaluation of patient charts were done from January 2013 until March Seventy-seven charts were reviewed. Twenty-four medication reconciliations errors were found (24/77-31%). After three month of the process redesign, two hundred and thirty charts were audited from July 2013 until September Thirty four medication reconciliation errors were found (34/230-15%). System Quality Review Journal Page 88

103 Date # Charts # Errors % Errors 01/29/13-03/22/ % 07/22/13-09/20/ % Conclusions We aim was to increase the awareness about the importance of medication reconciliation on patient safety by identifying errors and educating our PA providers. We found that by providing individualized error recognition and education, the percentage of errors decreased significantly from 31% to 15%; a 50% decrease over a period of a few months. The physician assistants at first were somewhat reluctant in accepting the process redesign and felt uncomfortable to have their chart reviewed. After the process was initiated and they got accustomed to individual education in a non punitive manner they gladly participated and are genuinely grateful for the feedback and education especially with a complex and changing EMR. The number of needed interventions decreased over time, and the PAs knowledge improved. Daily auditing, feedback, and teaching can improve patient safety. This process can be expanded to other services in the hospital. We are continuing to audit patient charts daily for medication reconciliation and were able to add daily chart review for selected core measures at discharge as well since the number and time invested in daily interventions decreased. We would like to see even better compliance moving forward. System Quality Review Journal Page 89

104 Poster Presentation A Novel Approach to Foster A Culture of Safety in Radiation Oncology Dattatreyudu Nori, MD FACR FACRO; Akkamma Ravi, MD; Baoqing Li, MD PhD; Adrian Osian, MS; Annu Kapoor, RNC MS; Jennifer Modena, BS RTT; Samuel Maiorano, MPA RTT; Catherine Lagos, BS RTT; Migdalia Sotillo, RN; Seshadri Sampath, PhD; Natalie Masino; JoAnn Pizzicarola Cruz; Maureen Buglino, RN MPH; Stephen Rimar, MD New York Hospital Queens Introduction Technological advances in Radiation Oncology have considerably increased the complexity of treatment planning and delivery, necessitating new measures to ensure quality and safety. There is a growing interest in the evolving nature of safety challenges in Radiation Oncology. However, safety concerns are not limited to dose calculations and data transfer associated with advanced techniques. They also stem from fundamental changes in work flow, loss of traditional tools and under appreciation of physical limitations of new technologies. Safety initiatives need to acknowledge the multiple factors affecting risks. One of the most significant factors being the Human Factor. We can incorporate principles into our workplace that minimize those risks such as customization, standardization, check lists, redundancy, but most important consideration should be given to the Human Factor. We need to develop a culture of safety in which all team members are alerted to the possibility of harm and they all work together to maximize safety. We have incorporated Best Practices for Safety from various clinical departments, industry and aviation and developed a comprehensive plan to ensure safety in our department. Problem Medical errors are an important cause of patient morbidity and mortality in the United States. The New York Times published a series of reports of severe morbidity and mortality caused by errors committed during the delivery of radiation therapy in the United States. They raised considerable concerns regarding the safety of patients treated with advanced RT technologies like intensity modulated RT (IMRT), image guided RT (IGRT), and stereotactic radiosurgery (SRS) that are specifically designed to improve, not worsen, patient outcomes. The specialty of radiation oncology has a long track record of safe delivery of radiation to cancer patients. Most quality assurance (QA) procedures in use currently are directed to ensure good functioning of treatment machines and treatment planning software. Although these are important, there is also an urgent need for greater emphasis on the quality of performance of personnel and procedures because most errors are the result of human performance failures rather than equipment failures. The Institute of Medicine has recommended the adoption of a comprehensive approach to improve patient safety because there is no single solution that would solve the problem of medical errors. They highlight the importance of analyzing errors and improving processes that would lead to the design of systems that will improve safety for all patients. Radiation treatment is a complex process involving many medical personnel and relies heavily on complex data transfer and handoffs between staff and systems that are all at risk for errors. This report describes a comprehensive program for all personnel involved in patient treatment with radiation to ensure the patient safety are of critical importance in radiation oncology. The vast majority of radiation treatments are safe and effective. However, System Quality Review Journal Page 90

105 treatment errors do occur and can have significant consequences. Goals 1) Develop and implement a comprehensive plan to foster a culture of safety in Radiation Oncology. 2) To measure the impact of the program in reducing radiation errors. Quality assurance and safety in radiation therapy is defined by the World Health Organization (WHO) as, all procedures that ensure consistency of the medical prescription, and safe fulfillment of that prescription, as regards to the dose to the target volume, together with minimal does to normal tissue, minimal exposure of personnel and adequate patient monitoring aimed at determining the end result of treatment. A quality assurance and safety program must therefore address all aspects of the timely delivery of radiation treatment, including programmatic organization, the qualifications of the personnel involved in radiation treatment, the performance of the planning and treatment equipment, policies and procedures and incident monitoring and reporting. The majority of safety incidents in radiation oncology around the country are related to human error or human software interface errors pointing to a need for design improvements using human factor engineering approaches to enhance safety culture for radiation oncology team. Methods The radiation oncology department at New York Hospital Queens consists of 5 full time physicians, 5 radiation physicists, 1 dosimetrist, 12 radiation technologists, 4 nurses, 6 secretaries, 1 Administrative Director, and supportive staff. The department has 3 linear accelerators, and a high-dose and low-dose brachytherapy program. The radiation treatment capabilities include IMRT, IGRT, SRS, stereotactic body RT (SBRT), and total body irradiation and we deliver 16,000 patient treatments annually. Results Table 10 and 11 demonstrate a significant increase in our time out compliance and a reduction in error incidence from 5 incidents from 2003 to 2008 to 0 incidents from 2009 to 2013 as a result of our comprehensive safety program. Conclusions In 2010, radiation therapy safety was the focus of Congressional hearings, a public meeting sponsored by the Food and Drug Administration, a Call to Action meeting (filled to capacity) jointly sponsored by the American Society for Radiation Oncology (ASTRO) and the American Association of Physicists in Medicine (AAPM), and ASTRO announced plans to Address safety concerns (Appendix). Some of the recommendations include to incorporate basic human factors that minimize risks into the design of our workspace. These basic principles will include things such as automation, standardization, checklists, workflow improvement, and redundancy for high-risk procedures. We need to develop a culture of safety in which all of the team members are working together to maximize safety, and in which safety initiatives acknowledge the hierarchy of effectiveness. New York State has maintained a central registry of reportable radiation events between 2001and Their database contains 230 events derived from an unknown number of patients and treatments. Using estimates based on System Quality Review Journal Page 91

106 radiation use and cancer incidence rates in the state of New York, one can estimate that the rate of reportable events is 230 of 373,000. Of these, 37 of 230 required medical intervention for a serious event rate of = 1.0 of 10,000 treated patients, according to the New York State Department of Health estimates (J. Krishnamoorthy, Personal communication, August 6, 2010). Therapist error was implicated in 84% of the events. Some reports provide data regarding the types and causes of errors. The State of New York s data implicates therapist error in 84% of events, failure to follow policies and procedures in 63%, and physics/dosimetry in 27% (some attributed to multiple causes ). How did we get to this point? In the past, RT planning and delivery were less complex, and the pace of technology change was relatively modest. The time and work demands on personnel were fewer, and clinical procedures, with QA approaches, evolved with the technology. More recently, the pace of technology change has hastened, and our existing clinical procedures and QA approaches might be strained. Advanced treatment techniques often require vastly more information to be gathered, considered, analyzed, checked, and transferred, thus increasing the risks for error. In addition, the move from 2-dimensional (2D) to 3-dimensional (3D), and more recently to IMRT and image-guided radiation therapy (IGRT), and so forth, introduced several challenges, including the following: Newer technologies require increased efforts for many members of the radiation oncology team (eg, for image segmentation, iterative dose calculations, patient-specific QA, image acquisition and review, treatment delivery, machine and multi-leaf collimator maintenance and repair). Individual s tasks are more interdependent, with more hand-offs, thus increasing opportunities for delay and suboptimal information transfer (eg, dosimetrist image segmentation --> medical doctor image segmentation and specification of dose and volume constraints --> dosimetrist planning --> medical doctor review --> dosimetrist replan --> iterate --> and so forth.). The time pressures on all involved are increased. The need for unambiguous communication and for easy-to-use-tools is increased. Care providers, including referring physicians, patients, and administrators have been accustomed to our historic ability to proceed with consultation, simulation, and treatment initiation in rapid succession. With advanced technologies, this is less practical and might be dangerous. Rushing is a contributing factor in errors. The transition to 3D, particularly IMRT, lengthens the planning process. Administrators and providers need to be educated on the increased complexity of modern techniques and possible hazards of work-arounds. Multi-leaf collimator-based IMRT increases the monitor units per delivered dose. Catastrophic failures of the system (eg, multi-leaf collimators mis-positioned), although extremely rare, can have dramatic clinical consequences because the ratio between unintended and intended doses may be high. This was a factor, in one of the The New York times reports. By comparison, failure to place a physical wedge typically has lesser, rarely catastrophic, dosimetric effects. Intensity-modulated radiation therapy markedly increases the number of parameters that need to be correctly generated and transferred, thus increasing opportunities for error. Three-dimensional and IMRT both rely on image segmentation. Institutions evolving from 2D to 3D to IMRT were able to refine their image-segmentation skills. Segmentation errors with3d are often detected on digitally reconstructed radiographs or simulator and portal films. Conversely, institutions rapidly moving from 2D to IMRT may have had less opportunity to refine image segmentations skills. Segmentation errors may be challenging to detect as they are not System Quality Review Journal Page 92

107 reflected in DVHs. Traditional RT is delivered during a span of many days and weeks. Thus, the dosimetric and clinical effects of a treatment deviation on a given day are diluted by the many other days of correct treatment delivery. Furthermore, a deviation on one day can often be compensated for on subsequent days. The move toward shorter and faster fractionation schedules reduces this ability to correct and compensate. As technologies address these uncertainties (eg, gating and IGRT shrink internal target volume and PTV margins, respectively), there is a widely embraced, perceived ability to shrink overall margins. However, tumor control may suffer with tighter margins. Electronic Medical records (EMR) greatly enhance care through things such as improved accessibility and legibility. However, the transition from a paper chart to EMR can be disruptive. Even when fully functional, it takes time to recreate workflows within EMRs. Some functions are diminished, multiple notes cannot be easily viewed concurrently or in rapid sequence, and thus the clinical context can often be difficult to appreciate. Change can be a major source of risk. The confluence of events previously noted have strained existing workflow and QA systems, and have likely led to some negative clinical events. The vast majority of patients treated with traditional and advanced technologies are treated safely as intended. Much of the effort to enhance safety focuses on the tangible (eg, hardware and software). These efforts are certainly necessary. However, we often fail to acknowledge that the user/operator has variable abilities and training, and performs under various operating conditions, equipment configurations, and work scenarios. Several broad concepts that can be applied to enhance safety are reviewed in this abstract. Staffing levels need to be adjusted to reflect the workload, particularly in physics and dosimetry where the demands have markedly increased (eg, patient-specific QA for IMRT). Systems that facilitate clear, unambiguous, and efficient communication between physicians and dosimetrists/physicists are critical, given the large number of hand-offs and interdependent tasks. Whenever possible, it is best to hardwire the system for success using simplification, standardization, automation, and forced functions to create workflows and systems that support human work. The rigor and standardization introduced into our practice, combined with the increase in communication and teamwork, have improved both safety and efficiency. Staff members have developed an extraordinary sense of teamwork combined with a high degree of personal responsibility to assure patient safety. They routinely speak up when they consider something potentially unsafe. System Quality Review Journal Page 93

108 Table 1 Fostering Culture of Safety Process Steps Patient Safety Committee Chair Department Chairman Members Include Representatives from all Sections of the Department Review and Presentations of Available Reports on safety by all team members Review of Existing Regulatory Framework and Policies to detect and prevent errors) Develop Comprehensive Safety Program Customized to Our Work Place Performance Evaluation Programs Implemented By Us A) Improved Communication With Signage: B) Check List & Methodology & Safety Checks 1) Patient Identification Barcoding 1) Extended Check List 2) Extended Time Out 2) Extended Chart Rounds 3) No Fly Policy 3)Additional Physics Check 4) Clear Delineation of Responsibilities 4) Morning & Evening Safety Huddles of 1 st Tech & 2 nd Tech on Machine 5) Daily Safety Reports to the Chairman 5) Stop Sign in each treatment room from all Section Heads 6)Empowering patients. 6) Weekly Report from Safety Champion 7) Monthly Safety Committee Meeting C) Education and Training 1) Safety Lab 2) Teaching & Self Assessment Module 3) Safety Newsletters 4) Quarterly Safety Grand Rounds from Invited Speakers System Quality Review Journal Page 94

109 Table 2 Culture Shift From (Individual) Single focus (clinical skills) Teamwork loose concept Individual performance Unbalanced workload Having information Self-advocacy Self-improvement Individual efficiency Under-informed, individual decisions To (Team) Dual focus (clinical & team skills) Teamwork clear understanding Mutual support team goals Managed workload Sharing information Patient advocacy Team improvement Team efficiency Informed and collaborative team decisions System Quality Review Journal Page 95

110 Table 3 ERRORS IN RADIATION ONCOLOGY Organization Major Responsible Factor 1) WHO Human Factor 2) IAEA Human Factor 3) NRC Human Factor 4) ACR Human Factor 5) ASTRO Human Factor 6) N.Y. State Human Factor System Quality Review Journal Page 96

111 Table 4 Point of Care Stopping Rule Process Consultation Simulation Treatment Start A consult is rescheduled if records are not obtained 24 hours in advance A 'Sim_Chart_Check' is performed the day prior to the simulation and if the prescription, pathology review and/or consent are incomplete,the simulation is rescheduled. The MD has 2 days to contour. If there is a delay in contouring, then the start is rescheduled by the same number of delayed days of the contouring. The MD needs to approve the plan as per QCL due date. If there is a delay then the start is rescheduled by the same number of days it takes for the MD to approve the plan. If for any reason during the planning phase there is a change in the prescription, planning rules or contours, the patient's start is moved up by 4 business days. if The second plan check identifies a problem with the plan, the patient's start is moved up by 4 business days. The MD is informed and can veto the cancellation for exceptional circumstances An is sent to the MD and the on call MD, either of whom may complete the tasks by 3PM that same day. If not, the patient appointment is cancelled. No recourse No recourse No recourse No recourse System Quality Review Journal Page 97

112 Post-Planning Checklist/Timeout Table 5 Extended Check List (New) Y N EMR PRESCRIPTION, Target Volumes, Pathology, Imaging Correct Patient in all systems? Is the Diagnosis in EMR correct? Is the Treatment Site correct? Simulation Note Approved? Treatment Note Approved? Staff Present (initials) First Treatment Checklist / Timeout Correct Patient on Treatment Table Treatment Consent present and complete Digitally Reconstructed Radiographs (DRRs) match Portal Images Y N Staff Present (Initials) Daily Radiation Treatment Checklist / Timeout Identify Patient Name \ Date of birth \ Photo Treatment Side \ Site Treatment Devices Isocenter with Read back Y N System Quality Review Journal Page 98

113 Table 6 HUDDLE Template A.M. AM HUDDLE PM HUDDLE 1. Manager s Opening Statement & Announcements 1. Debriefing Read File 2. Red Flags II. Debrief of yesterday. 1. What went well? 2. What are opportunities for improvement? III. Out of office: 1. Doctors out of office for any reason today? 2. Management out of office today? IV. Equipment problems 1. Any equipment problems? 2. Who is assigned responsibility of getting them fixed? V. Review of IN Patients & SPECIALS. 1. Who do we have & what is their status? VI. VII. VIII. IX. Review of Status Change Patient (i.e. IN PT to OUT PT) 1. Was a patient discharged or admitted? 2. Is front desk notified of status change? Review of Break Patients 1. Who is on break? Why? & How long? 2. Is it documented on schedule and on break log? Review of Setup Patients 1. Sim Tech: from rounds, what is needed? 2. Therapists: Any questions? Review of any known emergency add on patients. 1. Who are they and have they been placed on the schedule? 2. Who are the emergency coordinators to fill out Emergent CRM tool? Reinforce Safety Culture Statement Every Time Read this aloud: Safety Statement: If anyone has concerns or sees anything they think is unsafe or not in the best interests of the patient, please speak up! See it, say it, fix it! System Quality Review Journal Page 99

114 Table 7 Enhanced Operational Clarity and Responsibilities Therapist 1 Therapist 2 1. Read & Say: Prescription & Planning Parameters. Call out treatment Confirm & Say: Prescription is to treat (anatomy) to (Dose cgy). Confirm treatment If NO: STOP Get Physics or Chief Therapist 2. Open: Setup photos: Review with 2 nd therapist Confirm & Say GO or STOP 3. Open: Setup note: Say Aloud (Immobilization) and (SSD) and (single or double tattoos) Confirm aloud & Say Start at ( SSD) on (single or double tattoos). 4. Review: Port films (Need today or check past) Confirm aloud (Does or Does not) with 1 st therapist Say Aloud if need or not 5. Say Aloud Diodes needed? Confirm aloud (Does or Does not) with 1 st Therapist 6. Ask for: Wrist band, name & B Day (check) Say: Name & MR# is. Match to Aria EMR. GO or No match or STOP 7. Look at Face photo & patient. (confirm with 2 nd Confirm aloud: GO or STOP Therapist) 8. Ask for: Scan card & scan it Confirm aloud: GO or STOP (confirm with 2 nd therapist) 9. Read 4D screen and Say Aloud Confirm aloud: GO or STOP Fields are. 10. Ask: How are you feeling? On New Make note to Report to nurses if anything medications? 11. Complete: Pause for the cause then go into room Take patient in room, setup patient, & begin treatment. System Quality Review Journal Page 100

115 Table 8 Pre-Treatment Time Out Radiation Therapist Confirms the Following Information in the Treatment Room and at the Treatment Console Just Prior to Treatment Delivery: Photo Identification of Patient Name of Patient Date of Birth of Patient Treatment Site on Patient *Treatment Site in Mosaiq *Set-Up Verification- Immobilization devices, Treatment parameters, wedges, bolus, shifts, bite block, eye shield, etc. *Limit distractions at treatment console *New Daily Safety Measures Pre-Treatment Time-Out in Treatment Room and at Console Cone Beam Cat Scan (CBCT) BAT Ultrasound Gantry Clearance *Observation of MLC movement during IMRT delivery *Implement Bar Code Identification *Minimum of Two (2) Therapists per Patient Set-Up *Increase Appointment Time to Twenty (20) Minutes *New System Quality Review Journal Page 101

116 Table 9 Weekly Safety Measures Port Films Radiographic confirmation of treatment site. *Chart Checks Performed by Physics, Therapist, & Nurses *Chart Rounds-Peer Review *Increase participation of staff in chart rounds *New System Quality Review Journal Page 102

117 Table 10 Percentage Year Time Out Compliance Table 11 Error Incidence Implemented New Comprehensive Safety Program Error Incidence * 3 Documentation errors detected through our Safety Program before initiating patient treatment * System Quality Review Journal Page 103

118 Table 12 Safety Circle *Safety Lab Extended Time Out Operational Clarity of Tech 1 & 2 Responsbilities on the Machine Barcoding Scanner for Patient Name, MR#, & Date of Birth Monthly Safety Newsletter Quarterly Safety Grand Rounds Patient Centered Care Enchanced Culture of Safety & Quality Signs to Empower Patients Regarding Time Out in Various Languages Mandatory AM & PM HUDDLES Monthly Safety Committee Meeting Weekly Report to the Chairman from Safety Champion Daily Safety Reports to the Chairman from all Sections *In Process of Implementation System Quality Review Journal Page 104

119 Poster Presentation Improving Transitional Care Processes Between Hospital and Post Acute Care Partners Reduces Readmissions Steven H Silber, DO ScM; Kathleen P Treacy, MS RN NEA-BC; Carol Farina, RN BSN CCM; Dan Nguyen, MD; Amy E Boutwell, MD MPP New York Methodist Hospital Introduction Inadequate care coordination leading to avoidable hospital acquired complications and unnecessary readmissions has been estimated be responsible for $25 to $45 billion in wasteful spending. Of that, nearly $12 billion has been attributed to potentially preventable admissions. One-fifth of fee-for-service Medicare beneficiaries discharged from the hospital are readmitted within 30 days and three-quarters of these readmissions are considered potentially preventable. Problem New York Methodist Hospital (NYM) is a 651-bed academic medical center located in Brooklyn, New York. In FY2010, NYM had nearly 8,000 Medicare FFS discharges. One thousand nine hundred fifty (1,950; 24.3%) of these patients were readmitted within 30 days. Upon review of the data we identified that 3,475 (44%) of Medicare FFS patients were discharged to a Skilled Nursing Facility (SNF) or home to receive Home Health Care (HHC) services. Previous studies have shown that patients discharged to SNF or requiring HHC were 1.7 and 1.4 times more likely, respectively, to be readmitted than those going home without services, regardless of their medical diagnoses. The NYM readmission rate for the combined SNF/HHC cohort was 31.5% (1,095/3,475). This cohort accounted for 56% (1,095/1,950 ) of all Medicare FFS hospital readmissions. Goals The goal of the project was to develop robust post acute care transitional partnerships to deliver cross continuum care coordination with a resultant decrease in the 30-day readmission rate by greater than 20% for the high-risk cohort describe in the previous section. Methods In 2012, the New York Methodist Community Partnership (NYMCP) was created. This is a unique 10-partner collaboration, consisting of New York Methodist Hospital (NYM), Heights and Hills, a major Community Based Organization (CBO), 5 SNFs, 2 HHC agencies, and a physician house-call organization that cares for the homebound elderly. We performed a root cause analysis (RCA) of reasons for readmissions, which identified the following eight opportunities for improvement: 1. Identify patients at high risk of readmission; 2. Identify Family Caregiver (FCG); 3. Use teach-back at teachable moments; 4. Improve accuracy of medication review; 5. Communicate with receivers ; 6. Ensure follow-up plans are in place; 7. Address social and support services; 8. Clarify care and support team and what to do when needs arise. System Quality Review Journal Page 105

120 To address the results of the RCA, we developed the following four strategies: 1. Specifying transitional care roles and responsibilities: 2. Continuous quality improvement of the transitional care processes; 3. Enhancing existing information technology (IT) systems to facilitate better care transitions; 4. Providing evidence-based transitional services in the post-discharge period. In order to operationalize the strategies, a number of initiatives were implemented. Improvement of intra-partnership communication was deemed mission-critical. All partners designated personnel, known as Transitional Care Assets (TCAs), whose sole responsibility is to focus on the longitudinal care needs of the patient, taking a uniquely global and cross-setting perspective. Essential communications were defined, including mandatory Warm Handoffs between healthcare professionals. Processes for bidirectional real time communications were developed between the Hospital/ED and the SNF/ HHC/ CBO regarding patient regarding goals of care of transfer, including a dedicated physician to ED attending physician hot-line. Discharge communications checklists were developed, which included items, such as medications, advance directives, goals of care, lines, tubes and drains. In addition, the hospital granted to the partners limited, HIPPA compliant, access to the patient s medical record. Other important initiatives were developing alternatives to emergency department transfer for a number of procedures, such as PICC line insertion, elective transfusions, and PEG tube insertion. Thirty-day readmissions are reviewed to determine if they were preventable and if so, to developed improved processes. The CBO critical interventions utilize the widely accepted Bridge model and their interventions are essential but not necessarily medical in nature. It includes linking the patients and family caregivers up with needed services, such as meals on wheels and transportation. In addition, NYM personnel provided in-service training to SNF staff about disease states and INTERACT program and tools. These programs not only were educational, but strengthened the partnership bond. Results The operational phase of the project began in January of Three hundred and thirty nine (339) patients have been enrolled in the program and fifty four (54) have been readmitted, for a readmission rate of 15.9%. The preimplementation readmission rate was 31.5%. The 49.5% reduction in the readmission rate achieved to date is more than double our goal of a 20% reduction. Conclusions Significant reductions in preventable readmissions are achievable. Our success was realized through a unique closely aligned 10-member acute and post acute care partnership working together in a seamless, coordinated manner in the delivery of care along the longitudinal care continuum. We recommend this model for other institutions to follow in order to provide improved, patient centric care in their journey to reduce preventable readmissions of our valued patients. System Quality Review Journal Page 106

121 Impact of a Proactive Intravenous to Oral Antibiotic Conversion Program at a Tertiary Teaching Hospital Gary Wu, PharmD BCPS; Teena Abraham, MS PharmD BCPS; Nasser Saad, BS PharmD; Eric Balmir, BS MS PharmD; Steven Silber, DO FACEP New York Methodist Hospital Introduction A proactive intravenous (iv) to oral (po) antibiotics program was implemented at New York Methodist Hospital on February Conversion was based on a hospital-approved criteria targeting iv antibiotics with po formulations that exhibit excellent oral bioavailabilty and/or clinical studies supporting efficacy and safety. Antibiotic conversion targets included linezolid, moxifloxacin, ciprofloxacin, fluconazole, voriconazole, doxycycline and metronidazole. The criteria established is supported by and approved by the hospital's medical board. Problem Although the benefits of early conversion are well documented, literature has demonstrated that institutions continue to under utilize the oral route for administration of antibiotics. The advantages of early conversion of patients from iv to po antibiotics can include decreased length of hospitalization, complications from iv lines such as hospital-acquired bloodstream infections, nursing time, and intravenous antibiotic costs. Goals The primary objective was to increase utilization of oral antibiotics when deemed appropriate based on hospital approved criteria. Secondary objectives were to reduce the risk of complications associated with administering medications intravenously, including hospital acquired blood stream infections and/or phlebitis and to minimize unnecessary costs when oral administration was considered equally appropriate. Methods A daily report identifying patients that were receiving targeted antibiotics was created by the pharmacy informatics department. This daily report was printed and reviewed by a clinical pharmacist to identify possible candidates for conversion from iv to po antibiotics. The review was performed via completion of a paper-based checklist with the hospital approved conversion criteria. Upon completion, if all criteria for conversion are fulfilled, the clinical pharmacist contacted the responsible medical resident, medical attending and/or case manager and informed them regarding conversion criteria fulfillment. When immediately available, a brief discussion would commence, and if there were no clinical indications for the patient to continue antibiotics intravenously, a consensus would be reached regarding the conversion. When not immediately available, an electronic paging system and/or electronic note on the patient's medical record was utilized to inform the responsible parties that the patient has met the hospital criteria for conversion to po antibiotics. Overall iv to po assessments and conversion rates were collected and documented. Results Twenty seven thousand and thirteen patients from January 2011 to December 2012 were assessed for eligibility to convert from iv to po antibiotics. Overall, 439 patients (16%) were converted while 2,274 patients (84%) did not meet System Quality Review Journal Page 107

122 criteria or met hospital criteria for conversion but did not convert. Prior to implementation of the proactive iv to po antibiotic program, intravenous antibiotic costs were $3,287,101 (January 2010-December 2010). Post implementation of the proactive iv to po program, iv antibiotic costs decreased to $2,889,924 (January December 2011) and $2,796,015 (January December 2012). Mean iv antibiotic cost per patient day also decreased from $16.93 per day (January December 2010) to $14.56 (January December 2011) and $13.82 per day (January December 2012). Conclusions A proactive iv to po antibiotic program utilizing hospital approved clinical criteria for conversion was successful and effective for optimizing antibiotics route of administration while minimizing unnecessary costs and complications associated with iv therapy. The positive impact of this initiative echoes the results of similar programs implemented at other institutions. System Quality Review Journal Page 108

123 The Use of Tranexamic Acid in Orthopedic Surgery: Retrospective Study Henry Tischler, MD; Nasser Saad, PharmD; Teena Abraham, PharmD BCPS; Eric Balmir, PharmD; Orrin Robert, RPA; Steve Silber, DO; Eileen Tang, PharmD; Joseph Samide, PharmD New York Methodist Hospital Introduction Hyperfibrinolysis, or excessive clot dissolution, due to excessive blood loss is associated with a wide variety of conditions. The fibrinolytic system is activated by the deposition of fibrin and is an essential part of the coagulation cascade. Tranexamic acid is an FDA approved synthetic lysine amino acid derivative that reversibly binds to plasminogen and prevents its interaction with fibrin. This prevents the dissolution of the fibrin clot and enhances coagulation. Tranexamic acid has been studied in postoperative bleeding and has been found to reduce total blood loss and transfusion requirements in patients undergoing total knee and total hip replacements. All of the tranexamic acid trials evaluated the incidence of DVT and pulmonary embolism (PE). Most of the trials used low molecular weight heparin for DVT prophylaxis. Tranexamic acid was not associated with an increased incidence of thromboembolic events in any trial and appears to be safe, regardless of its use in total knee or total hip replacement. Problem Total hip and knee replacement surgery, collectively known as total joint replacement (TJR), are two of the most common major surgical procedures performed at New York Methodist Hospital. Postoperative bleeding and subsequent associated morbidities associated with blood loss and blood replacement are well-known complications of this type of surgery and decreasing this outcome without increasing the complication of DVT would be of benefit to patient safety as well as to hospital costs. Goals The goal of this project is to determine if the administration of tranexamic acid, given preoperatively, significantly reduces the need for transfusion in patients receiving total knee or total hip replacement. Secondarily, we want to establish that there will be no increase in the number of post-operative VTEs in the patients receiving tranexamic acid. Methods A total of 169 patients undergoing TJR were included in a retrospective analysis. Eighty four (84) patients received tranexamic acid (Active Arm) during the perioperative period. This was compared to a historical cohort of eight-five (85) that did not receive antifibrinolytic therapy. The primary outcomes were the decline in post-operative hemoglobin, transfusion requirements, and incidence of venous thromboembolism (VTE). Safety outcomes assessed were hypotension, nausea, vomiting, and visual changes. Results Our results showed there was a less of a decline in postoperative day one hemoglobin from baseline in patients receiving tranexamic acid (-2.3 g/dl) compared with the control (-2.9 g/dl; p<0.001). There was also less of a decline in postoperative day two hemoglobin in the active arm (-2.6 g/dl vs.-3.3 g/dl; p<0.001). The postoperative day 3 hemoglobin remained to be less in the tranexamic treatment arm compared to the control (-3 g/dl vs g/dl; System Quality Review Journal Page 109

124 p<0.001). NewYork-Presbyterian Healthcare System Quality Symposium 2013 Four (4.8%) were transfused in the Active Arm, compared to ten (12%) in the control arm. There was a 60% overall reduction in transfusions. This benefit was more apparent in knee replacement surgeries (1% Active Arm vs. 7% Control). However, the percentage of transfusions was similar in both treatment arms at 5%. The incidence of VTE was similar between the two groups, with two events in the control arm and three in the active arm. There was no increase in adverse events in the tranexamic acid arm. Conclusions Following orthopedic surgery, patients are at a high risk of bleeding due to hyperfibrinolysis. Our results indicate that the administration of tranexamic acid reduces perioperative blood loss and decreases the need for transfusion. The reduction in perioperative bleeding does not appear to come at an increase in thromboembolic events and the effectiveness of tranexamic acid is apparent in patients receiving the appropriate VTE prophylaxis. Hospital-wide policy was implemented for usage of Tranexamic acid all orthopedic surgeries. System Quality Review Journal Page 110

125 Multidisciplinary Rounds: The Answer to Fostering Teamwork and Education While Reducing Length of Stay Parmeet Saini, MD; Anthony Saleh, MD New York Methodist Hospital Introduction As health care providers, our work never ends. We spend hours obsessing over details entailing patient care and fulfillment of various health care policies. Even our education is ongoing, a continuous cycle of training ourselves and teaching others. In this field, it is of upmost importance to stay efficient, motivated, and well informed not only in reference to ourselves but also about our patients. A multidisciplinary approach does just that. Providing superior health care relies on consistent and prompt communication among the multiple providers involved in the care of the patient. Electronic systems have definitely made our lives easier but true teamwork tackles any task. By implementing multidisciplinary rounds, we've made multiple objective and subjective improvements. Problem New York Methodist Hospital, as most hospitals, has certain areas dedicated to levels of patient care provided. These specific "units" vary in regards to clinical specialty, nursing intensity, resident education, and services. Patient's are triaged and assigned to these locations based on their clinical presentation. In NYMH, we have a 30-bed pulmonary step down unit that acts as a chronic ventilator unit as well as an intermediate level of care between the regular medical floor and intensive care unit. Given the clinical condition of the majority of the patients on this floor, this unit had one of the highest lengths of stay, number of procedures performed, and social issues making disposition very difficult. In light of this stagnation of patients and their recurring/ chronic issues, resident house staff felt they were not learning new concepts or seeing a wide array of pathology. The attending staff also noted the lack of resident enthusiasm and encouraged them to look at multiple facets in each patient's care rather than just the "textbook" pathology and its treatment. This lead us to make a change in approaching patient care and education on this unit. Goals Our goal was to provide real-time effective patient centered medical care in an improved and fulfilling work environment. We focused most on the values of team work and communication. The way to implement such a thought process was to start multidisciplinary rounds. We would retrospectively assess objective data in the form of monthly length of stay, rate of hospital acquired infections, and new decubitus ulcer prevention, as well as subjective data in the form of education and general happiness across all disciplines involved. To be successful, all participants needed to understand that we must work together toward a common goal of safe and efficient patient disposition. Methods Early in the implementation, the cornerstone of this project, the director of the pulmonary step down unit, held multiple meetings with the chiefs of various disciplines to address the new workflow starting June 1, Rounds would promptly begin at 9:00 AM starting at one end of the floor. The director, himself, would round everyday as the administrative attending without breaking continuity except weekends. The nurse involved in the patient's care, respiratory therapist, dietician, nutritionist, physical therapist, pharmacy students, case management, and ethics (addressing social issues and goals of care) wound round in one group along with the residents and the attending. Rounds would not start unless every disciple was present. They would last a maximum of 1 hour and 30 minutes. System Quality Review Journal Page 111

126 These rounds not only allowed everyone to physically see the patient at one given time, but also foster education. Education would be an important component of the multidisciplinary rounds where every team member would be given a chance to provide his or her expertise and provide up and coming evidence-based practice. The attending would provide clarity and depth of knowledge on the pathophysiology of the patient s diagnosis. At the end of each week, the team as a whole verbalized feedback to making the process more efficient and bring out systems based problems. At the end of each 2 week rotation, the resident house staff would provide their strengths and weakness of the rotation separately. Ultimately, at the end of each month, a tabulation of objective data regarding morbidity, mortality, and length of stay was performed for interval comparison. Results The results were very encouraging. There were direct objective results that were obtained as well as certain indirect advantages found retrospectively. Objectively, the number of mortalities had decreased, the number of patient's who were full code had also decreased indicating an early step in discussing goals of care in a certain population of patients. Decubitus prevention had increased along with a strengthened effort by physical therapist to enhance mobilization. A "lift team" was created that ensured even the sickest patient be attempted out of bed to chair. Of all the positive results, the decline in length of stay was most significant. The length of stay in April 2013 was 18.2 days and in May 2013 was 17.8 days. Upon initiating multidisciplinary rounds on June 1, 2013, the length of stay decreased to 12.9 days in June, 15.4 days in July, and 15.2 days in August. The results were also confounded by 2 patients discharged in July and 3 patients discharged in August that had lengths of stay greater than 100 days. Other objective data that will be assessed in the future is time to ventilator weaning and rate of ventilator associated events. Such a drastic change helped in patient turnover, resident education, and job fulfillment subjectively. In questioning the residents, they felt they had seen more pathology, respected their colleagues, and enjoyed the rotation more so than prior rotating residents. On approaching various disciplines, they did not need to explain the "whole story" on multiple occasions. Indirect advantages existed in forms of more consistent documentation and transition of care. There was little or no conflicting documentation, thus, avoiding legal implications at a later date. Transferring patients to a higher or lower level of care was also uniform from nurse to nurse sign out as well as resident to resident sign out. Conclusions In conclusion, our project goals, just like our work will be ever ongoing. However, we have made a large step in the right direction by instituting multidisciplinary rounds in an area of the hospital that seems needed it the most. Starting a structured approach and addressing issues concurrently as they arise has greatly impacted patient care. Nurses admit to increased teamwork, job enjoyment, improved nurse-physician interactions, and quality of care. Resident physicians have voiced better education, more time bed-side with their patients, and less frustration in getting difficult tasks accomplished. Patient disposition is much more streamlined with numbers, such as length of stay, reflective of our success. Using our success as a stepping stone, we can continue to further improve our system. Feedback from this process, along with our existing electronic health record, will help design clinical decision making tools further making our rounds more efficient in the future. By "freeing up" the resident from tedious work, we have allowed more time for didactic lectures during the day. At this time, the director provides an hour long multidisciplinary lecture once every 2 weeks in the morning to collectively enhance clinical awareness. A new culture of transparency among various disciplines has been established with multidisciplinary rounds and should be encouraged. System Quality Review Journal Page 112

127 Development of Triage Criteria Protocol for Critical Care Patients in the Emergency Department Joanna Zanko, MS CCRN; Liziamma George, MD FCCP; Bashar Fahoum, MD FACS; Terence Sacchi, MD; Joseph Bove, MD FACEP; Anthony Tortolani, MD; Steve Silber, DO SCM New York Methodist Hospital Introduction Emergency department (ED) crowding has become a major barrier to receiving timely emergency care. The additional responsibilities of caring for complex patients and prolonged boarding of admitted patients place an increasing strain on already overcrowded facilities and often overextended emergency staff. Providing optimal care of the critically ill patient can present a dilemma. Patients requiring critical care in the emergency department account for a small proportion of total new patient admissions, but place high demands on ED resources. In order to ensure critical care standards are being met, it requires direct evaluation of the critical care needs and expeditious admission to the appropriate critical care unit. Problem Wait times in the emergency department for critical care admissions continue to be lengthy despite quality improvement efforts to streamline the process of making beds available for these admissions. In 2009, a quality improvement project was undertaken by the Department of Critical Care, Medicine, Surgery, Emergency Medicine and Nursing to improve throughput. This quality improvement project led to a decrease in wait time from 21 hours to 8 hours. During subsequent analyses, we found that acutely ill patients did not receive the care that would be standard in a critical care setting. From January to April of 2013, critically-ill patients continued to wait in the ED on average 4.3 hours. In addition, we determined that certain patient populations did not require as high intensity of care as did other patients and had an average length of stay (LOS) in Intensive Care Unit (ICU) of less than 24 hours. We identified these patients as intermediate level care, which is not currently available at our facility. Goals The goal of our project was to provide the necessary care to the most acutely-ill patient in the most appropriate time frame in the most appropriate location. In order to do this it was necessary to determine which patients were the most acutely-ill and which patients were only admitted to ICU for 24 hours of observation. The charge was to move patients requiring immediate admission to critical care within 1 hour of admission order. Methods From January to April 2013, the Director of the Medical Intensive Care Unit and the Director of Nursing for Critical Care Services evaluated the patient population being admitted to the ICU that was considered intermediate care and the LOS associated with those patients. Approximately 15% of ICU admissions per month averaging 21 hours LOS in the ICU were considered intermediate care. A protocol for triage, based on the Society of Critical Care Medicine Guidelines, was developed to determine which patients were considered the most acutely-ill and what unit was the most appropriate location for this critical care patient. The triage criteria is as follows: patients that would require immediate admission (level 1) to critical care, defined as admitted within 1 hour, and the patients that would require intermediate care (level 2), who could board in the ED longer than 1 hour. System Quality Review Journal Page 113

128 In May of 2013 led by the Medical Director for Safety and Quality and the Directors of all the critical care units, an agreement was forged that in order to met the triage criteria of 1 hour, any critical care unit would accept a critical care patient independent of the service team caring for that patient. In June of 2013, this process was implemented to improve care to the most acutely ill patients. Results From January to May 2013 the average time from admission order to transfer of the critically-ill patients from the ED for all levels of ICU patients ranged from 6.2 hours in January to 2.3 hours in May. After implementation of the triage criteria, the average time from admission order to transfer for the most acutely-ill (level 1) patients averaged 1.4 hours and for the intermediate care (level 2) patient was 4.5 hours. Conclusions The Directors of all ICUs were able to come to an agreement to determine the best way to met the needs of the sickest patients in the emergency department. Those patients with critical care needs could be provided in any of the available critical care units. The key elements were collaboration between the critical care units, direct evaluation and triage of critical care patients. In conclusion implementation of consensus derived critical care triage category system significantly decreased the dwell time in the ED for patients determined to require immediate admission to an ICU. System Quality Review Journal Page 114

129 The Effect of a Rapid Evaluation Unit on Our Emergency Department Door-to-Disposition Times and Workload Barbara Gatton, MD; Lawrence Melniker, MD; Josef Schenker, MD; Nicholas Vaccari, MD; Joseph Moss, MD; Joseph Bove Jr, MA; Joseph Bove, MD New York Methodist Hospital Introduction The number Emergency Department (ED) visits in the US has increased 35% while the number of Emergency Departments has dropped by 27%. This has led to efforts to improve efficiency in ED operations. To this end, some Emergency Departments have implemented Rapid Evaluation Units (REUs). The REU is contrasted with fast track most notably in that the REU sees mid-acuity patients (triage level 3 on Emergency Severity Index) while fast track sees low-acuity patients (triage levels 4-5 on Emergency Severity Index). In February 2011, without changes to overall staffing, our Emergency Department added an REU on weekdays from 12-10pm. An EM attending and nurse were pulled from the main ED to work in the REU resulting in zero net staffing change. A fast track was already in place in our ED. Problem Since 2000, 19 hospitals in New York City have closed. Demands are increasing while resources remain limited. Our urban academic teaching hospital has an annual census of 95,000 patient visits per year. We continue to work on ways to safely and efficiently care for these patients. Goals To introduce an REU model in an effort to improve the efficiency of the ED. Methods We collected patient data for two five-month periods: February to June 2010 and February to June This represents the first five months of the REU and the analogous period from the year prior. The data collected focused on efficiency parameters including times of arrival, triage, bed assignment, clinician encounter, disposition decision and departure from the ED (admit or discharge). We also gathered data on patient acuity, diagnoses, and dispositions. In order to assess clinical workload, we collected data regarding clinician orders and nursing documentation of completed tasks. Results Although the overall ED census increased by 12% between the two five-month periods, both door-to-discharge and door-to-admission times decreased from 2010 to 2011 when compared monthly. On average door-to-discharge times decreased by 31 minutes (3:42 vs. 3:11) and door-to-admission times decreased by 24 minutes (4:40 vs. 4:16). We also observed a 50% reduction in waiting room times and 21% reduction in clinical workload for staff in the main ED. When comparing REU vs. non-reu times in the five-month period in 2011, despite a 6% higher census during REU times we saw a 60% reduction in waiting room times and an 11% reduction in clinical workload. Conclusions In our high volume urban academic emergency department, the opening of the REU led to substantial benefits in the workflow of our ED, as measured by door-to-disposition time and staff workload, without requiring additional staff. System Quality Review Journal Page 115

130 Feb Mar Apr May Jun door to d/c :47 3:56 3:30 3:33 3: :27 3:20 3:00 2:55 3:14 0:20 0:36 0:30 0:38 0:31 0:31 door to adm :53 4:38 4:29 4:44 4: :33 4:18 4:10 4:18 4:02 0:20 0:20 0:19 0:26 0:35 0:24 Door-to-Discharge Times 4:00 Discharge Time (hr) 3: :00 Feb Mar Apr May Jun Fig. 1: Comparison of door-to-discharge times from February to June in 2010 vs Door-to-Admission Times 5:00 Admission Time (hr) 4: :00 Feb Mar Apr May Jun Fig. 2: Comparison of door-to-admission times from February to June in 2010 vs System Quality Review Journal Page 116

131 The Use of EHR Tools to Improve Physician Overall Efficiency and Satisfaction Eric Karu, MD; Parmeet Saini, MD; Parag Mehta, MD New York Methodist Hospital Introduction Many healthcare institutions have integrated Electronic Health Record (EHR) into their busy practice as a means to provide improved patient care while satisfying health policies. The transition to an EHR system is a painstaking process, which takes a great deal of patience and understanding. At New York Methodist Hospital, various Cerner EHR tools were used to successfully improve physician overall efficiency, satisfaction, and enhance adoption. Various standards were created to improve the productivity across all medical specialties using specific EHR tools, permitting physicians to work faster and smarter without compromising patient care. Problem The use of EHR can be a source of great frustration for users who are not familiar with the system and not using the it to their advantage. We needed to identify specific problem areas among the majority of users (physicians), and develop tools to rectify these problems. Goals We would use various tools provided by our EHR provider, Cerner, to generate reports to gain a clear understanding of problematic areas amongst physicians. We would retrospectively analyze these problem areas, and create ways of improving system usability. These tools could then be continued to be used to monitor progress within our institution. Methods There programs were used in this project. A program denoted "Physician Playbook" was run in the background which calculated the average number of clicks needed to complete a task across all physicians for a particular order. It also calculated, the average log in time for all physicians. In a way, this program suggests preferences (shortcuts) to the user based off their problem areas. It provides specialty specific content, such as menu page configurations, commonly selected orders, recommended workflows to improve productivity. Another program called "Lights on" tracks users to identify gaps in efficiency, compared to a set standard. After identification, we were able to focus on ways to correct these problem areas. The third tool, known as "Smart Auditor," allowed the information technology department to record on-screen activity of any user, which are archived for retrieval and playback. It remotely monitors mouse activity and visible output of keystrokes in secured video recordings to provide a record of activity for specific user types. Monthly Informatics Committee meetings were conducted where the results of these tools were discussed allowing us to understand problems and suggest ways to implement corrective strategies. Results The findings were positive and two-fold. First, helping the entire system in general. And two, it allowed identifying particular users who were having more trouble than others and focus training more so on them. This not only increased efficiency across the board but also enhanced adoption of EHR amongst the physicians having trouble with the system. Regarding log in time, in April 2012 the user login time was 5.40 seconds. In April 2013, it was reduced to 2.80 seconds. The number of system crashes in April 2012 was 605 and in April 2013 it was reduced to 360. In April 2012 the number of electronic notes, which were signed were 96,544 and in April 2013 the number of signed had increased System Quality Review Journal Page 117

132 to 104,379. The time taken per order was 85 seconds in April 2012 and had been reduced to 53.8 seconds in April These results were obtained by upgraded the server memory from 48 GB to 384 GB; in a way to speed up the system. A tool called "learning live" was developed that contained links to "Wiki" help pages and videos to assist in user training. Conclusions With the help of our EHR providers' tools, we were able to identify and re-mediate weak areas leading to an improvement of user efficiency and satisfaction. Enhanced adoption was noted by an increase in the number of signed electronic notes by 7,835 over the year. The time taken per order had decreased by 31.2 seconds, which demonstrates that users have become more proficient in using the EHR as well. Over the course of the year, the feedback obtained at monthly medical informatics meetings have been substantially positive. We encourage a system monitoring and efficiency committee be present at monthly intervals to keep work flow running smoothly. The tools to use in regards to this are up to the steering committee and medical informatics division of the institution. System Quality Review Journal Page 118

133 Optimizing Patient Tracking to Improve Patient Safety and Increase Efficiency Eric Karu, MD; Parmeet Saini, MD; Parag Mehta, MD New York Methodist Hospital Introduction Patient tracking systems play an integral role in maintaining patient safety and if properly implemented, such systems can help in streamlining patient flow in healthcare institutions. In New York Methodist Hospital, a Patient Flow Committee was created to develop workflow solutions to assist in optimizing a smooth transition and high quality of care from patient admission to discharge. Several different departments required re-engineering to coordinate their efforts to optimize patient flow. These departments included admitting, environmental services, nursing, pharmacy, food and nutrition, patient transport, and physicians. Multiple meetings to plan this new tracking system were conducted in conjunction with medical informatics prior to implementation. Problem Delays in discharging patients existed due to a delay in communication. Floor nurses and administrative staff were not aware of bed availability in a timely manner. Most departments still used paper documentation which was not readily accessible in all locations. This delay in bed availability lead to unnecessary extra costs, allowed for rocky transitions of care, and congested the admission process. Goals Our goal was to create a centralized forum of accountability at New York Methodist, though which patients' entire hospitalization from admission to discharge can be monitored and evaluated. This forum was called the Patient Flow Committee. After creation of this central committee, a tracking system based on our EHR provider would be implemented. Methods Prior to implementation, multiple phone calls used to be made by the admitting department in order to determine whether a bed was available newly admitted patients. Post-implementation, the admitting department receives electronic order requests via a work queue that is updated as soon as a task is completed. This allows the unit clerk to determine the status of pending requests in real time. Nurse Managers can also view other nursing units and determine bed availability and enhance the level of care directly within the unit. Beds are placed in a Held status, which signifies that the patient has been taken elsewhere for scans and/or procedures. Housekeeping managers carry mobile electronic devices, so that they can update the status on clean available beds in real-time. This eliminates the need to make haphazard phone calls to correspond whether the beds are available or not. Prioritizing beds will be communicated via the tracking shell. This Cerner EHR-based tracking shell, will provide the transport team with a work queue to manage the transport requests based on the completion of the nurse ISBAR. Patient assignment and task completion will then generate an electronic request for the admitting department to complete the bed transfer in real time. The unit clerks are able to place requests directly within the patient tracker and provide real time updates. Nurse Managers are now able to view other units to determine bed moves to enhance patient safety. Held beds and Hold status is communicated to all via a centralized communication format. The Cerner Tracking Shell also provides the pharmacy department with a list of recently transferred patients & patients that were System Quality Review Journal Page 119

134 taken off the floor for testing. The Tracking Shell also provides real time updates for the Food & Nutrition department to better organize food delivery. The radiology department can now place requests for transportation in the Cerner EHR as well. Results The tracking shell was successfully implemented. Subjective feedback from various departments is encouraging. Objective results regarding length of stay and patient turnover are pending. Conclusions Successful implementation of a patient tracking system is a big undertaking as it requires the cooperation of many different departments. The main purpose of this patient tracking system is to focus on patient safety and increase efficiency. Many of the staff members are very satisfied with the system as it has allowed them to improve patient care. System Quality Review Journal Page 120

135 Successful Project Implementation Following the New York State Mandate of HIV Testing Eric Karu, MD; Parmeet Saini, MD; Parag Mehta, MD New York Methodist Hospital Introduction New York State mandated a policy of offering HIV testing to all patients between the ages of years who are triaged through the Emergency Department, inpatient, and outpatient office visits. This is the experience of New York Methodist Hospital which is a community hospital in Brooklyn with 642 beds. Problem This undertaking required establishing an entirely new workflow and education of the entire staff. PCR HIV testing comes at a cost of $200, which may or may not be covered by certain insurance companies. Patients will also require a venipuncture to obtain the blood sample to be sent out for testing. This step can interrupt the workflow in many cases. The patients will require follow up for counseling with a social worker to discuss the test results (whether positive or negative) which is difficult for ED visits. In our case it took more than six months and minimum of 200 hours for designing the layout for the process. The exact cost is difficult to calculate but not difficult to envision. Goals Our goal was to understand the policy and finding a workflow for difficult levels and disciplines. These users needed to come to a consensus which would require multiple meetings on what task was needed from each person. Subsequently education and training ensured with ultimate implementation of the project. Retrospective analysis was then performed for monitoring. Methods The first stage was brainstorming sessions with the nurses, nurse managers, physicians, social workers, administration, and Information Technology team. It required approximately 20 meetings over 6 months. On average, there were 8 participants in these meetings lasting an hour each time. A plan was generated where as each discipline had a specific task to accomplish with appropriate communication to the next team member. The electronic health record tied all of these specialties together. A patient would be provided HIV testing literature in each health care encounter. After reviewing it, they would be offered HIV testing where the medical assistant would enter the answer within the EHR. Once placed, the physician would be informed if the answer was "yes" or "unsure." The physician would provide counseling after which the patient would be re-offered the test. If yes, the a blood sample would be collected and be instructed to return within 1 week. Within 1 week, the social worker would meet the patient in a central location and discuss results with them (whether negative or positive). If the result comes out to be positive, they would be referred directly to an infectious disease specialist for treatment. A total of 140 human hours was spent for initial phase. The analyst spent a total of 80 hours in building electronic process. There were, subsequently, 20 hours spent on training the staff. Training involved a superuser who was trained individually by a senior application analyst for a total of two hours. Patient education materials were developed, evaluated, printed, and distributed widely. It required 6 hours of social worker s time and evaluation by patient relations and legal department. Full electronic implementation was achieved by the end of August After implementation, it was constantly monitored and changes were made as per users requests or reporting of issues. System Quality Review Journal Page 121

136 Results There were many process meetings held over the course of 12 months prior to launching the HIV testing screening solution. Two meetings totaling 20 hours were spent for brainstorming and that included the legal department, administration, and social worker. Three meetings totaling 30 hours were held to discuss the workflow. Seven meetings totaling 80 hours were spent to develop the IT solution and the IT department & physicians were included in those meetings. Testing involved the super users and IT department, which totaled 2 meetings and 2 hours. Finally, 4 meetings totaling 8 hours were spent for implementation and involved the IT department and physicians. In retrospect, a successful process was initiated and able to be monitored. Conclusions Any system-wide change, no matter how small and straight forward, takes significant time at any institution as it requires a multidisciplinary approach. Each institution has to go through a rigorous, time consuming, and costly process. This was a good policy for community health but has a significant burden on the provider and institution. Most institutions have integrated electronic health record systems. If future unfunded mandates are introduced, pilot projects with implementation guidelines from leading EHR vendors prior to introduction will be very beneficial to all health care institution as these mandates will be easy to implement. System Quality Review Journal Page 122

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138 EHR Alerts: Are They Serving Their Intended Purpose? Eric Karu, MD; Parmeet Saini, MD; Parag Mehta, MD New York Methodist Hospital Introduction EHR alerts are clinical decision making tools used at New York Methodist Hospital to improve patient safety and quality. They can also potentially be the source of frustration due to interruptions in the workflow of documentation or placing orders. This can lead to many of these EHR alerts to be ignored ("alert fatigue"), which may question whether or not they are serving their purpose. There are regulatory, pharmacy, and notification alerts, which are specifically target toward residents, attending physicians, nursing, medical assistant, and unit clerks. A survey was distributed to the resident housestaff at New York Methodist Hospital to obtain feedback on the Cerner EHR alert system. Problem Excessive use of alerts can lead to "alert fatigue" and a decrease in efficiency. Goals Considering many complaints of using the EHR revolve around "pop ups" and "alerts," residents were given a survey to fill our regarding its usefulness. We would use this feedback to fine tune the EHR alerts so that they can be more effective. Methods An eight question survey was constructed and distributed to 39 of the internal medicine residents at New York Methodist to obtain feedback on their impressions of the EHR Alerts. Results When asked what types of EHR alerts the New York Methodist residents had come across, the majority of residents stated they usually came across alerts like foley catheter justification, rapid response team justification, and various medication alerts. Over 50% of the residents stated that that they ignore these alerts. Nearly 60% of the residents found they did not find the alerts to be helpful. Nearly 60% also found the EHR alerts to be an impediment to the efficiency of their workflow. Approximately 70% found the quantity of EHR alerts to be excessive. Conclusions Electronic medical records (EMRs) are potentially powerful systems-based interventions to facilitate diagnosis and treatment because they ensure the transfer of key new findings and other health related information to the practitioner. Electronic communication of abnormal findings such as laboratory test results, regulatory alerts such as foley catheter justification, and pharmacy alerts such as drug to drug interactions hold promise in improving patient safety and healthcare quality. 2,590 primary care providers were surveyed in the department of veterans affairs by researchers in a recently published study in JAMA. It was found that nearly one-third of physicians failed to follow up on electronic results about test results. 86.9% of the physicians found the quantity of EHR alerts to be excessive and 69.6% said that they received more alerts than they could effectively manage. Feedback from the residents at New York Methodist was also collected using a survey and their responses were similar to what was published in the JAMA article. Electronic health record alerts are designed to improve patient safety and quality but in order for them to be effective alerts, should be user specific. If they cannot be user specific, then EMR companies should innovate new ways of providing System Quality Review Journal Page 124

139 alerts by level of severity. An effective balance between enough and excessive is to be sought by every individual institution, this may require serial surveys and minor adjustments in the number of alerts. System Quality Review Journal Page 125

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143 Development and Implementation of New Physician Handoff Tool in the Department of Medicine Eric Karu, MD; Parmeet Saini, MD; Parag Mehta, MD New York Methodist Hospital Introduction At health institutions, a key component to maintaining patient safety is to properly carryout physician hand-offs. In the Department of Internal Medicine at New York Methodist Hospital, physician hand-offs have been taking place for many years and multiple attempts had been made to improve the system. Physician hand-offs were attempted to be carried out in a structured way and in writing with some success. There was initially no overt way to monitor the sign out either bedsides serial spot checks. We have created a new system of physician hand-offs using the Cerner electronic health record system with the help of feedback from the end user (medical resident physicians). Problem The old physician hand-off sheet was comprehensive but allowed for only a maximum of two patients per printed page. This sheet was difficult to edit and became problematic for the on-call physicians. They were an excessive bulky number of pages to carry. As a result, compliance in using the system was very low and the residents had gone back to using their previous individualized system (handwritten). Hand-offs on random computers using computer documentation programs created issues with HIPAA and lead to an overall de-standardization of communication. Goals Development and successful implementation of a user-friendly physician hand-off tool to improve user satisfaction and compliance. Methods The medical informatics fellow and designated resident team leaders constructed a survey, which was distributed to the interns of the Department of Internal Medicine. A tool in Cerner EHR was developed based on the needs of the users and implemented. In February 2013, a meeting was held for all the internal medicine residents where the system was demonstrated. Afterwards, the IT fellow and residents familiar with the hand-off system had trained the residents individually on its use and advantages. This hand-off had all the core requirements for safe patient transition of care approved as per JHACO regulations. The printed hand-off using the new Cerner based system contains much more concise and relevant information than the previous system. It also contained editable free text "comment" and "to do" sections. Results After running wilcoxon signed-rank tests, comparing responses to the questions that were asked both pre- and postimplementation, both tests were statistically significant, p<0.001, which indicates that the difference from pre- to postimplementation is very unlikely to be simply due to chance. Implementation was deemed successful, which was demonstrated by survey responses of 24 medicine floor residents. Only 8.7 % of the residents were using the old hand-off system whereas 83.34% of the residents are using the new Cerner based physician hand-off tool. The vast majority of residents were dissatisfied with the old hand-off system whereas the majority of residents were satisfied with the new Cerner based tool. The majority of residents were System Quality Review Journal Page 129

144 satisfied with the free text and comment sections. 83.3% of the residents stated that the new Cerner based hand-off tool saved them time as compared to what they were using previously. The new system also standardized the content of each sign-out making patient transition of care safer, uniform, and fitting for supervisory regulatory agencies. Conclusions An integral component in maintaining patient safety at the highest level is to properly carry out physician hand-offs. There are many different ways that hand-offs could be implemented in the electronic health record system and some ways are better than others. An efficient system, which saves the residents time is likely to lead to an increase in satisfaction and compliance in using the system by the residents. At New York Methodist, with the help of a survey and direct feedback from the residents, we have determined that the new system has proven to be beneficial to the old system. We have found the residents to be enthusiastic in using the new system and thus are more inclined to developing innovative ways to improving quality in the hospital. System Quality Review Journal Page 130

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150 Process Improvements Decompress Emergency Department in the Face of Increased Admissions and Decreased Capacity Steven H Silber, DO ScM; Joann Amitrano, RN; Carol Farina, RN BSN CCM; Eric Karu, MD; Parag Mehta, MD; Todd Simon, MD; Paul Weissblatt, MD; Aown Syed. New York Methodist Hospital Introduction Unnecessary delays in hospital discharge contribute to hospital congestion. Reasons for these delays are multifactorial, and include necessary testing and consultations being ordered late in the admission, unnecessary labs and consults being ordered, performance of elective procedures on hospitalized patients during a hospital admission for another reason, as well as post discharge disposition issues. These factors have a direct impact on Emergency Department congestion and overcrowding and contribute to staff and patient dissatisfaction as well as to increased healthcare costs. Problem New York Methodist Hospital is a 651-bed acute care teaching hospital located in Brooklyn, New York. The recent influx of patients admitted to the hospital through the emergency department secondary to hospital closures due to Hurricane Sandy (Coney Island Hospital) and the potential closures of Long Island College Hospital and Interfaith Hospital, as well as the increase in patient volume due to physicians with large established practices joining the medical staff from the aforementioned hospitals, has stressed the capacity of the institution. In addition, the closing a 40 bed unit for renovation, which accounts for 10% of the medical beds, in June 2013, put an increased strain on the institution to improve flow. Goals The goal of this project was to develop a robust process of expediting the admission care process as well as identifying each patient nearing discharge to address potential delays in real time to prevent excess ED boarding of admitted patients. Methods In May of 2013 the Hospital s Patient Flow Committee met to develop processes to improve flow throughout the hospital for patients admitted to the Medical/Surgical Units. The committee developed a program that consisted 4 of components: Having an admitting team stationed in the Emergency Department to immediately address the inpatient evaluation and care plan; Mandatory daily interdisciplinary utilization rounds; Development of an interdisciplinary electronic Anticipated Discharge Plan (ADP) report; and twice daily (8am and 4pm) leadership review of these reports. The admitting team stationed in the Emergency Department consists of a full complement of residents and an accountable supervising attending physician. The ED is managed as an inpatient unit and the team is responsible to immediately address the inpatient evaluation and care plan of each patient as well as give a full transition report as the patient gets assigned to an inpatient bed. Comprehensive interdisciplinary utilization rounds are conducted each morning with Physician Advisors, House staff, Nursing, Case Management, and Social Work. Each case is discussed and those considered potentially discharge ready are assessed for pending items and potential delays. System Quality Review Journal Page 136

151 An ADP Communications Order is located within the Electronic Medical Record of each patient. As the patient is nearing discharge, information is entered into the ADP tool by clinicians and care coordinators at the completion of the utilization rounds. Data entry includes patient demographics plus pending items that may lead to discharge delays, such as pending tests and consults, potential medical issues, and post discharge disposition concerns. A complete ADP report is generated twice a day but can be accessed in real time. The leadership, consisting of the Vice President of Medical Affairs, a Vice President for Nursing, Chief Residents, Directors of Social Work and Case Management, and Admitting, review all information on the report for each patient and then attempt to address the issues encountered in real time. This may include expediting necessary testing and consultation, contacting the PCP to ask to cancel unnecessary inpatient tests, consults, and procedures, and clarifying goals of post discharge care in order to make the most appropriate disposition. The project would be considered a success if there was no increase in patients Admitted Without Assigned Beds (AWAB) on the 7am daily Hospital Census Report in the three months post intervention as compared to the three months pre intervention. Results In March, April and May of 2013, the Pre-Intervention Period, there was a total of 6,648 Med/Surg Admissions to the hospital. The available bed days during that period were 35,420. During that time there we 157 AWAB patients, or, on average 1.7 patients per day. In June, July and August of 2013, the Post-Intervention Period, there was a total of 6,884 Med/Surg Admissions to the hospital. The available bed days during that period were 31,740. During that time there we 233 AWAB patients, or on average, 2.5 per day. There were 216 more admissions, 3,680 less available bed days, and 76 more AWB patients, or 0.8 per day, in the Post- Intervention Period compared to the Pre-Intervention Period. Conclusions This initiative is considered a major success. Despite 216 more admissions and a loss of 3,680 bed days, there was only a negligible increase in admitted patients residing in the Emergency Department without an assigned bed, less than one patient per day, as per the daily 7am census report. There is continued opportunity for improvement. In this initiative we only targeted the front end and the back end processes. We did not address improving efficiencies of care during the patient's stay. We are designing an initiative to address this and hope it meets with similar success. With hospitals being stretched to their capacity and with a projected increase in annual emergency department visits with resulting increases in admissions, a process such as the one that we ve implemented should be considered. In order to do this successfully there needs to be commitment from the staff as well as cooperation and collaboration of all stakeholders. Systems like these will hopefully become more commonplace in the future and will help to expedite the discharge process and reduce unnecessary congestion, increase patient and staff satisfaction, and reduce costs. System Quality Review Journal Page 137

152 Poster Presentation Integrating and Analyzing Patient-Level Electronic Health Records and Risk Adjusted Outcomes Data for Performance Improvement - Laparoscopic Cholecystectomy at New York Methodist Hospital: July December 2012 Donald A Risucci, PhD; John G Hunter, MD; James A Rucinski, MD; Rasha Jadalhack, MPA; Anthony J Tortolani, MD New York Methodist Hospital Introduction The increasing availability of sophisticated technologies for collecting and processing clinical data (i.e. electronic health records) coupled with validated tools for risk adjusted outcomes assessment are increasingly helpful to clinicians aiming to improve the quality and safety of their practices. The Accreditation Council on Graduate Medical Education (ACGME) has defined practice-based learning and improvement as a core competency that all physicians must acquire during residency training. More recently, the ACGME initiated the Clinical Learning Environment Review (CLER) process, which investigates, among other factors, the extent to which individual teaching institutions provide appropriate resources for residents to assess and improve patient care. At least one recent study has demonstrated that indicators of the quality of care provided at a teaching hospital correlate with indicators of the quality of care provided by graduates of that hospital's residency programs many years later when practicing as attending physicians (1). Observations such as these, combined with requirements put forth by the ACGME, point to the importance and potential long term benefits of examining patient outcomes in relation to pertinent characteristics of the residency training environment and enabling faculty and residents to engage in quality improvement efforts including assessment of risk adjusted outcomes. Problem In order to facilitate acquisition of competencies in the areas of practice-based learning and improvement and systems based practice - and ultimately, to improve outcomes - residents, like the clinical faculty that trains them, need access to clinical data and quality indicators of the care they provide to their own patients as well as resources to assist them in critically analyzing and improving their own performance. A key challenge for educators and quality improvement professionals is to develop a learning environment that includes educational programs, as well as monitoring and reporting systems that can address these needs. Residents in surgical specialties, in particular, are in a position to have a significant impact on the quality and safety of patient care by virtue of their direct, instrumental role in performance of surgical procedures and post-operative care. However, in practice, the role of a particular resident in a particular surgical procedure varies not only on the basis of experience and/or competence but also a myriad of other factors such as surgeon preference, team composition and scheduling issues. It is therefore important to examine whether there may be significant variations in risk adjusted outcomes that may be associated with variations in resident involvement and experiences in the care of surgical patients. Observations of significant variability in outcomes associated with variations in the composition and/or practice patterns of operative teams would point to the need to address these sources of variability in performance improvement efforts. System Quality Review Journal Page 138

153 Goals The overall goal of the current project is twofold: 1) to initiate a process for integrating patient-level clinical data from electronic health records (EHR) with patient-level risk-adjusted outcome data from New York Presbyterian Health System s (NYPHS) COQPIT quality data management system, and 2) to enable faculty and residents to access and analyze these data using statistical quality improvement methods. As a first step toward the overall goal, this initial study examines variability in risk adjusted patient outcomes that may be associated with differences in the composition of the teams of attending surgeons and residents operating on and caring for surgical patients. The focus of this initial study is on Laparoscopic Cholecystectomy (LC), which is the most commonly performed surgical procedure at NYMH. Methods Data Sources COQPIT is a quality data management system that was developed by the Quality and Patient Safety Department of NYPHS. It captures administrative data (i.e. demographics and ICD-9 diagnosis and procedure codes) pertaining to all patients hospitalized and discharged from all hospitals within the NYPHS. These data are statistically analyzed using proprietary statistical risk adjustment models from a commercial vendor that have been developed on the basis of data from hundreds of thousands of patients that have been discharged from several hundred hospitals throughout the United States. The data for each patient is entered into a regression equation that computes a patient-specific expected probability of death and an expected probability of experiencing one or more of a specific set of complications while in the hospital. In addition, an expected length-of-stay is computed for each patient. These data are compared to actual outcomes for each patient and can then be used to calculate risk-adjusted mortality and complication rates as well as a length of stay index for subgroups of patients that may be defined by an array of factors such as surgeon, time period, diagnosis-related group (DRG) or type of procedure. For purposes of the current study, COQPIT was queried for patient-level data pertaining to all Laparoscopic Cholecystectomies performed on inpatients at NYMH between July 2009 and December The following data were collected from COQPIT and retained in an electronic spreadsheet: medical record number, operating surgeon, discharge date, actual and expected length of stay, expected probability of death, expected probability of complications, discharge status (alive, dead) and whether or not the patient experienced a complication. Data from the NYMH OR logs were likewise queried to identify LCs performed during the same period and the following patient-level data were collected and retained in an electronic spreadsheet: medical record number, procedure date, residents involved in the operation and the resident team responsible for caring for each patient. Data from the two sources were merged, matching patients on the basis of medical record number, date of surgery, surgeon and discharge date. In addition, data were available from components of the hospital's EHR for a more focused study of cases performed between July - December This included analysis of clinical and demographic data (i.e. preoperative LOS, laboratory results, age, gender, race). These data were also merged with COQPIT data. Statistical Analysis Due to the very low complication and mortality rates among LC patients, the length-of-stay (LOS) Index was chosen as the primary outcome metric. For any defined subgroup of patients, the LOS Index is calculated by summing the actual number of days those patients stayed in the hospital and dividing that sum by the sum of the number of days those System Quality Review Journal Page 139

154 patients were expected to stay in the hospital. An LOS Index of 1.0 indicates that, on average, the actual LOS for the subgroup of patients was exactly what was expected based on the risk adjustment analysis. If the Index is less than 1, then actual LOS was lower than expected; if it is greater than 1, then actual LOS was greater than expected. The overall purpose of the data analyses was to examine variance in the LOS Index in relation to resident involvement in the surgery, the composition of surgeon/resident teams and specific practice patterns. First, the LOS Index was computed and compared between cases in which a resident was involved in the operation and those that did not have resident involvement. This was then repeated separately for cases performed by each of two surgical teams. Next, a subset of all cases was selected for analysis. Specifically, all LC cases that were performed between July 2009 through December 2012 by the 3 chief residents that graduated in June 2013 were examined. An LOS Index was computed and compared across cases performed by each of these 3 residents. The LOS Index was also examined at the surgeon-level in relation to the number of cases performed per surgeon. A Pearson correlation coefficient was computed to assess the statistical significance of the association between volume and LOS Index. Last, a more focused analysis was conducted of data on LC procedures performed between July - December The data available for this analysis included clinical parameters derived from the EHR (i.e. labs, demographics, preoperative LOS, surgery start time) as well as the aforementioned Coqpit and OR data. Analyses focused on exploring the associations between LOS and variations in practice patterns across teams (e.g. case start times, preoperative LOS). The LOS Index was computed for specific subgroups of patients. Student t-tests and the Pearson chi square statistic were used as appropriate to analyze group differences (e.g. between teams). Results OR log data were available for a total of 1255 LC patients/procedures. Of these, resident involvement in the operation was documented in 1207 (96%) cases. Approximately one half of these patients (n=617, 49%) had been admitted to the hospital and had surgery performed by one of 10 surgeons. Resident involvement in the operation was documented in 598 (97%) of these inpatient cases. Table 1 presents descriptive statistics concerning expected and actual LOS and the LOS Index for these inpatients. The overall LOS Index was The LOS Index for the 19 cases in which residents were not involved was 1.32; for the 598 cases with resident involvement it was Figure 1 displays the LOS Index for all cases performed during the study period by each of the chief residents that graduated from our program in June The LOS Index ranged from 1.35 for Resident C to 1.74 for Resident B. Figure 2 presents a scatterplot of the relationship between the number of inpatient LC cases per surgeon and the LOS Index of patients operated on by each surgeon. The number of cases performed per surgeon varied widely from The median number of cases per surgeon was 49. Eight of the 10 surgeons performed 30 or more cases during the study period. There was a direct, statistically significant correlation between the number of LC inpatient cases performed and the LOS Index for these 10 surgeons (r=0.69, p <0.01). All inpatient LC procedures were performed by one of two surgical teams, labeled Team A and Team C. Team A is comprised of surgeons who are not full time employees of the hospital and tend to operate on a smaller volume of patients at NYMH than do surgeons on Team C, which is comprised of relatively high volume general surgeons who System Quality Review Journal Page 140

155 are full time employees of NYMH. The overall resident:patient ratio for Team A tends to be significantly less than that of Team C. Figure 3 presents a comparison of the LOS Index for cases performed with and without resident involvement by both Teams A and C. The LOS Index was lower overall for Team A (n = 150) than for Team C cases (n=467). The LOS Index was highest for the 15 cases performed without resident involvement by surgeons on Team C. A more focused analysis was conducted of 114 LC cases performed between July - December In particular, data were explored to identify possible differences between patients treated by Team A and Team C with respect to preoperative LOS, demographic factors, OR start times and operative procedure durations. Of these 114 patients, 93 were inpatients for whom risk adjusted outcome data were available. The LOS Index for Team A was 0.83; for Team C it was There were no statistically significant differences between patients treated by Teams A and C with respect to age, gender or race. Overall, patients treated by Team A (n=17) had significantly shorter preoperative LOS than patients treated by Team C (n=97; Mean + SD: vs respectively, p=0.02). Among inpatients only, this difference was not statistically significant), however, on average, Team A patients were in the hospital preoperatively approximately 1 day less than those treated by Team C ( vs respectively). Procedures performed by Team A were of significantly longer duration than those performed by Team C ( vs minutes respectively, p=0.02) and procedures by Team A were significantly more likely than those of Team C to be performed between 7am and 12pm (64% vs. 28% respectively, p < 0.01). Conclusions In the current study, integration of data from several hospital and health system sources enabled identification and analysis of variations in risk adjusted surgical outcomes that appear to be associated with variations in the composition and practice patterns of different surgeon/resident operative teams. We chose to focus on a single commonly performed general surgical procedure, Laparoscopic Cholecystectomy, so that observations would be based on a relatively large sample size and the practice patterns and outcome metrics studied would be specific to the performance of a single procedure. Overall, the data suggest that there are specific differences in practice patterns across surgical teams that may account for significant variations in risk adjusted outcomes. Further investigation into the root causes of these differences may point to specific modifications that can be made to improve outcomes. The overall LOS Index of 1.29 indicates that on average, patients undergoing LC at NYMH during the study period stayed in the hospital approximately 1 day longer than expected according to the risk adjustment model employed by Coqpit. This observation points to a general need to decrease LOS for LC. General Surgery residents were involved in the vast majority of LC cases in the current study. The very small difference in the LOS Index between cases with and without resident involvement suggests that the involvement of residents in and of itself is not an important source of variability in patient outcomes. When we examined the cases performed by each of three graduating chief residents and the LOS Index it was clear that the proportion of cases each resident had performed with the various surgeons was different and this was reflected in the LOS Index (i.e. the LOS Index was higher among cases performed by one resident compared to the other two residents). Since it is important that residents are trained in an environment that provides consistent, high quality care, this observation suggests that quality improvement efforts need to focus not only on reducing overall LOS, but also insuring balance in resident operative experience with various surgeons whose differing practice patterns may differentially influence outcomes. System Quality Review Journal Page 141

156 When the LOS Index was examined at the surgeon level, we observed a large, statistically significant correlation between volume and LOS Index. We then analyzed the LOS Index separately for the two teams that perform all the LCs at NYMH. Large differences were observed between the team comprised of mostly high volume general surgeons employed full time by NYMH (Team C) and the team comprised of surgeons in private practice who tend to perform relatively fewer LC procedures at NYMH (Team A). The LOS Index was particularly high for the small number of cases performed by Team C without resident involvement. These observations suggested that there may be differences in practice patterns between these teams of surgeons, which may account for the differences in the LOS Index. More detailed analyses of data on LC patients between July - December 2012 enabled a closer examination of practice patterns that may differentiate the two surgical teams and may help to explain the differences in outcomes and perhaps point to underlying causes that may be addressed. Among these cases, we observed that the preoperative LOS was significantly longer for Team C than Team A patients and Team A patients were much more likely to have surgery in the morning between 7 a.m. and 12 p.m. than were Team C patients. Team A patients also had significantly longer procedure durations. These observations suggest that there may be opportunities to decrease excess LOS by exploring and implementing changes that can reduce preoperative LOS, later case start times and other practices that may reduce OR times but increase "minor" surgical complications that sometimes cause small increases in LOS in LC patients. This study illustrates that the ability to integrate and analyze data currently available in quality data management systems and electronic health records can lead to important insights into the role of teams and practice patterns in determining measurable risk adjusted outcomes. These capabilities are essential for improving quality and patient safety and also for creating an environment in which residents can achieve milestone competencies in practice based learning and improvement. Going forward, we plan to expand real-time access to an increasingly integrated and wider ranging database that will enable both faculty and residents to more closely monitor and improve outcomes. System Quality Review Journal Page 142

157 Table 1. Length of Stay for Inpatient Laparoscopic Cholecystectomies at NYMH: July 2009 December 2012 Cases performed by Residents (n=598) Cases not performed by Resident (n=19) All Cases (N=617) Actual LOS Mean (SD) Expected LOS Mean (SD) 4.44 (4.78) 3.47 (2.87) (4.34) 3.37 (2.31) (4.77) 3.46 (2.86) 1.29 LOS Index Figure 1. Length of Stay Index for Laparoscopic Cholecystectomies: All cases performed by 3 Recent Graduating Chief Residents LOS Index Resident A Resident B Resident C System Quality Review Journal Page 143

158 Figure 3. Length of Stay Index for Laparoscopic Cholecystectomies: Comparison of cases performed with and without residents by 2 different Surgical Teams LOS Index Team A Team C With Resident Without Resident System Quality Review Journal Page 144

159 Clinical Decision Making Tools Used to Reduce Cost and Improve Patient Care at a Teaching Hospital Parmeet Saini, MD; Eric Karu, MD; Parag Mehta, MD New York Methodist Hospital Introduction Order-sets are effective tools for guiding management and improving efficiency within an electronic medical system. At our 642-bed teaching hospital with 106 internal medicine residents, a specific general admission order-set is used by all residents during patient admission to a regular floor. The order set contained a thyroid stimulating hormone (TSH) order within the set of laboratory orders by default. Problem During admission, a resident would click on it within the set despite clinical relevance in part due to a lack of understanding for the test. This resulted in unnecessary direct costs of the test as well as indirect costs of repeating an abnormal test, endocrine consultation, and follow up. Goals Our direct or primary goal was to reduce avoidable costs by reducing clinically unwarranted TSH tests. Indirectly, this would also reduce the number of consults and repeat tests if the initial test was spuriously abnormal. Methods From January to May of 2012, the TSH order was present in this order-set. Understanding that routine inpatient TSH testing is not warranted, this was removed on June 18, 2012 in an effort to not only decrease cost (primary outcome), but also assess the percentage change of abnormal results (secondary outcome) if the resident felt the test was clinically warranted. The study included all patients admitted to general floor, under medical service, using this order-set only, on average within 24-hours. All residents were blinded. The number of total TSH orders and abnormal results were tabulated 5 months before and 9 months after the change, excluding June. Results From January to May, the average number of TSH orders had dropped from 455.4/month to 248 (July-March). Assessing only the cost of the test, approximated $8, an average decrease from $3,643.20/month to $1,984.00/month was observed. If just the cost of the test is considered, the cost per annum would decrease from $43, to $23, Compared to January-May, the mean number of abnormal TSH results had dropped from 108.4/month to 87.3/month (July-March). Compared to January-May, the percentage of abnormal results rose from 23.7%/month to 31.2% (July-March). These results were statistically significant when graphed on a scatter-plot with linear regression. Conclusions TSH is a sensitive test for evaluating thyroid function. Its derangements can occur in a multitude of illnesses. In an illness, there may be a high incidence of sick euthyroid syndrome (notably 23% of patients admitted to the hospital compared to 5% that have true thyroid disease) that corrects with the treatment of the underlying condition. The diagnostic dilemma is to differentiate true hypothyroidism from sick euthyroid syndrome. Critically ill or geriatric patients may be wrongly evaluated for hypothyroidism. On removal of the TSH order, a decrease in TSH orders but unchanged percentage of abnormal results indicates the test was likely ordered with a clinical thought process. Despite order-sets being helpful, they may also be detrimental in training hospitals. Its proper use must be enforced and System Quality Review Journal Page 145

160 individualized per hospital. Avoiding unnecessary tests leads to cost reduction, improved patient care by reduced length of stay, procedures, and needless treatment. In this case, a change was made to already provided decision making tools that improved patient care within our hospital. System Quality Review Journal Page 146

161 Average number of tests ordered per month Average cost per test Total cost of the test alone per month Estimated Cost of the test alone in 1 year 5 months before the change 9 months after the change dollars $ 3, $ 43, dollars $ 1, $ 23, Tabulation of DATA: System Quality Review Journal Page 147

162 Statistical Analysis of Data: Scatterplot with linear regression line for TSH testing by Month Pearson r = 0.84, p = System Quality Review Journal Page 148

163 Scatterplot with linear regression line for TSH testing by Month excluding units (ICU/CCU) Pearson r = 0.81, p = System Quality Review Journal Page 149

164 Scatterplot with linear regression line for Abnormal TSH tests by Month excluding units (ICU/CCU) Pearson r = 0.85, p = System Quality Review Journal Page 150

165 The Process of Becoming Near Paperless at a Community Hospital Eric Karu, MD; Parag Mehta, MD; Mena Foaud New York Methodist Hospital Introduction New York Methodist Hospital in Brooklyn have now nearly eliminated the use of paper charts and most paper documents. It was a long and arduous journey to make their transition towards a paperless EHR system, but their goal was nevertheless accomplished with the help and cooperation of the IT department, Physicians, Nurses, Housestaff, Administration, and their Cerner EHR provider. There are benefits and drawbacks towards becoming paperless, but the former greatly outweighs the latter in the long run. Problem The ongoing transition to an EHR can be described as being rather chaotic as the vast majority of practicing physicians had been using paper documentation for years. A clinician being naturally set in their way of practice makes their transition to a paperless environment a monumental challenge. Goals The main goal was for the eligible providers and the institution to make a near seamless transition from paper documentation to the EHR. Methods In 2002 New York Methodist Hospital had decided to adopt an electronic health record system and they had decided to go with Cerner Classic. With that system, physicians were able to check labs, vitals, and read reports. Then in 2004 they had switched from Classic to Cerner Millennium, which offered more features, such as computerized physician order entry (CPOE) and nursing documentation for all inpatients. With CPOE, physicians were able to actually place orders via the EHR rather than in the paper chart. In 2007 CPOE, Nursing documentation, and scheduling became available in the outpatient setting at NY Methodist. In 2009 physicians were able to do their documentation for their patients via the EHR in the outpatient setting. Finally, in 2011 inpatient documentation became available for each floor sequentially. The personnel in the Information Technology department at New York Methodist Hospital had to rely on physicians to gain an understanding of their workflow, but many physicians don't have the extra time to allocate to IT. It was therefore necessary to establish an IT fellowship position. An IT fellow would have had residency training and would also be well versed with most facets of IT, including the EHR. The IT fellow's main purpose is to conduct needs assessment, assist in streamlining the workflow for the users, and act as the liaison between the physicians and IT. All of this helps to smoothen the transition towards paperless documentation. The IT fellow would round with different medical teams obtaining feedback from attendings, residents, and housestaff on the EHR and deliver the feedback to the IT department. With the use of EHR tools, it is possible to monitor the users' progress with the EHR as well as identify areas and individuals in need of remediation. It was also possible to identify individuals that were still using paper charts. System Quality Review Journal Page 151

166 Results The results indicate progress and success. As of today, all physicians rely on the EHR to do their documentation. The average number of monthly powernotes have significantly increased over the last 3 years. 35,318 (Sept Sept. 2011) 79,818 (Sept Sept. 2012) 101,555 (Sept Sept. 2013) These results indicate that the goal has been reached in transitioning physicians from paper documentation to the EHR. Conclusions According to the latest data from the Healthcare Information and Management Systems Society (HIMSS) only 1.9% of all hospitals in the US have gone paperless. Nevertheless, with 329 certified EHR providers, more and more hospitals will make the switch to going paperless in the future. There are many reasons why going paperless will be in the best interest for physicians. One reason is that there will be reimbursement cuts to physicians not using EHR systems. Starting in 2015, physicians who don't use electronic health record will see their Medicare payments cut by 1 percent and that penalty that will increase to 3 percent by In the year 2009, President Obama signed the Health and Information Technology for Economic and Clinical Health Act to offer incentives for hospitals that go paperless. Another advantage is that paperless systems reduces the chances of medical errors, transcription errors, prevents deaths caused by mistakes, alerts physicians and nurses to allergies, drug interactions, rapid response etc. Another advantage is increased efficiency by optimizing the use of hospital resources throughout the medical care process. Going paperless also eliminates hard to read handwriting and allows the convenience of 24 hour access, which would not be possible with paper charts. With the EHR, physicians are also able to access charts remotely from home and they can also perform chart searches, using keywords. There are some disadvantages of going paperless as well. Seasoned physicians who have been in practice for many years tend to be reluctant to make the switch to a paperless system. Some are reluctant because they are not tech savvy and others want to stick to what they have been used to doing, so the transition isn t easy for many. There are psychological factors for why individuals use paper. Paper is familiar to all of us so we are very comfortable in using it and some people simply prefer the physical presence of document that they can hold. (Dykstra, 2009) The initial cost for a medical institution to go paperless ranges from $500,000-$1,500,00+ and then there are ongoing costs to maintain and upgrade the systems. As with anything that is computer based, there s a risk of system downtime, which can happen at any time. There s also an increased risk of HIPPA and security violations with a paperless system. In this day and age, the transition to a near paperless environment for any institution is a long and arduous journey. Many physicians are understandably obstinate in making that transition because they have been using paper for documentation for many years. They are also many seasoned physicians who may not be as tech savvy as recent med school graduates. Fortunately, with the assistance of the IT fellow, tech savvy residents, and the cooperation of the IT department, New York Methodist Hospital has thus far been successful in their efforts of eliminating the paper chart. System Quality Review Journal Page 152

167 The Big Picture From EHR Data Collection at a Community Hospital for Practice Based Learning Parag Mehta, MD FACP; David Conner, MD; Eric Karu, MD New York Methodist Hospital Introduction We created resident physician report cards to improve care of diabetes in our outpatient medical clinic. During the project, our methods of data collection have changed. Initially we used resident self-reporting on their patients. For many residents this was a tedious and cumbersome process. With the introduction of our electronic health records, we became able to collect data directly from laboratory reports and outpatient encounters. The residents were freed from chart review and could use the data for patient care. Also, we noted a significant discrepancy in reported outcomes. Problem Different methods of data collection lead to drastically different reported results. Goals Taking advantage of the natural evolution of data collection from manual self-reporting to automated collection from an electronic repository we are able to describe some of the differences in reported outcomes. Methods From academic year and residents recorded their diabetic patients data in to a paper binder. During the academic year the residents recorded their diabetic patients' data into a computerized database. During the year we used a query of our electronic records to identify diabetic patients in each resident s panel and asked the residents to complete data sheets based on this information however there was extremely poor response. From we developed a query in our electronic health record to return the most recent data for each patient lined to a continuity clinic resident. The residents identify themselves as continuity resident or covering resident when they open the patient s chart at the beginning of each visit. In 2012 a sampling error was noted: that data only from patients with "controlled diabetes ICD-9 code " was collected. The query was corrected so that data from patients with any ICD-9 code 250.xx diagnosis would be collected. Results See figures. Conclusions Sample size increased dramatically when electronic health records were used and correspondingly reported outcomes worsened. We assume that there is a bias in self-reporting data. For instance, a selection bias of only recording the best patients data would lead to the kinds of results demonstrated. We are somewhat biased in assuming that data from the automatically collected data from the electronic health records are closer to the truth. A careful comparison of selfreported data with data recorded in the patients charts and with other patients with diabetes mellitus in the clinic not reported on would further support our claims. However, in designing physician report cards for practice improvement in the future, it would seem that electronically collected data offers a superior sample size at more convenience and likely more reliable results when compared to self-reported data. System Quality Review Journal Page 153

168 Jul Dec 2012 % BP at goal (<130/80) % HbAIc at goal (<7 %) % cholesterol at goal ( LDL < 100 ) Sample Size ,678 Method of data collection Automated collection from hospital electronic health record (250.xx) Jul Dec 2011 Jul 2010 Mar 2011 July - Dec Automated collection from hospital electronic health record (250.00) July - Dec 2007 Jan - June 2007 July - Dec 2006 Jan - June 2006 July - Dec 2005 Jan - June 2005 July - Dec 2004 National Data for MCD* Self Report into computerized database Self Report into paper binder System Quality Review Journal Page 154

169 Process Improvement: Best Practices for Dysphagia Screening in Patients Post-Stroke Barbara Gatton, MD; Luis F Riquelme, PhD CCC-SLP BRS-S; Rebecca D Kaplan, MS CCC-SLP; Matt Dros; Lawrence Melniker, MD; Waleed Mina New York Methodist Hospital; New York Medical College Introduction Dysphagia has been reported to occur in 42%-60% of acute stroke patients on the basis of standardized clinical bedside swallowing assessments performed within a median of 3 days from stroke diagnosis (Mann & Hankey, 2001). Aspiration has been reported to occur in 38%-70% of acute stroke patients (Daniels et al.,1998; Horner & Massey, 1988; Horner, Massey, Riski, Lathrop, & Chase, 1988; Linden & Siebens, 1983). Silent aspiration occurs in 40%-67% of patients with dysphagia who aspirate (Daniels et al.,1998; Splaingard, Hutchins, Sulton, & Chaudhuri, 1988). These alarmingly high numbers are of great concern because of the potential for airway obstruction, malnutrition and aspiration pneumonia. Our data highlights the need for compliance with dysphagia screening for this population. In 2004, The Joint Commission established a standard for dysphagia screening for all patients seen with signs and symptoms of stroke upon arrival to the Emergency Department (ED). Namely, before any PO medications, food or liquid were to be administered, a dysphagia screening was to be documented. Due to the lack of national guidelines in this area, The Joint Commission eliminated this standard in However, many State Departments of Health, including New York, maintain this requirement for designated Stroke Centers. Efforts to develop the most reliable and sensitive tool to achieve a good screening have continued. Screening methods may include, but are not limited to, (a) water swallow tests, such as the Burke water swallow test (De Pippo, Holas, Reding, Mandel, & Lesser, 1994) or the 3 oz. water swallow test (Suiter & Leder, 2008); (b) swallowing screening protocols including brief assessments of oral motor and sensory function as well as water swallow tests, such as the Toronto Bedside Swallowing Screening Test (TOR-BSST; Martino et al., 2009) or the Simple Standardized Bedside Swallowing Assessment (SSA; Perry, 2001); or (c) clinical (bedside) swallow examinations. At New York Methodist Hospital (NYM) we developed and follow a protocol that includes swallowing three sips of water from a standard cup. This screening is administered by the ER physician to patients who present with signs and symptoms of stroke. Several signs and symptoms are highlighted on the electronic form, allowing the physician to make a decision about oral medications and diet. These include clear voice, absence of dysarthria, good voluntary cough and normal eating/drinking prior to arrival to the hospital (and after onset of symptoms). The screening procedure was last reviewed for overall compliance and effectiveness in March of Problem In order to rely on a screening tool, it should meet acceptable standards of construct validity, sensitivity and specificity. Sensitivity refers to identifying the correct number of patients that present with a swallowing problem; and specificity refers to identifying the correct number of patients that do not present with a swallowing problem. As previously mentioned, no nationally accepted dysphagia screening tool has yet been developed. In the meantime, compliance and following appropriate procedures remain paramount in ensuring overall patient safety. System Quality Review Journal Page 155

170 A previous performance improvement (PI) study, conducted in March 2012, revealed that 89% of patients with signs of stroke underwent a dysphagia screening in the ED; and of those, 25% failed. Of note was that of these 25% who failed the screening, only 57% were referred to speech-language pathology (SLP) for a swallowing assessment. Of further note was that 57% of patients who passed the NYM dysphagia screen presented with some form of dysphagia, upon speech-language pathology assessment. These results yielded a sensitivity of 62% (correctly identified persons with swallowing problems) and a specificity of 23% (no swallowing problem correctly identified). Based on the unsatisfactory number of referrals for further swallowing assessment by SLP, and the relatively low sensitivity and specificity of our tool, our Team has worked on developing and implementing a plan to improve overall compliance. The present study aimed to address the following questions: (1) Are all patients who fail the NYM dysphagia screening being referred for a swallowing assessment by SLP? (2) What are the new levels of sensitivity for the NYM dysphagia screening tool? (3) What are the new levels of specificity for the NYM dysphagia screening tool? Goals a. To ensure patients with signs of stroke undergo the NYM dysphagia screening; b. To ensure those who fail the NYM dysphagia screening are seen for a swallowing assessment by speech-language pathology; c. To assess compliance with NPO status post failure of the NYM dysphagia screening (prior to swallowing assessment by SLP); d. To re-calculate sensitivity and specificity for the NYM dysphagia screening tool. Methods The proposed actions to improve care and service following the March 2012 PI study included: (a) automatic referrals to SLP upon failing the NYM dysphagia screening; and (b) establish an educational program for medical residents on the relevance of this tool and appropriate procedures (e.g., referral to SLP upon failure of the screening). Automatic referral, as approved by the NYM Medical Board, included work with Cerner/IT on generating a referral to SLP upon failure of the dysphagia screen and placing the NPO order for that patient until such consult was completed. The educational program for the medical residents included increased emphasis on the dysphagia screening protocol and procedures during training, a lecture by the SLP Team, improved access to the electronic data collection tool and frequent reminders by senior residents. We also reassessed the NYM dysphagia screening tool presently in use while we await evidence-based consensus guidelines in this area. The present study involved a retrospective review of all stroke admissions to New York Methodist Hospital for the months of July and August of 2013, immediately following full implementation of the interventions. Data reviewed from each medical record included: completion of NYM dysphagia screening; referral to SLP upon failure; and NPO status upon failure. In addition, review of patients that passed the NYM dysphagia screening included presence or absence of subsequent referral to speech-language pathology for a swallowing assessment. Results Data analysis for the 51 patients admitted with signs/symptoms of stroke to New York Methodist Hospital in July and August of 2013 revealed that 48, or 95%, underwent the NYM Dysphagia Screening. This is in comparison to a compliance rate of 75% in In addition, 94% of patients who failed the NYM Dysphagia Screening were referred System Quality Review Journal Page 156

171 to SLP for a swallowing evaluation, compared to 57% in On a related concern, 89% of patients who failed the NYM Dysphagia Screening were kept NPO until the swallowing assessment was completed. This was not analyzed in 2012, but was felt to be an important patient care indicator. Sensitivity and specificity were also calculated, although not the aim of this project. Sensitivity improved from 62% in 2012 to 67%. Specificity improved from 43% to 79%. Conclusions In general, this data denotes improvement in completion of the NYM Dysphagia Screening, as well as great improvement in appropriate referral to SLP for swallowing assessment upon failing the screening. In addition, patients who failed were kept NPO until further assessment. Improvement in compliance rate was judged to be significant, and related to medical resident education efforts, as well as improved use of the electronic medical record system (Cerner). While there is no standard tool for dysphagia screening, the improvements in sensitivity and specificity are also appreciated in the current tool being used at NYM. REFERENCES Daniels, S. K., Brailey, K., Priestly, D. H., Herrington, L. R., Weisberg, L. A., & Foundas, A. L. (1998). Aspiration in patients with acute stroke. Archives of Physical Medicine and Rehabilitation, 79, De Pippo, K. L., Holas, M. A., Reding, M. J., Mandel, F. S., & Lesser, M. L. (1994). Dysphagia therapy following stroke: a controlled trial. Neurology, 44(9), Horner, J., & Massey, E. W. (1988). Silent aspiration following stroke. Neurology, 38(2), Horner, J., Massey, E. W., Riski, J. E., Lathrop, D. L., & Chase, K. N. (1988). Aspiration following stroke: clinical correlates and outcome. Neurology, 38(9), Linden, P., & Siebens, A. A. (1983). Dysphagia: predicting laryngeal penetration. Archives of Physical Medicine & Rehabilitation, 64(6), Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G., Streiner, D. L., & Diamant, N. E. (2009). The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and validation of a dysphagia screening tool for patients with stroke. Stroke, 40, Mann, G., & Hankey, G. J. (2001). Initial clinical and demographic predictors of swallowing impairment following acute stroke. Dysphagia, 16, Perry, L. (2001). Screening swallowing function of patients with acute stroke. Part II: Detailed evaluation of the tool used by nurses. Journal of Clinical Nursing, 10, Perry, L., & Love, C. P. (2001). Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia, 16(1), Splaingard, M. L., Hutchins, B., Sulton, L. D., & Chaudhuri, G. (1988). Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Archives of Physical Medicine & Rehabilitation., 69(8), Suiter, D. M., & Leder, S. B. (2008). Clinical utility of the 3-ounce water swallow test. Dysphagia, 23, System Quality Review Journal Page 157

172 Fig Screen Documented 75% 95% Referred to SLP upon failed screen 57% 94% Fig % 90% 80% 75% 95% 94% 70% 60% 50% 40% 30% 57% Screen Documented Referred to SLP upon Failed Screen Fig Sensitivity 62% 67% Specificity 43% 79% Fig. 2 80% 70% 62% 67% 79% 60% 50% 40% 43% % Sensitivity Specificity System Quality Review Journal Page 158

173 Poster Presentation Disproportionate Effects of Dementia in Predicting Home Discharge in DRG Hospitalizations Prevalent with Dementia: Implications in Prevention Quality Assessments Robert Y Lin, MD; Brian C Scanlan, MD; Truc Phuong Thanh Nguyen, BA NewYork-Presbyterian - Lower Manhattan Hospital Introduction Prevention quality indicators have been developed for the purpose of tracking certain categories of hospitalizations that reflect access to quality non-hospitalization (such as ambulatory) medical care. Ambulatory care-sensitive conditions and nursing home-sensitive avoidable conditions relate to hospitalizations that could have been avoided by care in their respective non-hospital settings (Spector et al. 2013). Some disorders such as dementia have been shown to have statistical predictor effects for acute ambulatory care-sensitive hospitalizations (Saver et al. 2013), thus underscoring the importance of adjusting for certain comorbidities in examining trends and prevalence of prevention quality indicator hospitalizations. Problem Caring for dementia patients is most frequently performed in the outpatient setting. With more advanced disease, institutional care is often required. We hypothesized that hospitalized patients with dementia would, upon discharge, require further institutionalized care (instead of being discharged home) based on various key clinical and demographic factors, with dementia showing a similar adjusted predictor effects for various disease entities. With an aging population, we also sought to determine whether the number and proportions of hospitalizations associated with dementia would increase in key diagnosis related groups (DRG). Goals This project had several goals. The first goal was to identify diagnosis-related group hospitalizations which have a high prevalence of dementia in the United States in the second millenium. The second goal was to assess the predictor effects of a dementia diagnosis on hospital length of stay, and on discharge disposition in DRGs which have a high prevalence of dementia. The third goal was to characterize the time trends in dementia proportion in these DRG hospitalizations. Methods The National Inpatient Sample (NIS) databases of the Healthcare Cost and Utilization Project (HCUP), for 2000 to 2010 were queried for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9), codes relating to dementia which included (Alzheimer s disease), 290.* (dementias) and (dementia in conditions classified elsewhere) present in any diagnosis field. As all databases used in this study had DRG coding for version 18 (DRG version 24 was also used to code hospitalizations), this DRG version 18 was used to tabulate the frequency of dementia coding by DRG. Seven medical DRGs which were among the 20 highest number of dementia coding DRG's for each years were identified. These 7 DRGs were DRG 79 (respiratory infections and inflammations), DRG 320 (kidney & urinary tract infections age>17 with complications or comorbidities[cc]), DRG 141 (syncope & collapse with complications, comorbidities), DRG 14 (intra-cranial hemorrhage and stroke with infarction), DRG 89 (simple pneumonia & pleurisy age>17 with CC), DRG 127 (heart failure & shock) and DRG 88 (chronic obstructive pulmonary disease). System Quality Review Journal Page 159

174 All hospitalizations for these 7 DRG s were examined separately for patients aged 65 or older. ICD9 codes most frequently observed in the dementia coding hospitalizations were identified and included: urinary tract infection NOS, pneumonia, organism NOS, septicemia NOS, Food/vomit pneumonitis, acute kidney failure, unspecified, cerebral artery occlusion, unspecified with cerebral infarction, syncope and collapse, hip fractures, dehydration, congestive heart failure, subendocardial infarction, initial, care involving other specified rehabilitation procedure, obstructive chronic bronchitis with exacerbation, atrial fibrillation, unspecified transient cerebral ischemia, acute respiratory failure, unspecified anemia, diabetes mellitus, and hyponatremia. Also of interest were adverse drug effects, falls and delirium. Primary reimbursement status coded as Medicaid or self-pay was considered a field reflecting socioeconomic status. Medicare as the only reimbursement source was also considered a field, as this has bearing on the hospital length of stay requirement prior to reimbursable skilled nursing facilities transfer. Discharges were grouped into expired, discharge to home and transfers to other facilities. The number of hospitalizations with dementia coding for each DRG was plotted for each year. Negative binomial regression was performed using SAS for Windows to analyze time (year) trends in dementia for each DRG using the GENMOD procedure taking into account the total number of hospitalizations for that DRG as the offset variable. Summary data generation and all other data analysis were performed using SPSS for Windows. Linear regression was performed to examine whether dementia had a significant effect on length of stay. The predicted variable was the logarithm of the length of stay (a half day was added to the length of stay prior to logarithmic transformation so that same day discharges could be used in the models). Predictor variables included age, gender, Medicaid or self-pay status, Medicare alone status, a coding for a fall, any adverse drug effect, and the other common co-morbidities noted above that were observed in at least 1% of all hospitalizations for each DRG. Stepwise forward selection was employed for multivariate regression. Multinomial logistic regression was also performed to examine for the role of dementia on discharge disposition (3 categories as previously defined). Hospitalizations ending with transfer to another institution were used as the baseline reference group. The same predictor variables used to predict length of stay were used. Forward selection was employed. Regression analyses were performed without race, as this was missing in a significant number of discharges. Hospitalizations that had missing race ranged from 14% in 2009 to 28% in Results Diabetes mellitus, atrial fibrillation and congestive heart failure were prevalent in all DRG admissions. Delirium, hip fracture, transient ischemic attacks, and rehabilitation treatments were coded in less than 1% for all DRG s. The greatest number of hospitalizations were for DRG 127 (heart failure and shock) and the least number was for DRG 141 (syncope). DRGs 79 and 320 had a highest cumulative proportions of dementia codings and Alzheimer s disease ( %). Proportions of dementia codings between 5% and 10% were noted in DRGs 141, 14 and 89. Lowest proportions of dementia codings (2-5%) were noted in DRG s 88 and 127. Hospitalizations with any dementia or with Alzheimer s disease had higher aged patients, higher proportions of females, higher proportions of falls and urinary tract infections, and lower proportions of adverse drug effects. The average length of stay for patients with and without dementia/alzheimer's was identical in all DRGs except DRG 89 where the mean and median length of stay was 1 day longer for dementia/alzheimer s disease hospitalizations. A significant positive time effect(negative binomial regression) was observed for dementia proportions in DRGs 88 (p<0.0001), 127 (p<0.0001), 141 (p<0.0001), and 14 (p=0.04). A significant negative time effect was noted for DRG System Quality Review Journal Page 160

175 89 (p<0.0001). For Alzheimer s disease, significant positive time effects were noted for DRGs 88 (p<0.0001), 127 (p<0.0001), 141 (p<0.0001), 14 (p<0.0001), and 320 (p=0.03). No significant time effects were noted DRGs 79 and 89. Dementia had a modest but significant positive effect on length of stay (logarithm length of stay as previously defined) for DRGs 141, 14, 127, 320, and 89. The coefficient was higher for DRGs 141, 320 and 14. The forward selection step at which dementia was selected was more than 10 (out of more than 20 steps) for all DRGs. The coefficients for other clinical criteria were selected earlier and were larger. For example in DRG 89, the coefficient for predicting the log length of stay with acute kidney injury was (95%CI: ) while for dementia the coefficient was (95% CI: ). For DRG 88 and 79, dementia had a significant negative effect on length of stay. When Alzheimer s disease was used instead of the more broadly defined dementia, similar findings were obtained (not shown) except that in DRG 89, Alzheimer s had a negative effect on length of stay (albeit with an exceedingly small coefficient. Nominal regression showed an adjusted odds ratio of less than 1 for dementia as a predictor of home discharge for all DRGs. For DRGs 89, 127 and 141 the adjusted odds ratio was less than 0.4, whereas in DRGs 14, 79 and 88, the adjusted odds ratio was greater than 0.5. Urinary tract infection also showed an adjusted odds ratio of less than 1 as a predictor of home discharge for all DRGs. Both dementia and urinary tract infection were among the first 5 variables selected in the forward regression modeling. When Alzheimer s disease was used instead of the more broadly defined dementia category, similar overall findings were obtained but with a more pronounced effect (for Alzheimer s disease) in DRG 88 and a weaker effect in DRG 141. Conclusions These data show that dementia is most prevalent in the 2 DRGs (79 [resp inf] & 320 [UTI]) that are associated with the oldest patients. For these DRGs, there was no change in the prevalence with time when broadly defined dementia was used as the key variable. When only Alzheimer s disease was used, only a modest time effect was noted for DRG 320 [UTI]. In contrast, highly significant positive time effects (p<0.0001) were noted for DRGs 88 [COPD], 141 [syncope] and 127 [CHF] (but not DRG 89 [PNA]) when either broader or more restricted dementia definitions were used. These data would suggest that pneumonia, despite being the most common condition precipitating hospitalization in advanced dementia, 17 is not demonstrating a disproportionate increase with time, when defined by DRGs 79 [resp inf] and 89 [PNA]. Moreover the absolute number of hospitalizations for these 2 DRGs decreased over time. Banta et al. noted that Medicare hospitalizations charges for dementia and delirium increased from US$1.4 billion in 1999 to US$2.2 billion in However their study only considered discharges with a primary diagnosis of delirium, dementia, and amnestic and other cognitive disorders (CCS 653) in these calculations. It is of interest that both CHF and COPD DRGs (127 and 88) showed an increase in dementia proportions over time. The diagnoses CHF and COPD as well as dementia have been shown to have statistical predictor effects for acute ambulatory care sensitive hospitalizations. Ambulatory care-sensitive conditions (ASCS) and nursing home-sensitive avoidable conditions (NHSAC) relate to hospitalizations that could have been avoided by care in their respective nonhospital settings. The increasing dementia proportion in both CHF and COPD DRGs suggests that dementia may influence the potential for avoidable hospitalizations in recent years for these DRGs. The proportion of Medicare beneficiaries with CHF and COPD with concurrent dementia has been estimated to be 16% and 15% respectively. CHF and COPD were 2 of the 4 DRGs that had a stronger dementia predictor effect in not being discharged to home in multivariate modeling compared to that observed in DRGs 79 [resp inf], 320 [UTI] and 14 [stroke]. System Quality Review Journal Page 161

176 This raises the possibility that patients with CHF and COPD were more likely (than DRG 79 [resp inf] and 14 [stroke] patients) to be admitted because they could not be managed in a non-institutionalized setting and/or because they needed skilled nursing facility or long term custodial care. In community dwelling patients with Alzheimer s disease, syncope or falls are the largest reasons for hospitalization. The increase in DRG 141 [syncope] dementia proportions (constituting the DRG with the third highest dementia proportion by the last year of the study) may thus be related to that DRG having an increasing proportion of community dwelling dementia patients. Medicare has targeted syncope in their recovery audit program. DRG 141 [syncope] was also one of the 4 DRGs that in our study, had a stronger dementia predictor effect in not being discharged to home. Taken together these data would suggest that syncope is associated with hospitalizations that favor more SNF/long term care institution discharges and that awareness of these non-acute needs may have driven the hospital admission of these patients. There is a dilemma for hospitals seeking to provide SNF/long term care to poorly functioning elderly patients who present to the hospital, with no clear acute hospitalization indication. Current Medicare policy disallows reimbursement for SNF transfer admissions unless preceded by a 3-day acute care hospitalization. These hospitals face a dilemma of whether to admit patients and keep them hospitalized for the requisite period of time in order to allow for SNF care to be provided or to deny this option to patients by discharging them sooner (or not admitting them at all). When medical necessity is inadequately documented or not present, this places hospitals at risk for payment denial. Our data shows that dementia contributes only marginally to increased hospital length of stay in some of DRGs where dementia is prevalent, and actually was a negative predictor in DRGs 88 [COPD] and 79 [resp inf]. This is consistent with the findings of Naumova et al. who reported that in a large retrospective study of older Medicare patients with pneumonia or influenza hospitalizations, dementia was associated with a shorter, not longer, length of stay. The largest positive predictor coefficient for dementia was observed for DRG 14 [syncope] and the smallest was observed for DRG 127 [CHF]. It is interesting to note that reports of longer lengths of stay from dementia are from countries that have a national health service, including the United Kingdom, Australia, Spain, and Switzerland. It is conceivable that countries which do not have pressure to minimize dementia related hospitalizations because of reimbursement policies, can provide more ancillary services and make better transitional dispositions that provide for more holistic care for dementia patients, and this may make hospitalizations longer. Indeed there is a movement in the United States for more hospital involvement in dementia patients, with pilot projects showing that these efforts can reduce hospital readmissions and overall health care costs. This study has strengths in that the data is sampled in a manner that allows national estimates to be made. The dementia predictor effects in logistic regression modeling for discharge status were estimated using multivariate analyses, which allowed for adjusted estimates to be made. We reasoned that the older patients in DRGs 320 [UTI] and 79 [resp inf] would have a higher proportion of more advanced dementia, thus reducing the probability of home discharge, and that DRG 14 [stroke] would be associated with less of a predictor effect from dementia because the institutional needs for rehabilitation would drive the discharge pattern. The adjusted dementia predictor effects (for being discharged home) were less in DRG 14 [stroke], but contrary to our hypothesis, it was also less in DRGs 320 [UTI] and 79 [resp inf]. We speculate that the DRGs 141 [syncope], 127 [CHF], 88 [COPD] and 89 [PNA] had greater adjusted dementia predictor effects because some admissions related to ACSCs and NHSACs 19 and that DRGs 320 [UTI], 14 [stroke] and 79 [resp inf] had less of an influence from dementia as an admission determinant. It is interesting that urinary tract infections also had influences on disposition outcome. Urinary tract infections are one of System Quality Review Journal Page 162

177 the conditions that are used in algorithms to identify both ACSCs and NHSACs. Thus it is conceivable that urinary tract infections also influenced admission decisions as related to anticipated/assessed SNF or long term care needs. In a cohort study of older(>=65) adults, Phalen et al. found that adjusted admission rates for all types of ACSCs, including bacterial pneumonia, congestive heart failure, dehydration, duodenal ulcer, and urinary tract infection, were significantly higher among those with dementia. Because the data was de-identification of data and sampled rather than complete, readmissions could not be identified. Readmission is an important measure of the effectiveness of comprehensive geriatric care models and patient centered care. It is possible that more readmissions for the same patient in the same year could have accounted for some of the trend findings. However, the analysis of primary cases, which eliminated matching and possible repeat admissions, showed that the positive trends in DRGs 141 [syncope], 88 [COPD], and 127 [CHF] remained highly significant for dementia. Caring for dementia patients is most frequently performed in the outpatient setting. With more advanced disease, institutional care is often required. We originally hypothesized that hospitalized patients with dementia would, upon discharge, require care in settings other than home, based on various key clinical and demographic factors, with dementia showing a similar adjusted predictor effects for various DRGs. Our findings of greater dementia associated odds ratios for particular DRGs suggest a more influential role for this disorder in certain types of hospitalizations. This finding has implications in the AHRQ concept of prevention quality indicators which has been developed for the purpose of tracking categories of hospitalizations that reflect access to quality community based medical care. Disproportionate dementia effects on home discharge may be an indicator of avoidable hospitalizations, which are particularly comorbidity sensitive. This should be examined in prevention quality assessments and algorithms. System Quality Review Journal Page 163

178 Poster Presentation Utilization of EMR Technologies to Improve Safety of Anticoagulation Therapies Lynn I Kim, RPh; Liz Ramos, PharmD; Karlene Ma, PharmD; Matthew Fred, MD; Robert Green, MD; Karen A Scott, MD MPH NewYork-Presbyterian Hospital Introduction The Institute of Medicine (IOM) estimates that more people die from medication errors than from breast cancer, AIDS and motor vehicle accidents combined. The Institute of Safe Medication Practices (ISMP) lists anticoagulants among the top classes for potential for serious medication errors (Category G I Error, see Figure 1). In order to reduce this risk, the ISMP recommends a proactive examination of hospital workflow processes to identify areas of potential medication error. To a similar end, The Joint Commission established a set of anticoagulation-related National Patient Safety Goals in 2007, which require hospitals to create and adhere to processes designed to ensure safe initiation and maintenance of anticoagulation therapy. Problem In order to minimize the risk of bleeding as a result of inappropriate anticoagulant dosing, agents have specific guidelines for tests to help guide dosing recommendations. Warfarin requires a daily review of international normalized ratio (INR) results prior to ordering a warfarin dose for that day. Heparin administration requires monitoring of activated partial thromboplastin time (aptt) times and low molecular weight heparins (LMWH) require a baseline assessment of renal function prior to initiating therapy. Due to the high risk nature of anticoagulation therapies, hospital leadership set a goal of close to 100% to meet required measurements for each anticoagulant class utilized at NewYork-Presbyterian Hospital (NYPH). Despite educational efforts, the assessment of INR prior to warfarin therapy averaged 90%; the assessment of aptt prior to heparin administration averaged 90%; and the assessment of renal function prior to LMWH therapy averaged 90%. Thus, for each of these anticoagulant classes, 1 in 10 patients was at risk for over or under-dosing of anticoagulant. Goals 1. Proactively reduce potential anticoagulant-related medication errors by enhancing clinical decision support systems to prevent inappropriate dosing of anticoagulant agents Warfarin: Ordering and examination of daily INR tests for all inpatients prior to determining daily warfarin dose Heparin: Ordering and examination of baseline and daily aptt tests for all inpatients prior to heparin administration Low Molecular Weight Heparins: Ordering and examination of baseline serum creatinine prior to determining LMWH dose 2. Utilize Computerized Physician Order Entry (COPE) system to enforce the anticoagulant ordering and monitoring policies 3. Utilize CPOE system to eliminate lengthy, manual chart reviews to monitor adherence Methods We utilized a multidisciplinary approach, including participants from the quality, medicine, pharmacy, and information systems (IS) departments in order to meet the National Patient Safety Goals regarding anticoagulation. In Phase I, the group specifically addressed warfarin safety and modified the CPOE system to embed a hard stop requiring a System Quality Review Journal Page 164

179 documented INR result prior to warfarin orders for both adults and pediatrics. The hard stop was implemented at NYPH February Warfarin was unable to be ordered unless a resulted INR was in the EMR within the last 18 hours. Based on this positive experience with warfarin, the multidisciplinary team reconvened and rolled out Phase II and modified the CPOE system to address heparin and LMWH safety. Phase II embedded a hard stop requiring a documented aptt results prior to heparin orders and a baseline SCr prior to LMWH orders. The hard stop for aptt results prior to heparin orders was implemented in June 2012 and the hard stop for SCr prior to LMWH orders was implemented shortly thereafter in September An automated report from the EMR system was created to help monitor adherence to the NYPH warfarin, heparin and LMWH ordering and monitoring policies while a manual chart review was conducted monthly to validate accuracy of the automated report. Results 1. INR prior to warfarin orders aptt prior to heparin administration Scr prior to LMWH orders 2012 Conclusions The changes made to our CPOE system significantly improved prescribers compliance with the NYPH anticoagulant ordering and monitoring policies. Closer adherence to the policy decreases patient risk due to medication errors, consistent with National Patient Safety Goals. Adherence to the INR hard stop prior to warfarin orders has been maintained for 2 years and early indications suggest the same will hold true for aptt prior to heparin administration and SCr prior to LMWH therapies. In addition, we have created a validated Crystal Report to monitor adherence to the CPOE anticoagulant measures. This report has eliminated the need for labor-intensive manual chart review to reconcile INR results and warfarin orders as well as aptt with Heparin administration and SCr with LMWH orders. Recently, there has been the addition of a new class of anticoagulants called the Novel Oral Anticoagulants. These products have been recently included into the NYPH Formulary and include their own baseline criteria for determining appropriate dosing of these agents. The multidisciplinary team that developed the first 2 Phases of this EMR CPOE safety strategy for the traditional anticoagulants may need to roll out a Phase 3 to address the Novel Oral Anticoagulants that are coming to market. System Quality Review Journal Page 165

180 New York Presbyterian Hosptial Anticoagulation Quality and Patient Safety Anticoagulation Metrics Therapeutic Unfractionated Heparin March April May June July August September October November December Data Source % Patients with aptt order prior to first heparin administration Crystal Report NYP Overall 91% 93% 94% 91% 98% 98% 99% 99% 99% 99% Eclipsys XA Weill Cornell 90% 93% 94% 94% 96% 98% 99% 99% 98% 98% Cerner Allen 100% 100% 100% 94% 100% 100% 100% 100% 100% 100% Manual Chart Review Chony 100% 89% (8/9) 100% 100% 100% 100% 100% 100% 100% 100% Milstein 91% 92% 94% 88% 99% 98% 100% 99% 99% 99% Therapeutic Low Molecular Weight Heparin March April May June July August September October November December Data Source % Patients with creatinine resulted prior to LMWH Crystal Report d NYP Overall 91% 93% 90% 91% 90% 89% 90% 98% 99% 99% Eclipsys XA East Campus 94% 95% 90% 90% 90% 92% 92% 99% 99% 99% Cerner West Campus Manual Chart 89% 90% 89% 92% 90% 87% 89% 98% 100% 99% Review Warfarin January February March April May June July August September October % Patients with PT/INR resulted prior to first warfarin order NYP Overall 98% 97% 97% 98% 98% Weill Cornell 98% 98% 96% 98% 97% Allen 93% 96% 91% 96% 100% CHONY 100% 100% 100% 100% 100% Milstein 98% 96% 97% 98% 98% Warfarin August September October November December January February March April May % Patients with PT/INR resulted prior to first warfarin order NYP Overall 91% 95% 93% 93% 91% 92% 91% 97% 99% 98% Weill Cornell 92% 96% 93% 93% 91% 94% 90% 96% 99% 98% Allen 94% 93% 91% 90% 91% 91% 92% 100% 100% 97% Chony 69% 90% 100% 100% 100% 63% 90% 100% 100% 100% Milstein 90% 94% 92% 93% 91% 91% 91% 98% 99% 98% System Quality Review Journal Page 166

181 % Patients with creatinine resulted prior to LMWH order March April May June July August September October November December Mar Apr May June July Aug Sept Oct Nov Dec NYP Composite 91% 93% 90% 91% 90% 89% 90% 98% 99% 99% SCr prior to LMWH Orders % 99% 99% 93% 91% 90% 91% 90% 89% 90% Mar Apr May June July Aug Sept Oct Nov Dec System Quality Review Journal Page 167

182 New York Presbyterian Hosptial Anticoagulation Quality and Patient Safety Anticoagulation Metrics Therapeutic Unfractionated Heparin March April May June July August September October November December Data Source % Patients with aptt order prior to first heparin administration Crystal Report NYP Overall 91% 93% 94% 91% 98% 98% 99% 99% 99% 99% Eclipsys XA Weill Cornell 90% 93% 94% 94% 96% 98% 99% 99% 98% 98% Cerner Allen 100% 100% 100% 94% 100% 100% 100% 100% 100% 100% Manual Chart Review Chony 100% 89% (8/9) 100% 100% 100% 100% 100% 100% 100% 100% Milstein 91% 92% 94% 88% 99% 98% 100% 99% 99% 99% Therapeutic Low Molecular Weight Heparin March April May June July August September October November December Data Source % Patients with creatinine resulted prior to LMWH Crystal Report d NYP Overall 91% 93% 90% 91% 90% 89% 90% 98% 99% 99% Eclipsys XA East Campus 94% 95% 90% 90% 90% 92% 92% 99% 99% 99% Cerner West Campus Manual Chart 89% 90% 89% 92% 90% 87% 89% 98% 100% 99% Review Warfarin January February March April May June July August September October % Patients with PT/INR resulted prior to first warfarin order NYP Overall 98% 97% 97% 98% 98% Weill Cornell 98% 98% 96% 98% 97% Allen 93% 96% 91% 96% 100% CHONY 100% 100% 100% 100% 100% Milstein 98% 96% 97% 98% 98% Warfarin August September October November December January February March April May % Patients with PT/INR resulted prior to first warfarin order NYP Overall 91% 95% 93% 93% 91% 92% 91% 97% 99% 98% Weill Cornell 92% 96% 93% 93% 91% 94% 90% 96% 99% 98% Allen 94% 93% 91% 90% 91% 91% 92% 100% 100% 97% Chony 69% 90% 100% 100% 100% 63% 90% 100% 100% 100% Milstein 90% 94% 92% 93% 91% 91% 91% 98% 99% 98% System Quality Review Journal Page 168

183 Therapeutic Unfractionated Heparin March April May June July August September October November December Mar Apr May June July Aug Sept Oct Nov Dec NYP Composite 91% 93% 94% 91% 98% 98% 99% 99% 99% 99% aptt prior to Heparin Administration % 98% 99% 99% 99% 99% 93% 94% 91% 91% Mar Apr May June July Aug Sept Oct Nov Dec System Quality Review Journal Page 169

184 INR Prior to Warfarin Orders Dec '10 Jan '11 Feb '11 Mar '11 Apr '11 May '11 Mar '13 Apr '13 Jun '13 91% 92% 91% 97% 99% 98% 97% 98% 98% INR Prior to Warfarin Orders % 99% 98% 98% 97% 96% 97% 98% 98% 94% 92% 91% 92% 91% 90% 88% 86% Dec '10 Jan '11 Feb '11 Mar '11 Apr '11 May '11 Mar '13 Apr '13 Jun '13 System Quality Review Journal Page 170

185 Design and Implementation of a Process for Periodic Review of Order Sets in the Electronic Medical Record Adam Rio, MPA RN CPHQ; Amy Reiterman, RN BSN; Jamie MacDonald, RN MSN MBA; Karen Scott, MD MPH; Robert Green, MD; Susan Bostwick, MD MBA NewYork-Presbyterian Hospital Introduction Research indicates that implementation of standardized order sets can improve compliance and delivery of evidencebased care (Ballard et al., 2008, Murphy, 2013). Although, if order sets are not carefully designed, regularly reviewed, and maintained to reflect best practice, they can contribute to errors and lead to the practice of outdated medicine on a widespread basis (Bobb, Payne, & Gross 2007; Institute for Safe Medication Practice, 2012). NewYork-Presbyterian Hospital (NYPH) recognizes the importance of healthcare informatics and leadership supports projects that improve the delivery of care. Thus, an oversight committee was created as the single repository for all electronic medical records (EMR) requests for changes. In 2011, a need was recognized for a dedicated multidisciplinary working group to specifically address new order set requests and modifications to existing order sets. The Order Set Working Group (OSWG) was created with the goal to prioritize and standardize these enhancements across all sites and settings of NYPH; membership includes physician leadership, a Quality administrator, Pharmacy, Nursing, and Information Technology. Vendors and organizations have not yet determined the best practice for EMR customizations, such as order set development and maintenance, and it appears that many healthcare organizations are struggling to define a process (McDonnell, Werner, & Wendel, 2012). Problem In spring of 2013, NYPH completed the Joint Commission s Focused Standards Assessment (FSA) and found an opportunity for improvement, specifically with Medication Management standard , Element of Performance 15, which the Joint Commission 2013 Comprehensive Accreditation Manual for Hospitals defines as the processes for the use of pre-printed and electronic standing orders, order sets, and protocols for medication orders. This includes the need to perform regular review of such standing orders by the medical staff and the hospital s nursing and pharmacy leadership to determine the continuing usefulness and safety of the standing orders and protocols. The Centers for Medicare & Medicaid Services (CMS) also requires periodic review of order sets in their most recent standards. An action plan to address this issue was a collaborative effort between the departments of Quality and Patient Safety, physician leaders, Pharmacy, Nursing, and ancillary departments. Goals The goal of this project was to create a formal standard process for order set review and approval every three years, design of a software user interface to facilitate this new process, assignment of clinical ownership, and engagement of key stakeholders and order set reviewers. A primary focus of the project is ensuring that the order sets are effective in driving evidence-based patient care, aligned with current NYPH standards of care, hospital policies, and nationally System Quality Review Journal Page 171

186 recognized guidelines. As NYPH lacked a clear policy regarding periodic review of order sets, a policy had to be created and submitted to the Medical Board for approval. Methods Creation of the formal periodic review process was led by Quality with collaboration from OSWG leadership. The method utilizes a top-down approach to review order sets, prioritizing those with the highest volume of use. An organizational goal was set to review approximately 85 of the most commonly used order sets, which represent 90% of all order set use, by September 30, The same process will be used for continued review of each order set every three years and as needed to ensure that each order set remains consistent with clinical best practices. Review of each order set will be completed by the physician leaders as well as by the disciplines that receive orders when the order set is used. Additionally, each order set was assigned a clinical owner by OSWG, which may be a Hospital committee or department, but may not be an individual. A secure web-based application was chosen as the technology platform to facilitate this new process. It allows the working group to effectively store, access, and organize information. The application allows collaboration among the reviewers while providing oversight in version control, a method to track approvals, and manage the suggested changes for each order set. Each specialty was provided their custom link to view only the specific order sets that require review from that respective discipline. This software platform, maintained by the Quality administrator, allows reviewers self-service access to the order sets requiring their review. Order sets identified for review are uploaded and assigned to the different disciplines based on content of the order set by the Quality administrator. The reviewer completes an initial review looking at discipline-specific appropriateness, current best practices, and alignment with NYPH policies. The owner, clinical experts of the department, of the order set conduct a concurrent review. Any changes or updates recommended are reconciled and final approval is given by OSWG. (Refer to appendix for the process data flow diagram.) Early in the process, a bottleneck was identified. With the additional work of reviewing existing order sets, the physician leads on the OSWG were not able to allocate any additional time in their schedules. Thus, the process was designed such that the physician leads would only review the order sets once all other applicable disciplines had completed their reviews and recommended any changes, if applicable. Results This project kicked off in July A weekly meeting was held to obtain updates from all reviewers. On September 24, 2013, NYPH reached its goal of reviewing order sets representing 90% of all order set use across the Organization. Revisions included medication updates to match current medication guidelines, removal of lab tests unsupported by evidence, and modification of nursing orders to be consistent with updated polices. The hospital policy on review and maintenance of order sets was approved by the Medical Boards in September A formal process has been established for continuing periodic review of order sets and built into the OSWG weekly process to ensure continuation. Multidisciplinary reviewers have been identified, educated, and engaged in the process. Challenges for the future include continuing engagement in the process of order set reviewers; ensuring that the process runs efficiently such that all order sets are reviewed in advance of their triannual due date; and the complexity of communication between disciplines which can lead to confusion. These barriers can be overcome with vigilance on the part of the Quality administrator with adequate support from Leadership. System Quality Review Journal Page 172

187 Conclusions Even with increasing use of CPOE and order sets, there is little evidence supporting the need for systematic order set management, which may explain the conflicting results in the literature regarding CPOE and patient safety outcomes. It is not sufficient for organizations to simply implement CPOE with order sets; they must be maintained to be consistent with standards of care, medication formulary standards, and informatics standards. With more organizations rapidly implementing EMRs and CPOE to meet government incentives and deadlines for Meaningful Use, it is imperative to define these processes specifically for order sets (Leu et al, 2013). System Quality Review Journal Page 173

188 DESIGN AND IMPLEMENTATION OF A PROCESS FOR PERIODIC REVIEW OF ORDER SETS IN THE ELECTRONIC MEDICAL RECORD Appendix System Quality Review Journal Page 174

189 DESIGN AND IMPLEMENTATION OF A PROCESS FOR PERIODIC REVIEW OF ORDER SETS IN THE ELECTRONIC MEDICAL RECORD References Ballard D.J., Ogola G., Fleming N.S., et al. (2008). The Impact of Standardized Order Sets on Quality and Financial Outcomes. In Henriksen K, Battles JB, Keyes MA, et al., (Eds.), Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: Bobb, A. M., Payne, T. H., & Gross, P. A. (2007). Viewpoint: Controversies Surrounding Use of Order Sets for Clinical Decision Support in Computerized Provider Order Entry. Journal of the American Medical Informatics Association, 14: doi: /jamia.M2184 Institute for Safe Medication Practice. (2012). Guidelines for Standard Order Sets. Retrieved from: Leu, M. G., Morelli, S. A., Chung, O., & Radford S. (2013). Systematic Update of Computerized Physician Order Entry Order Sets to Improve Quality of Care: A Case Study. PEDIATRICS, 131(S60).doi: /peds g McDonnell C., Werner K., & Wendel L. (2012). Electronic Health Record Usability: Vendor Practices and Perspectives. AHRQ Publication No. 09(10) EF. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: type=pdf Murphy, R. (2013, March). Clinical Decision Support Provides Better Care. Baseline Magazine. Retrieved from: The Joint Commission. (2013) Hospital Accreditation Standards. USA System Quality Review Journal Page 175

190 Reducing LOS for the Admitted Non complicated Cellulitus Patient Anna Maw, MD; Anthony Ogedegebee, MD; Nell Eisenberg, MD; Paula Tinghitella, MSN RN NewYork-Presbyterian Hospital Introduction Data review revealed opportunities to standardize care and reduce Length of Stay for the admitted cellulitis patient at NewYork-Presbyterian/ Weill Cornell Medical Center. This reduction in LOS would have a corresponding decrease in cost by patient. Daily patient cost calculated at $600/day. Problem The Length of Stay in 2011 and 2012, for the admitted patient with the diagnosis of cellulitis was approximately one day longer than the expected LOS as compared with UHC Peer Hospitals. The diagnosis and treatment for cellulitis varied by Physician as well as by antibiotic choice, route and dose. Goals 1) Create guideline for the admitted uncomplicated cellulitis patient 2) Collaborate with the ED to initiate the guideline in the ED. (antibiotic administration as per algorithm) 3) Decrease LOS for the admitted uncomplicated cellulitis patient 4) By decreasing LOS for this population, decrease cost/patient 5) Arrange for bridge appointment for patient follow up if the patient could be discharged from the ED Methods 1) Chart Review 2) LOS data and Benchmarking 3) Review of Physician Practice using Atlas Data Base 4) Method for Improvement: Improvement Team comprised of Physicians from the Departments of Medicine, Infectious Disease and Emergency Medicine Results Length of stay decreased after implementation in April 2013 (see LOS graphs and Guidelines.) Conclusions Accomplishments: 1) Cellulitis Guideline created by Physicians from Department of Medicine, Infectious Disease and Emergency Medicine. 2) Guideline Implemented by Department of Medicine & Emergency Department 3) Guideline posted on ED internal team site 4) Education developed for Medicine Residents 5) Guideline reproduced on laminated pocket card LOS has decreased by approximately one day for the admitted cellulitis patient in the first quarter following implementation. LOS has continued to decrease in the first two months of the second quarter post implementation and volume has remained stable. System Quality Review Journal Page 176

191 There is a corresponding decrease in the cost of care for these patients as the LOS decreases. Budgeted YTD Cost Avoidance (based on 2012 discharges): $84,359 Actual YTD Cost Avoidance ( August 2013): $80,600 Continued Education of Physicians is crucial to implementation of this guideline. It is expected that this algorithm will be extended to include the complicated cellulitis patient. System Quality Review Journal Page 177

192 System Quality Review Journal Page 178

193 Cornell Cellulites 2012 thru 3rd quarter 2013 (YTD aug 2013) st quarter nd quarter rd Quarter th Quarter st quarter nd 3rd quarter quarter 2013 (ytd 2013 Aug) Variance ALOS Cornell Cellulites 2012 thru 3rd Quarter 2013 (YTD aug 2013) st quarter nd quarter rd Quarter th Quarter st quarter nd quarter rd quarter 2013 (ytd Aug) Excess Days Discharges Cellulites Excess Days 2012 thru 3rd Quarter 2013 (YTD aug 2103) st quarter nd quarter rd Quarter th Quarter st quarter nd quarter rd quarter 2013 (ytd Aug) Excess Days System Quality Review Journal Page 179

194 Management Algorithm for Uncomplicated Cellulitis * Inclusion Criteria Adults with an admitting diagnosis of cellulitis Exclusion Criteria By History: Diabetic or decubitus ulcers Animal bite, post-trauma or burn-related cellulitis Sea-water, fresh-water or hot-tub immersion-related cellulitis By Physical Exam Findings: Hemodynamically unstable or ICU-bound patient Attendant acute renal or respiratory failure Facial, orbital, scrotal or perineal involvement Skin necrosis or bullae Exposed tendon, muscle or bone Signs or symptoms of acute limb ischemia Acute foot drop Acute hand or wrist motor weakness By Laboratory Data: >30% decrease in GFR from baseline Unexplained hyperkalemia Evidence of rhabdomyolysis By Radiologic Data: Acute fracture Contiguous osteomyelitis Gas in tissues Retained foreign object *See inclusion and exclusion criteria for valid uses of this algorithm #Majority of cases will be either MRSA or MSSA. However, in cases where abscess cultures yield other pathogens, such as MSSA or b-hemolytic strep, empiric MRSA coverage should be discontinued in favor of pathogen-specific therapy for the best clinical Acute-onset, non-purulent/fluctuant, well-demarcated, erythematous rash with raised margins associated with malaise, fever or leukocytosis $ Undifferentiated cellulitis refers to non-purulent cellulitis cases that do not meet the algorithm definition for probable -hemolytic strep infection. In such cases the antibiotic regimen must include definitive coverage for both -hemolytic streptococci and MRSA. **Antibiotic Dosing Recommendations:Vancomycin (IV) mg/kg/dose q8-12 hours; Daptomycin (IV) 4 mg/kg/qd; Linezolid (oral) 600 mg BID;Ceftriaxone (IV) 1 g QD; Cefazolin 1-2 g (IV) Q8 hours; Nafcillin/Oxacillin (IV) 1-2 g Q4 hours; TMP-SMZ (oral) 1-2 tabs BID; Cephalexin (oral) 500 mg QID; Amoxicillin (oral) 500 mg TID; Doxycycline (oral) 100 mg BID; Clindamycin (oral) mg TID; Dicloxacillin (oral) 500 mg QID (NOTE: Underlined antibiotics require dose adjustments for renal failure) System Quality Review Journal Page 180

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