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Abstract

“Ask Me How!” A provider-driven intervention to increase usage of the inpatient MyHealth App




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John Chan and Aditya Ullal
Benjamin Catanese
Lyndly Tamura
Erik Blomain
Nivetha Subramanian
Ann Mitchell
Joanne Meneses
Medicine Department BACKGROUND:
The MyHealth App is an individualized mobile application that allows patients to follow up-to-date test results, learn about recent medication changes, track mobility and pain goals, and request ancillary wellness resources while admitted to the hospital. The goal of the app is to improve patient communication with their care team. While the app can be used by both inpatients and outpatients, overall penetration and active use of the app is lower in the inpatient setting than in outpatient settings.
 
OBJECTIVE:
Increase active use among inpatients in Medicine units (B3, C2, C3, M6, M7 and L6) to at least 50% by the end of calendar year 2021.
 
METHODS:
Interventions were introduced at 3 interventional Medicine units (C3, M6, M7): 1) A voluntary survey was sent to Medicine residents to gauge awareness of the app and introduce features, 2) Informational fliers that including a technical support line and details on how to download the app were posted in patient rooms, 3) A nursing intervention including nursing huddles to promote the application in direct patient care roles, 4) Gathered monthly data on app usage from the patient-facing MyHealth inpatient team.
 
RESULTS:
Prior to deployment of provider-based interventions, active use of the MyHealth app across all medicine units was 48% in February 2020. At the end of the first PDSA cycle, active use among interventional units in April 2020 was 63.8%. Active use in non-interventional Medicine units was 55.4%. Among 35 MD survey respondents, 29% of respondents stated that they were unaware of the existence of an inpatient version of the MyHealth app, 38% were unaware of the app’s features, and 50% were “somewhat aware” of app features.
 
CONCLUSION:
Awareness of the inpatient MyHealth app varied substantially among MD survey respondents. Meaningful opportunities exist to increase health provider engagement with the app. Barriers to discussion of the app with patients can be reduced by making app setup and technical support resources available at bedside for both patients and providers.
A Culture of "Yes!": Next Level Radiology Service Excellence


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Philip Y. Cheung, MD, MEng
Marc Willis DO, MMM; Department of Radiology
Lisa M Knowlton, MD, MPH; Department of Surgery
Jerry Siebenaller, MHA; Department of Radiology
Tracey Fung, DC; Department of Radiology
Camille Castro; Department of Radiology
Elizabeth Knoff, RT(R)(CT)(QM); Department of Radiology
Peter Poullos MD; Department of Radiology
Radiology Department PURPOSE
In 2014, our Department of Radiology instituted a physician-to-physician Radiology Consult Line (RCL), a dedicated phone number through which providers may reach a radiologist to discuss exam ordering, appropriateness, or results. Trained reading room assistants (RRAs) triage incoming calls by acuity and question type, routing calls to the appropriate subspecialty. RRAs also assist radiologists by facilitating outgoing communication to patient care teams. Satisfaction with the RCL program is mostly high, but gaps and variability exist in (1) radiologist availability, (2) call routing accuracy, (3) timeliness and consistency of return calls, and (4) professionalism.

A team of representative stakeholders, including a faculty surgeon, an RRA, two faculty radiologists, a radiology resident, and two radiology administrators, developed an improvement process via a five-month guided quality improvement curriculum. The goal was two-pronged: improving timely, accurate connection to desired subspecialty radiologists, and improving RCL service satisfaction.

 
METHODS
Team members conducted multiple detailed observations ("Gemba") of all aspects of the RCL workflow. We performed a root cause analysis of barriers in the current workflow from the perspective of radiologists, RRAs and referring physicians. We documented our analysis using a structured problem-solving tool (A3 report).

Specific, Measurable, Achievable, Realistic, and Timely (SMART) goals were developed to guide and assess project progress:
A. Achieving 4/5 or higher on 75% of RCL audits. The composite audit score:
a. RRA provides their name and role (1 point)
b. Connection to the correct reading room (2 points) on the first attempt (1 point)
c. Answering radiologist provides their name, role, and subspecialty (all 3 = 1 point, no partial credit)
B. Achieving 5/5 on a 5-point Likert scale on 85% or greater of surveys of all RCL callers:
a. “On the day referenced in your email, how satisfied were you with the service provided by the Radiology Consult Line?”

Key drivers included:
1. Developing and maintaining an excellent customer service culture and attitude
2. Setting clear expectations around radiologist availability
3. Developing more uniform, clear coverage policies across subspecialty sections with varying responsibilities and workflow.
4. Clarifying escalation policies for expedited subspecialty faculty review
5. Appropriate triage of heterogeneous demands by urgency

Interventions were developed and iterated through several Plan-Do-Study-Act (PDSA) cycles. Interventions implemented during this project included:
1. Installing a call center management software.
2. Promotion, through meetings and emails, of a service-centered culture to department leadership, faculty, and trainees.
3. Deployment of telephone reference cards with suggested answering scripts and means for re-routing misdirected calls back to the RCL.
 

 
RESULTS
At baseline, 60% of RCL audits achieved a composite score of 4/5 or greater. After initiating interventions, this increased to 88%, an absolute increase of 28% and relative increase of 46.7%.

At baseline, 75% of customer satisfaction surveys returned a 5/5 score. After initiating interventions, the mean increased to 80%, an absolute increase of 5% and a relative increase of 6.7%.

 
CONCLUSION
An interprofessional, team-based approach to continuous quality improvement can positively impact service excellence in radiology. In our institution, subspecialty sections have variable coverage and workflow models. Thus, the RRA workflow is extremely complex. Standardizing processes and expectations for radiologist availability, along with installation of call management software to decrease unanswered calls, markedly improved the frequency of connection to the desired subspecialty on the first attempt. Except for one outlying week, interventions appear to have shifted departmental performance on this metric. Auditing efforts were extensive during the project; this may have contributed to improved RCL audit scores via the Hawthorne effect. Telephone scripting was generally well-received, but a small minority of callers unexpectedly found it excessive and time-consuming.

Overall satisfaction with the RCL program prior to this effort had been already high, with approximately 90% of respondents giving scores of 4/5 or greater. As a result, significant improvements on this metric are challenging to achieve. Modest improvement in satisfaction after customer service training suggests that these 'soft skills' play a small, though important, role in perceptions of referring providers.

Future efforts will leverage technology solutions to streamline inbound and outbound messaging and prioritize by level of acuity to improve closed-loop communication. Our goal is that streamlined, customer-service focused workflow and professional communication will translate into improved patient safety and clinical outcomes.
A Novel Goals of Care Communication Curriculum for Neurology Residents Improves Confidence and Skills


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Tarini Goyal, MD
Sylvia Bereknyei Merrell, DrPH
Barbette Weimer-Elder, PhD, RN
Merisa Kline, MHA
Carl A. Gold, MD, MS
Neurology Department Background
Neurology residents care for patients facing life-altering and life-limiting diseases. It is crucial that they are proficient in the principles of palliative care, including counseling patients and their families regarding goals of care. However, national surveys have demonstrated that neurology trainees are inadequately prepared to care for patients at the end of life. We previously conducted a needs assessment with Stanford neurology residents to identify barriers to effective goals of care conversations. Here, we present data on the impact of a curricular intervention after 3 months.

Methods
We developed two 3-hour workshops based on themes identified from the needs assessment. Topics included fundamental physician-patient communication skills, counseling surrogate decisionmakers, and tenets of prognostication. We conducted resident and patient surveys and direct observations of resident-patient interactions to evaluate the impact of the curriculum.

Results
Residents reported a significant increase in their confidence practicing fundamental communication skills and goals of care communication skills. Observed resident-patient interactions showed significant improvement in fundamental communication skills. However, there was no significant impact on patient perception of resident communication skills in the three months following the intervention.

Conclusions
A short, learner-centric, targeted curricular intervention improved neurology residents’ confidence in goals of care communication and improved their skills as judged by trained observers. The lack of significant impact on patient perception of resident skill may reflect inadequate sensitivity of the Communication Assessment Tool to detect differences in patient perception of nuanced conversations. Our next steps include a longitudinal coaching program for faculty-resident feedback and enhancing the next version of the curriculum using the Serious Illness Conversation Guide.
A Standardized Evidence-based Protocol for Use of Peripheral Vasopressors


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Jai Madhok, MD
Adjoa Boateng, MD
Javier Lorenzo, MD
Jenny Wilson, MD
Anesthesia Department There is tremendous variability in provider preferences regarding peripheral intravenous administration of vasopressors for hypotension. Historical fear of extravasation and ischemia have mandated central venous catheters (CVCs) for vasoactive drug administration but no standardized guidelines exist. Recent literature (7 studies, n = 16,000 patients) reports a 2-4% demonstrates the risk of complications from peripheral vasopressor administration; none requiring intervention beyond supportive care (elevation +/- subcutaneous phentolamine). On the other hand, risk of CVC-associated complications is between 5-26%, which includes: infectious (CLABSI), thrombotic (DVT), and mechanical (pneumothorax, inadvertent arterial puncture, bleeding, AV fistula, etc.) causes. Further, in a significant percentage of patients, vasoactive agents are weaned off in 1-2 days but unfortunately CVCs are often left in longer than needed increasing risk of long-term complications. We suspect that by being risk averse and requiring CVC placement for all vasopressors we are potentially exposing patients to a greater risk than the risk of minor complications from extravasation. This QI project began with evaluation of provider preferences, experiences, and comfort with peripheral use of vasopressors. Subsequently, an evidence-based protocol for peripheral vasopressors was proposed, iteratively revised at multidisciplinary committees (ICU Continuous Quality Improvement and SHC Medication Safety Committee) based on the input of physicians, nursing, and pharmacists, and is now in its final pre-deployment stage with a framework in place for evaluating use of protocol and patient safety. 
Analyzing Impact of an Institutional Protocol for MRI in Patients with Legacy Cardiac Rhythm Devices


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Collin J. Culbertson MD
Laurel Jakubowski MD
Jingjing Chen MD MBA
Max Wintermark MD
Paul Wang MD
Angela Tsiperfal MS RN ACNP CNS
Rosalie Geronimo DNP RN NEA-BC CNL
Teresa Nelson
Connie Lund
Carl A. Gold MD MS
Neurology Department Background Prior to 2018, patients with older pacemakers or implantable cardioverter defibrillators, also called “legacy” devices, could not receive MRI scans at SHC. Data from large studies published in 2017 showed no significant safety issues with MRI in patients with legacy devices. In response, a committee with representatives from Neurology, Neuroradiology, and Cardiac Electrophysiology was formed and updated SHC policy to allow MRI with a standardized safety protocol, starting in August 2019. For this study, we prospectively tracked all SHC patients with legacy devices undergoing MRI and attempted to estimate the impact of MRI on patient care.

Methods The project was granted Chart Review exemption from Stanford IRB (#52411). Radiology technicians prospectively recorded all legacy device MRI scans. Data was pulled monthly from Radiant and compiled for review. Patient charts were reviewed in STARR/Epic to extract clinical and device data and determine the impact of MRI on clinical care.

Results A total of 14 MRI scans were performed on 11 unique patients with legacy devices from August 2019-March 2020. In 8 patients (73%), MRI expanded treatment options or significantly changed management. In 5 patients (45%), MRI confirmed a suspected diagnosis and/or changed the diagnosis meaningfully. In 3 patients (27%), the availability of MRI avoided a more invasive procedure. There were no patient safety events. In 2 patients (18%), earlier MRI may have avoided a delay in appropriate treatment.

Conclusions With successful implementation of a multidisciplinary SHC protocol, we now safely offer MRI to patients with legacy devices. Amongst this initial cohort, MRI frequently added crucial information or expanded treatment options, possibly changing the diagnosis or management. In the future, we hope to expand weekend/evening access for inpatients including emergency cases, as well as offer the service to outpatient Neuroscience clinics and other departments.
Antibiotic Clinical Decision Support Tool Improves Management of Beta-Lactam Allergies


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Theresa Dunham, MD
Danielle Fasani, PharmD
Elizabeth Lipper, MD
Bonnie Halpern-Felsher, PhD
Anne Liu, MD
Medicine Department Introduction: Antibiotic allergies are associated with suboptimal antibiotic use, treatment failures, longer hospitalizations, and multidrug resistant organisms. SHC providers report insufficient knowledge and confidence in managing antibiotic allergies, often resulting in poor documentation and classification of allergies.
Methods: 55 residents, pharmacists, and attendings/fellows chose actions, grouped into risk-stratified categories, in six clinical vignettes both with and without a clinical decision support tool (CDST), preceded and followed by surveys.
Results: All providers recently encountered patients who needed an antibiotic possibly related to a listed allergy. At baseline, 80% of providers were at most “moderately” confident in taking an antibiotic allergy history, while the use of the CDST increased confidence in doing so for 89%. The CDST significantly increased confidence in determining when antibiotics are related for 98% of providers (paired t=5.38, p<0.0001). Participants were overall more likely to choose the correct action, categorized as having equal or lesser risk, in all clinical vignettes with the use of the CDST compared to without (chi-square 21.7587, p<0.00001). 95% of participants would use the CDST in the future.
Conclusion: This tool increased confidence and improved decision-making in managing antibiotic allergies. This tool allows for increased safety and improves antibiotic selection as indicated by influencing users’ choices. Implementation of this tool should be piloted on SHC services with high antibiotic use and burden. A prospective analysis could be performed to assess for changes in patterns of antibiotic prescribing, efficacy of antibiotic treatment, adverse reactions to antibiotics, and healthcare costs among patients with listed antibiotic allergies. 
Breathing Easier on Acute Care


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Julia Marlow, MD
Felice Su, MD
Amy Chapman, MSN, RN, CNS, NEA-BC
Lauren Destino, MD
Pediatrics Department Background: Patients on high flow nasal cannula (HFNC) who are otherwise stable for acute care are kept in the intensive care unit (ICU), utilizing limited ICU bed space. This leads to surgical case cancellations and hospital diversions which negatively affect continuity of care, patient and family satisfaction and cost.

Methods: We reviewed other hospital policies and clinical pathways to inform the creation of a clinical pathway at our institution. This pathway would assist in the identification and standardization of pediatric patients on HFNC being transferred from the ICU to acute care while still on HFNC for continued respiratory management. Our SMART goal: to increase the number of pediatric patient transfers from the pediatric intensive care unit to the acute care ward who remain on HFNC respiratory support from 0 patients during January – April 2019 to 12 patients during January – April 2020. Based upon stakeholder feedback and continued review, we instituted several PDSA cycles to further disseminate the clinical pathway and support the identification and transfer of eligible patients.

Results: Thus far in the implementation process, 26 PICU days have been saved from January - March 2020 (approximately 633 hours). No patient transfer led to a return to the ICU. Our processes were affected by the global pandemic, COVID-19. As safe and appropriate, we are continuing this initiative, including analysis of balance measures.

Conclusion: There is a cohort of pediatric patients, identifiable through our clinical pathway who can be safely transitioned from the ICU to the acute care wards while on HFNC, without an increase in rapid response or transfers back to the ICU. These transfers improve ICU bed availability. 
Characterizing Interruptions to Attending Rounds on an Academic General Medicine Service


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Julia Armendariz, MD
Carla Tamayo, MD
Justin Slade, MD
Ilana Belitskaya-Levy, PhD
Caroline Gray, PhD
Nazima Allaudeen, MD
Medicine Department Background: Daily attending rounds is a cornerstone of teaching and patient care for medicine services in academic health centers. The literature and local experience show that interruptions in healthcare are common, and suggest there are adverse effects such as increased risk of errors and incomplete work, and decreasing decision-making accuracy. There is also literature to support that interruptions during teaching diminishes a trainee’s capacity to learn and retain information. To our knowledge, no study has yet characterized the types of interruptions that occur during attending rounds.
Methods. This study utilized a mixed method design: a prospective observational study to characterize interruptions, and a qualitative study to elucidate the impact of interruptions on workflow and the educational value of rounds.
Results. A total of 30 attending rounds were evaluated resulting in 378 observed interruptions, averaging 12.6 (range 1-22, median 13) interruptions per rounding episode. The most common sources of interruptions were from bedside nursing staff (25%), but the most common topic of interruption was consultant recommendations (21%). Most interruptions occurred during patient presentations (76%), and the most common method of interaction was text message (24%). For the qualitative portion of our study, team members described how interruptions impacted their work flow and education in addition to proposing solutions.
Conclusions. Interruptions to attending rounds are common and diverse in their characteristics. The qualitative portion of our study suggested many similar concerns and descriptive solutions. Next steps include interventions to decrease the quantity and frequency of interruptions.
Cost Transparency Affected Expensive Drug Prescribing and IV to PO Substitution


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Rebecca Linfield, MD
Bo Wang, MD
Janjri Desai, PharmD, MBA
Lisa Shieh, MD, PhD
Medicine Department Healthcare costs in the United States continue to increase, largely driven by the high cost of pharmaceuticals. Cost transparency, the act of showing the price of drugs to providers, has been proposed as a method of reducing healthcare costs, but its effectiveness has not been studied on a large scale. By tracking the volume of the top 50 medications in the Stanford Health Care network before and after the introduction of price transparency in the electronic medical record on August 1, 2017, with a second group on June 27, 2018, we sought to determine if this intervention would generate at least a 10% decrease in the orders of expensive medications (greater than $200 per dose) and at least a 10% decrease in intravenous (IV) prescriptions when the oral substitute was available. We show only a 5% decrease in the volume of expensive medications ordered in the 12 months following the intervention but did note a 25% decrease in IV medications during the same time frame, with the decrease in IV volumes roughly matched by increase in PO volumes. This led to ~$225K in cost savings. We believe that cost transparency can be a low-intensity intervention to decrease unnecessary prescribing.
Decreasing ED Visits for Breakthrough Seizures in Patients Established with the Epilepsy Clinic


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Erica Von Stein, MD
Erica von Stein, MD1
Aditya Joshi, MD1
Katherine Werbaneth, MD1
Dominic Hovsepian, MD1
Laurice Yang, MD, MHA1
Neurology Department Background:
Breakthrough seizures in patients with known epilepsy account for approximately 83,000 emergency department (ED) visits annually. The most common cause for breakthrough seizures is sub-therapeutic anti-epileptic drug (AED) levels, which may be from non-adherence, inappropriate dosing, or drug-drug interactions. Other common causes include illness, toxic/metabolic conditions, or lack of abortive medication. Once a patient has a breakthrough seizure, factors such as communication issues with healthcare providers, lack of access to care, and poor education regarding breakthrough seizures, may lead them to present to the ED.  Prior studies have shown that interventions including providing proper abortive therapies, improving access to urgent neurologic care, developing seizure action plans for patients, and providing assistance for those at highest risk, may decrease unnecessary ED visits.

Current State/SMART Goal:
To analyze the current state, we limited our study population to patients who have established care at the Stanford Comprehensive Epilepsy Center and who also presented to the Stanford ED for breakthrough seizure from December 2017 to December 2018.  A total of 120 patient visits met this criteria, and were reviewed for primary reason of breakthrough seizure and disposition of the patient.  Our SMART goal is to decrease annual rate of Stanford ED visits for our established Epilepsy patients from 120 to 96 (20%), and sustain this reduction for at least 1 year after implementation of intervention. 

Analysis/Intervention:
Retrospective review of these 120 patients revealed that the majority were discharged from the ED.  Only 29% (n=34) were admitted under inpatient or observation status. Non-adherence to medications accounted for only 10% of visits (n=12) and sub-therapeutic antiepileptic levels were found in only 8% of patients (n=9). The most common reason for presenting to the ED was refractory epilepsy in 39% of patients (n=46).  Key drivers for ED presentation included access to patient services and unclear contingency plan for a breakthrough seizure. “Action plans” are common for pediatric conditions, though less so in adult practice. A formalized “seizure action plan” will help address the gap in management of a breakthrough seizure. Furthermore, these guidelines will help to reinforce the notion that breakthrough seizure can be managed appropriately in the outpatient setting.

Results/Sustain Plan:
We plan to implement a seizure action plan to aid patients and their family in home management of breakthrough seizures and hopefully reduce unnecessary ED visits. The form will be completed together by the attending epileptologist and the patient, and the patient will keep the form with them. Results are pending, and we plan to continue the project during the next academic year. The seizure action plan can be sustained by completing the form with every new patient with epilepsy and updating the form during each subsequent visit prior to leaving the clinic encounter. In the future, the form will be computerized, avoiding the necessity of repetitively writing information (such as seizure type) that typically does not change.
Decreasing Provider Discordance in Code Status Ordering and Interpretation at SHC


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Emily Shearer
Jason Batten
Mukund Ramkumar
Kimberly Kopecky
Haley Manella
Lisa Shieh
Stephanie Harman
Winnie Teuteberg
David Magnus
Medicine Department Background: Stanford currently has five code status orders available for patients: Full Code, Partial Code, DNR/DNI, DNR/DNE, and DNR/C. These code status orders are meant to reflect patients’ wishes regarding limitation of life-sustaining treatments.
Local Problem: Despite the importance of correct ordering and interpretation of code status orders in achieving goal-concordant care for patients, particularly near the end of life, previous qualitative work undertaken at Stanford has shown there may be variation in ordering and interpretation of code statuses.
Methods: In this quality improvement project, we employed qualitative interviewing among 24 physicians and nurses at SHC across five departments to identify problems with our current code status options. These interviews revealed SHC’s current code status options operate in three domains: interventions, level of care (treatment unit), and philosophy of care. From these insights and from our qualitative interviews, we devised eight hypothetical patient scenarios that represent areas of confusion among providers in the current code status system at Stanford. We then used these scenarios to assess provider concordance among 54 nurses and physicians in a) code status ordering and b) code status interpretation for patients with given clinical scenarios. From these qualitative and quantitative results, we worked with the Stanford Epic Informatics team and the Stanford Design School to develop a new code status ordering menu for our electronic health record.
Results: Our results show significant discordance among providers at our institution in both a) code status ordering and b) code status interpretation for patients across eight identified problematic clinical scenarios.
Conclusions & Future Steps: There is currently significant discordance among providers at SHC.  Testing of our eight patient scenarios against our newly developed code status options, as well as cognitive interviewing with providers to assess their views of the new options, are needed to see if our newly devised system 1) decreases discordance in code status ordering and interpretation, and 2) is acceptable to providers at Stanford.
Developing a Telemedicine Curriculum for a Family Medicine Residency


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Emmeline Ha MD
Kristen Zwicky MD
Andrew Schechtman MD
Family Medicine Department Background: Telemedicine has rapidly become an essential part of outpatient medicine in order to provide high-quality care during the COVID-19 pandemic. Currently, the Stanford-O’Connor Family Medicine Residency curriculum has no formal training in telemedicine. We sought to develop a telemedicine curriculum and investigate its effect on resident confidence in practicing telemedicine.

Methods: A process map of the telemedicine visit workflow at our residency outpatient clinic was created to identify key topics to cover in our curriculum. We then developed 1) a live 50-minute didactic lecture for residents on best practices in telemedicine, and 2) a quick-reference handout. A recording of the didactic was made available to ensure all residents had access to the information. Pre- and post-intervention surveys were distributed to current residents (n=24) to assess the effect of the educational resources on their practice of telemedicine. Statistical significance was determined by paired t-test analysis.

Results: 14 residents (58% response rate) completed all aspects of the study, including both surveys and participation in the educational intervention. Confidence levels in conducting telemedicine visits increased in all domains, with three domains showing statistical significance. These three domains each increased by 57%: 1) doing a virtual physical exam (p=0.015), 2) documenting a telemedicine visit (p=0.012), and 3) staffing a telemedicine visit with an attending (p=0.013). Additionally, resident interest in practicing telemedicine post-residency increased following the educational intervention, but was not statistically significant.

Conclusions: Telemedicine requires a unique skill set. Formal education on best practices improves resident confidence levels and interest in practicing telemedicine. Primary care residency programs should incorporate telemedicine training to adequately prepare their graduates for clinical practice.
Discomfort from povodone-iodine ocular antiseptic swabs


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Victor Eng
Ryan Shields
Theodore Leng
Steven Sanislo
Darius Moshfeghi
Sandeep Randhawa
Stephen Smith
Ophthalmology Department Discomfort from povodone-iodine ocular antiseptic swabs

Victor Eng1, Ryan Shields2, Theodore Leng1, Steven Sanislo1, Darius Moshfeghi1, Sandeep Randhawa2, Stephen Smith1

1Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA
2Beaumont Eye Institute, William Beaumont Hospital, Royal Oak, MI

Background: The use of povodone-iodine (PI) has become the standard of care for disinfecting the ocular surface prior to anti-VEGF intravitreal injections (IVI). However, use of PI as prophylaxis commonly causes severe irritation and sensitivity that may last for days after injection. Aggressive irrigation of the adnexa after IVI reduces the severity of perioperative pain.

Objective: To assess 1) the prevalence and severity of ocular pain after IVI and 2) methods for alleviating discomfort (e.g. additional irrigation, over-the-counter NSAIDs, hot/cold packs)

Methods: Patients with a history of receiving anti-VEGF IVI were surveyed in-person in March 2020

Results:
Survey response rate was high (>95%). A total of 104 patients (53% male; current age 75.1 ± 12.4 years) participated in the survey. 70% reported usually experiencing discomfort after IVI with 33% having experienced at least one episode of perioperative pain rated above 8/10. Pain was not significantly associated with the total number of intravitreal injections a patient had received (p = 0.44). Roughly half of patients (46%) ask for extra rinsing of the eye after injection procedures. Patients also reported alleviating pain and irritation with artificial tear drops (34%), over-the-counter NSAIDs (19%), and cold and/or hot compresses (23%). 16% of patients said that the pain affected their decision to continue receiving injections. 80% would be interested in a less-irritating alternative to povodone-iodine swabs.

Conclusions:
Postoperative pain after use of povodone-iodine is common among Stanford patients with a substantial percentage of patients resorting to self-treatment with artificial tear drops, over-the-counter NSAIDs, or hot/cold compresses. Providers should actively offer extra rinsing to patients who may be unaware or hesitant. These findings demonstrate a possible market for a less-irritating antiseptic swab as well as the value of upcoming extended-release anti-VEGF agents that permit longer intervals between dosing.
Effect of Brief Education Course on Provider Utilization of Telehealth Video Visits During the SARS-CoV-2 Pandemic


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Katherine Thomas MD (PM&R, PGY-3)
Molly Timmerman DO (PM&R Attending)
Orthopedic Surgery Department BACKGROUND: With the unfolding of the SARS-CoV-2 pandemic, many healthcare organizations have advocated the telehealth video visit as a method for fulfilling their mission of healthcare delivery while minimizing risk of infection for both patient and provider. Furthermore, video visits offer additional clinical insight not available through telephone visits. Despite organizations’ new-found interest in telehealth video visits, many physicians are reluctant to use telehealth video software. This reluctance may be due to inexperience using the software or negative preconceived opinions regarding video visits. For example, a survey of physicians in 2015 showed that only 5% had ever used video visit software(1) and a 2019 survey showed that 31% of physicians were not willing to have a video visit with their patients (2). Given the relatively recent onset of the SARS-CoV-2 pandemic, there is a need for novel, evidence-based methods of quickly augmenting provider utilization of telehealth.

OBJECTIVE: The primary study aim is to evaluate the effectiveness of a virtually delivered lecture, which provides brief instruction on how to perform telehealth video visits, to improve provider utilization of telehealth video visits during the SARS-CoV-2 pandemic. Specifically, our SMART goal is to decrease the number of physicians doing 0 video visits weekly by 50% over the course of 1 month (from March 30, 2020 to April 30, 2020).

METHODS: 17 Physical Medicine and Rehabilitation (PM&R) attendings and residents at the VA Palo Alto Health Care System (VAPAHCS) were emailed an anonymous pre-intervention survey to assess their baseline utilization of the VAPAHCS’ video visit software (Virtual Care Manager).  A 45-minute virtually delivered PowerPoint lecture was then presented, which provided a brief description of the required video visit equipment and reviewed how to use the telehealth video visit software, maintain HIPPA compliance during video visits, bill for video visits, as well as assist patients in troubleshooting the video visit software. A PDF of the lecture was also made available to all providers after the PowerPoint lecture. The providers were then emailed an anonymous post-intervention survey regarding their utilization of the video visit software 1 month after the lecture.

RESULTS: Surveys were completed by 12/17 PM&R resident and attending physicians. Survey results indicate that providers’ perceived importance of video telehealth visits significantly increased, by approximately 2-fold, as a result of the SARS-CoV-2 pandemic (p-value: 0.0004). Furthermore, data show that just prior to the lecture, approximately 91% of physicians reported doing 0 video visits in an average week. One month after the lecture was given, there was a significant decrease to only 33% of providers reporting doing 0 video visits weekly (p-value: 0.008), which exceeded our original SMART goal.

CONCLUSIONS: Although the study is limited by a small sample size, our findings suggest that the SARS-CoV-2 pandemic has significantly increased providers’ perceived importance of video telehealth visits. Results of the current study further show that a short, virtually delivered lecture regarding how to perform video visits can effectively increase providers’ utilization of this software. Utilization of this software for patient visits is beneficial as it offers additional clinical insight not available through telephone visits, while minimizing risk of COVID-19 infection for both patient and provider.

FOOTNOTES:
1. “Telehealth Index: 2015 Physician Survey.” American Well, June 2015. http://go.americanwell.com/rs/335-QLG-882/images/Telehealth-Physician-Survey-eBook.pdf
2. “Telehealth Index: 2019 Physician Survey.” American Well, July 2019. https://static.americanwell.com/app/uploads/2019/04/American-Well-Telehealth-Index-2019-Physician-Survey.pdf
Efficacy of a formalized Skilled Nursing Facility Curriculum for Geriatric Medicine and Geriatric Psychiatry Fellows


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Chen, Zeng Zaneta
Chen, Can
Choe, Philip
Martin, Marina
Sheffrin, Meera
Gould, Christine
Medicine Department Background: During the 2018-2019 academic year, Stanford-Palo Alto VA Geriatrics Fellowship undertook a Quality Improvement project to assess preparedness for working in a Skilled Nursing Facility (SNF) after graduation from fellowship. The results showed that only 45% of fellows felt very prepared to begin a career in a SNF setting at the end of their fellowship. With this information, a formalized SNF curriculum was formed and implemented during the 2019-2020 academic year to assess its effectiveness.

Methods: Geriatric Medicine and Geriatric Psychiatry fellows underwent 30 minute oral and slide-based didactic presentations during their SNF rotation with a SNF faculty member on 7 SNF-specific topics as determined by an expert panel of SNF geriatricians: Introduction to Long-Term Care, Fever, Dysphagia, Falls, Transfer to Hospital, Role of the Medical Director and Attending Physician, and Capacity and Ethical Issues in the setting of nursing homes.  Before and after these sessions, a 20-question self-survey and a 23-question board-style multiple choice test were given to the fellows to assess their subjective comfort and objective knowledge regarding these topics.

Results: Both overall subjective comfort and objective knowledge improved after fellows underwent formal didactics, with a 72% increase in overall subjective comfort and a 12.5% increase in objective knowledge. By specific topic, the greatest increase in objective knowledge was regarding roles of the medical director and attending physician in nursing homes. While subject comfort increased in all 7 topics, objective knowledge as reflected by test scores was lower in the topic of “ Introduction to Long-Term Care”, and remained unchanged for dysphagia, falls, and discharge planning.

Conclusions: With a formalized Skilled Nursing Facility Curriculum dedicated to improving Geriatric Medicine and Geriatric Psychiatry Fellow’s knowledge, there is an overall increase in the Fellow’s comfort and expertise in practicing in the SNF setting after fellowship. However, some adjustments to specific topics of the curriculum are perhaps warranted to further improve education in these topics.
EMR Handoff Tool Improves Transitions of Care for Acute Rehabilitation Handoffs


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Nitin Prabhakar MD, David Bakal MD
Nitin Prabhakar MD
David Bakal MD
Henry Huie MD
Orthopedic Surgery Department Purpose
Sufficient communication during patient handoffs and transitions of care are key to preventing adverse events in the hospital setting. The Rehabilitation Center at Santa Clara Valley Medical Center (SCVMC) rehabilitates patients with catastrophic injuries, such as brain injuries and spinal cord injuries.  These patients can present to acute rehabilitation with a higher degree of medical complexity, such as having a tracheostomy or requiring mechanical ventilation. Despite the medical complexity of its patients, the rehabilitation unit at SCVMC did not have a standard handoff process for when patients were transitioned from the “day team” to the overnight on call resident. A variety of methods were used to transition care, including in person communication, phone communication, and secure emails. The purpose of this project was to create a secure, standardized handoff procedure for when rehabilitation patients at SCVMC were transitioned from the day team to the overnight resident.

Methods
Working with the IT department at SCVMC, we created a new “handoff” tab in Epic with three separate sections derived from the I-PASS handoff curriculum – patient summary, current to-do list, and situation awareness/contingency plan. The primary team was asked to fill out this information for each patient prior to the start of the overnight resident’s shift. In addition, access to this handoff function was developed for Epic’s mobile application Haiku to improve the ease at which physicians could efficiently access the information while on call.  Pre-intervention surveys were sent to all residents and attendings prior to implementation of the new handoff tab. Post-intervention surveys were sent to all residents and attendings four months after implementation of the new handoff tab. Data was collected via online surveys using SurveyMonkey.com and statistical analyses were performed using R studio version 1.2.

Results
Pre-intervention surveys were completed by 23 physicians (16 residents, 7 attendings) and post-intervention surveys were completed by 21 physicians (14 residents, 7 attendings). Pre-intervention, 30.4% of physicians reported that they provided handoff on at least half of their patients; post-intervention 88.2% of physicians reported that they provided handoff on at least half of their patients (p<0.001). Both pre- and post-intervention, the majority of residents indicated that they typically received at least one page per night regarding a change in a patient’s vital signs or mental status. In these situations, prior to intervention, 43.8% of residents indicated that necessary handoff was “rarely” provided and 56.2% indicated that it was “sometimes” provided. In these situations post-intervention, 7.1% of residents felt that the necessary handoff was “rarely” provided, 35.7% felt that it was “sometimes” provided, and 57.1% felt that it was “often” provided (p<0.001). When physicians were asked to rate their satisfaction level with the handoff process on a scale of 1 to 5 (corresponding to highly dissatisfied to highly satisfied), the median score pre-intervention was 3 (IQR 2.5-4.0) versus post-intervention 5 (IQR: 3-5) (p<0.001).

Conclusion
By implementing a standardized EMR handoff tool for the rehabilitation unit at SCVMC, we found that physicians provided handoff information to the overnight resident on more of their patients. Additionally, we saw that after the implementation of the handoff tab, residents working overnight felt that they were more easily able to manage patient care, likely as a result of having been provided more information from the day team. Lastly, we saw that physicians generally felt more satisfied with the handoff process after implementation of the handoff tab. Implementing an EMR-based tool to improve the handoff process provided the ability to create a HIPAA-compliant intervention that resulted in improved transitions of care for a medically complex acute rehabilitation unit.  
Evaluation and deprescribing of high-risk medications in geriatric population with dementia


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Liana So, PharmD
Catherine Hong, PharmD, BCCCP
Vittavat Termglinchan MD
Philip Choe, DO
Medicine Department Background: The Veterans Affairs (VA) Sierra Pacific Network developed a population health management tool, referred to as a dashboard, that identifies patients with dementia who are on high-risk medications (opioids, benzodiazepines (BZDs), and highly anticholinergics (ACs)). This study aims to evaluate the impact of this dashboard on the patient outcome of deprescribing inappropriate high-risk medications.

Methods: This is a prospective quality improvement pilot study at the VA Palo Alto Health Care System. The study period is from November 1, 2019 to April 17, 2020. Patients in the geriatric clinic with a dementia diagnosis or received dementia pharmacotherapy from the VA on pre-determined high-risk medications were included. They were excluded if on hospice care, passed away during the study period, or received high-risk medication from non-VA providers, during inpatient stay, or for one-time use. Providers conducted a goals of care discussion with the patient at next clinic visit and results were documented in a standardized template. Primary outcome was the percentage of patients with initiation of deprescribing. Secondary outcome was the percentage of patients not initiated on a deprescribing trial.

Results: A total of ten patients were included in the study (n=8 on highly ACs, n=1 on BZDs, n=1 on chronic opioids). Of the ten patients, 30% (n=3) were initiated on a deprescribing trial (discontinuation of high-risk medication and dose reduction). 70% (n=7) of patients were not initiated on a deprescribing trial (risks of deprescribing outweighed benefits).

Conclusions: The dementia dashboard is a promising tool to monitor inappropriate prescribing of ACs in older adults with dementia. By refining the dashboard definitions to identify actionable patients, effectiveness and usability in a broader primary care clinic setting can be achieved.
Evaluation of seizure risk in neonates after cardiopulmonary bypass in the absence of deep hypothermic cardiac arrest


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Rebecca Levy
Elizabeth Mayne
Amanda G Sandoval Karamian
Mehreen Iqbal
Natasha Purington
Rajani Kaimal
Kathleen Ryan
Courtney Wusthoff
Neurology Department Objective: The American Clinical Neurophysiology Society suggests continuous EEG (cEEG) for seizure detection after neonatal surgery involving cardiopulmonary bypass (CPB). Early reports described seizures in 21% of children after CPB, with recent estimates ranging 3-12%. Seizures have been associated with deep hypothermic cardiac arrest (DHCA), bypass duration, and age. This study characterizes seizure prevalence in a neonatal cohort after CPB without standard DHCA.
Methods: Single-center chart review of all infants from July 2017 through June 2019 monitored with cEEG for 48 hours after CPB, as per institutional guideline. Clinical and EEG variables were recorded for univariate and multivariate analyses.
Results: 12 of 112 (10.7%) patients had seizures on cEEG; 5 (42%) had status epilepticus. All 12 had subclinical seizures; 2 also had electroclinical seizures. Median time from bypass end to first seizure was 28.1 hours [IQR 18.9-32.2 hours, range 6-52 hours]. Only 2 patients underwent DHCA; neither had seizures. Highly predictive risk factors include: post-op paralysis, abnormal brain imaging, prematurity, delayed sternal closure, bypass time, critical illness pre-op (number of codes, oxygen or ventilator dependence), and lactate peak peri-op. These confirm many findings in the literature.
Conclusions: Seizure prevalence in our cohort was analogous to other reports, despite minimal DHCA in our group. Among infants with seizures, time to first seizure ranged from 6-52 hours after end of CPB, suggesting a window of highest yield for cEEG. Modeling risk factors in our sample had high accuracy and can be used as a calculator to predict risk in future patients. 
If a Tree Falls in the Woods…Improving POLST Documentation Rates to Memorialize Patient Preferences


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Mukund Ramkumar
J. Langston
C. Henley
L. Shieh
S. Harman
W. Teuteberg
Medicine Department Background: Patients with code status limitations are at high risk of receiving undesired treatments. The Physician Orders for Life-Sustaining Treatment (POLST) is a portable medical order with treatment limitations for emergency care. Treatment limiting POLSTs are associated with lower rates of unwanted CPR, hospitalizations, antibiotic use, and artificial nutrition(1). POLST forms help deliver patients the care they want. Rates of POLST completion for patients with code status limitations at Stanford Hospital are low. From January 2017 – December 2018, 4906 patients with code status limitations were discharged and 2507 had a POLST form upon discharge; thus only 51% of patients with known code status limitations were discharged with a POLST. The vast majority of these 4906 patients were discharged from Internal medicine and medicine subspecialty services.
SMART Goal: Increase POLST completion rate for patients with code status limitations from 60% to 80% by October 2019 on the Internal Medicine service.
Methods: The process of clarifying a patient’s code status limitations and completion of a treatment limiting POLST were analyzed. Key drivers were identified as discomfort with goals of care conversation and the desire to avoid reproducing challenging conversations while completing POLST form, which are often completed by busy providers during the discharge process. The Goals of Care (GOC) note in EPIC is frequently utilized to document code status limitations. We modified this note template to include a question regarding POLST completion with the aim of encouraging providers to complete POLST forms at the time of a GOC conversation.
Results: The GOC template was modified on July 1, 2019. POLST completion for patients with code status limitations discharged from Internal Medicine went from 63% in June 2019 to 72% in July and subsequently went up to 79% in September. However rates fell to 62%, 61%, and 55% in October, November, and December respectively.
Key Learning: This documentation based intervention initially yielded an increase in POLST completion rates, but this increase was not sustained. Additional key drivers are education and systems to prompt providers to complete POLSTs; these should be areas of interest for future interventions.

1. Hickman  SE, Keevern  E, Hammes  BJ.  Use of the physician orders for life-sustaining treatment program in the clinical setting: a systematic review of the literature.  J Am Geriatr Soc. 2015;63(2):341-350.
Impact of a Best Practice Alert Intervention on Potentially Inappropriate Platelet Transfusion Ordering in the Inpatient Hospital Setting


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Emily Pang, MS
 Eric Mou, MD
Colin Murphy, MD
Jason Hom, MD
Lisa Shieh, MD, PhD
Neil Shah, MD
Medicine Department Introduction
Platelets are transfused prophylactically to prevent hemorrhage in a variety of patient populations, including those with hematologic malignancies, and individuals undergoing transplant, surgery, or beside procedures. Guidelines indicate that prophylactic platelet transfusions patients with platelet counts above 50k/uL are usually not indicated, with notable exceptions including patients undergoing neurological or cardiac bypass surgery. Common minor procedures such as paracentesis, central line placement, bone marrow biopsy, and lumbar puncture have been safely performed at platelet counts below 50k/uL. Despite this evidence, large numbers of platelet transfusions occur even when the patient’s most recent platelet count exceeds 50k/uL. In 2017, our institution incurred approximately 10 million (USD) in direct platelet costs, with nearly 40% of platelet transfusions are occurring when the patient’s platelet count exceeded 50k/uL. Given the significant financial impact of, and potential adverse effects associated with inappropriate platelet transfusion, we implemented a best practice advisory (BPA) in our electronic medical record (EMR) in order to characterize patterns of platelet transfusion orders in patients with platelet counts >50k/uL.

Methods
 An EMR-embedded BPA was activated in the inpatient hospital setting of a large, tertiary care academic medical center on May 6, 2019. The BPA was triggered whenever a platelet transfusion order was placed on a patient whose most recent documented platelet count was >50k/uL. To inform the comparative impact of BPA alerts on provider behavior, alerts were randomized at the patient level to trigger either in standard or silent fashion. For silent alerts, no BPA was show on-screen, but the occurrence was recorded. For standard alerts, the BPA appeared on-screen, informing the provider that their platelet transfusion order was potentially inappropriate and citing supportive evidence. Providers had the option of following or overriding the alert, but for the latter a pre-specified or free text justification was requested. Pre-specified options included upcoming neurosurgery, cardiac bypass surgery, known qualitative platelet defects, or patients taking antiplatelet drugs. Charge data were based on charges for platelet transfusion orders as listed in the hospital charge master.

Results
Over the 9-month, 275-day study period, 6222 platelets were issued to 1532 patients in orders of 2 or less platelets. This included 811 orders for 490 patients that were eligible for the BPA. 237 patient charts were randomized to the control or invisible alert, and 253 were randomized to the visible alert. Over the study period, the control group used 461 platelets and the intervention group used 354 platelets, a 23.1% reduction. In the control group, all 421 instances of platelet orders were subsequently issued. In the visible alert group, 390 orders were placed and 335 were issued after interaction with the BPA (p<0.001). All 237 patients in the control group were subsequently transfused, whereas 17 of 253 visible alert patients were not transfused (p<0.001). The estimated hospital charge savings as a result of the BPA intervention was $43,450 (USD).

Discussion
Over 9 months, patients with a visible BPA in their chart were significantly less likely to be transfused platelets when their platelet count was over 50k/uL than patients in the control group, resulting in substantial cost savings. Platelets are frequently ordered in potentially inappropriate settings, and that reducing these orders may impart significant financial savings. Though provider decision-making with regard to transfusions is multi-faceted, the presence of a BPA may have a more general effect of modifying behaviors towards platelet utilization. The insights from this intervention highlight the importance of building common bypass reasons into a BPA and evaluating the efficacy of context-specific BPA targeting to optimize alert triggering and minimize alert fatigue. Overall, these results provide an impetus for interventions directed at educating providers on appropriate platelet ordering practices to further reduce unnecessary expenditures and optimize patient care.
Implementation and Evaluation of Neurology Residency Program Changes on Well-being During COVID-19 Pandemic


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Sara Pavitt
Jingjing (Jenny) Chen, MD, MBA
 Shefali Dujari, MD
Rebecca Miller-Kuhlmann, MD
Nirali Vora, MD
Neurology Department Background: Well-being research has shown increased rates of burnout are associated with decreased satisfaction with work-life balance and career, while opportunities for professional development are protective. Well-being worsens during times of change when there is loss of the sense of control.

In March 2020, Stanford residents faced a great transition in medicine with the onset of the COVID-19 pandemic. Residents have had to cope with constant uncertainty and disruption of existing clinical and educational traditions, while understanding their role amidst dynamic governmental and institutional guidelines.

Stanford Neurology and Child Neurology residency programs rapidly implemented multiple changes to mitigate these disruptions. While it is assumed that the COVID-19 pandemic has negatively impacted a global sense of well-being, there is a gap in the existing literature in quantifying how interventions have affected resident well-being. We aim to evaluate the impact of our specific interventions on neurology resident well-being.

Methods: In the response to new guidelines put in place with COVID-19, Stanford Neurology departmental and residency leaders designed and implemented multiple interventions aimed to protect patient and physician safety, resident education, and resident well-being.  An anonymous survey was distributed to neurology residents 6 weeks after implementation to assess current level of wellbeing based on validated scales (1) and the effects of specific neurology interventions during the COVID-19 pandemic on anxiety, burnout, professional fulfillment, and engagement with peers using a Likert scale. Current well-being will be compared to identical survey results completed amongst the same cohort 5 months prior. Results of specific interventions will be analyzed using exploratory analysis. Based on these results, interventions implemented during pandemic will be re-designed to target optimizing resident wellbeing.

Results: Data collection is ongoing; currently 66% of adult and child neurology residents (n=22) have completed the survey. Final results of the survey will be available in mid-May 2020.

Conclusion:
The COVID-19 pandemic has brought rapid and dramatic change to the way we provide care to our patients and education during our formative training years, coupled with high concern for individual, family, and patient safety. A survey of healthcare providers in Wuhan demonstrated high rates of depression, anxiety, and distress, with higher risk in frontline providers (2). Optimizing resident wellbeing through innovative changes must be prioritized during this dynamic and uncertain time. Interventions require ongoing assessment and present opportunity for rapid improvement that may last beyond the threats of the COVID-19 pandemic. 

1. Trockel M, Bohman B, Lesure E, et al. A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians. Acad Psychiatry (2018) 42:11–24
2. Jianbo L, Simeng M, Ying W, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3(3):e203976.
Improving and Standardizing Inpatient RN-MD Communication with a Voalte Messaging Protocol



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Nima Harandi, MD
Garrison Carlos, MD
R. Conner Dixon, MD
Medicine Department Improving and Standardizing Inpatient RN-MD Communication with a Voalte Messaging Protocol

Problem Statement/Background:

The quality and efficiency of current inpatient RN-MD communication, largely through the Voalte messaging platform, is limited by lack of a standardized protocol and etiquette to define best practices, frustrating providers and potentially adversely impacting patient care. There is broad dissatisfaction among both RNs and MDs regarding current practices, with concerns including over-messaging and response times, inconsistent prioritization of urgent messages, and inability to identify providers.

Target State: SMART Goal:

To establish an RN-MD communication protocol standardizing best practices and paging etiquette to pilot on at least one inpatient unit by May 2020. A secondary goal included improving satisfaction ratings among RNs and MDs involved.

Root Cause Analysis:

Voalte messaging data was obtained and analyzed, identifying inpatient units K5-7 as sending the highest average number of messages among units for which data was available. A focus group was performed with RNs from these units, as well as surgical MDs, to identify specific issues with Voalte and communication. A survey of these individuals (n=18) found baseline satisfaction as 2.8/5 among residents/MDs and 3.7/5 among RNs. Root Cause Analysis (RCA) identified the dominant root cause as institutional given the lack of a universal protocol. Second were cultural and human factors, including providers not being “assigned” to patients, not responding to pages promptly, and paging multiple times in a short interval for routine issues.

Interventions:

Utilizing focus group and survey data of key stakeholders, a novel communication protocol was developed to guide best practices. Central features included categorization of emergent, urgent, and routine messages. The protocol specifies clinical issues for each priority level, how to designate urgent messages, appropriate response times, and escalation policy for a lack of response. Recommendations were also given for standardizing Voalte “sign in” time, grouping routine issues to minimize message burden, including complete patient identifiers, and changing Voalte “status” when unavailable with alternate contact clearly listed.

Results:

The proposed protocol was shared with RN and MD stakeholders associated with K5-7 units, who were again surveyed with 34 respondents. Among RNs (n=19), mean and median satisfaction was 3.6/5 and 4/5, respectively. Among MDs (n=15), mean and median satisfaction with the protocol was 3.9/5 and 4/5, respectively. When asked if the protocol will improve understanding of message urgency, 100% and 93% of RNs and MDs respectively agreed, with 26% and 73% agreeing “very much.” When asked if the protocol would improve patient care, 84% and 87% of RNs and MDs agreed, with 32% and 53% agreeing “very much.” When asked if the protocol would improve their work satisfaction, 84% and 93% of RNs and MDs, with 37% and 67% agreeing “very much.” Subjective feedback was also collected regarding specific elements of the protocol, which will guide future efforts to modify and implement the protocol.

Key Learning:

Our proposed Voalte-based communication protocol received high ratings of satisfaction among both RNs and MDs. Surveyed providers showed high agreement that the protocol would improve message urgency understanding (>90%), patient care (>80%), and work satisfaction (>80%). Future directions include continuing to work with stakeholders to optimize and implement the protocol at the hospital-wide level.
Improving Bedside Care and Cognitive Assessment of Adult Epilepsy Monitoring Unit (EMU) Patients


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Wendy Chen, MD
Victoria Liu, MD
Kimford Meador, MD
Scheherazade Le, MD
Neurology Department Problem Statement / Background:
Patients admitted to the Stanford adult epilepsy monitoring unit (EMU) commonly have medications weaned off or reduced in order to capture their spells. Thus, these patients are at risk for status epilepticus and in rare cases, death. “Seizure first aid” includes measures such as turning the patient on his/her side, assessment of vital signs, and providing appropriate rescue medications. Furthermore, ictal cognition can oftentimes be impaired during seizures.

Current State:
Currently, staff members rely on patient or witness report of a seizure or by EEG recording of seizure activity to come into a patient’s room to assess a patient during a seizure. There is also currently no international consensus for peri-ictal cognitive testing in the EMU and most providers ask simple questions and commands as ways of testing ictal cognition.

SMART Goals:
- Reducing the time from seizure detection to staff bedside assessment by at least 50%.
- Improving “seizure first aid” to 100% in patients with GTCS (generalized tonic clonic seizures) and FTBTCS (focal to bilateral tonic clonic seizures).
- Using a “responsometer” app on the SmartMonitor© SmartWatch device to standardize ictal cognitive assessment on patients and improve the ictal cognitive assessment rate of patients to >50%.

Key Drivers / Interventions / Countermeasures:
The SmartMonitor© SmartWatch is a wearable device that detects shaking using an accelerometer. This study aims to extend the functionalities of the SmartWatch by enabling it to assess responsiveness during seizures using the “responsometer” app created by the company. Staff members at Stanford Hospital were trained to activate the watch in July 2019. Adult patients aged 18 and older with epilepsy or epilepsy imitators admitted for differential diagnosis or Phase I monitoring were included in the study. Phase II intracranial monitoring patients, pregnant patients, and patients who were unable to operate the watch either due to physical or cognitive limitations were excluded. Data on time of staff response to a seizure, seizure first aid administration, and type of cognitive assessment performed were compared between patients on the watch study and those who were not. 

Results / Key Learning:
Ten patients were recruited in this study from August 2019 to February 2020. Due to patient factors or technical difficulties, only 2 had the watch activated during typical spells. "Seizure first aid” was performed in 100% of patients with FTBTCS in the study phase and 66% of patients in the pre-study phase. No patients had GTCS. On average, the time from seizure detection to staff coming in the room was reduced from reduced from 1.11 minutes to 0.21 minutes (difference of 0.9 minutes and percent change of 81%). The preliminary results from this ongoing study demonstrate that the “responsometer” app has some technical issues but is effective at testing ictal cognition and improving patient safety in the EMU.
Improving Guideline-Directed Medical Therapy Utilization for Heart Failure with Reduced Ejection Fraction Within a Veteran's Affairs Health System



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Justin Slade, MD
Michelle Lee, PharmD
Jun Park, PharmD
 Alexander Liu, MD
Paul A Heidenreich, MD
Nazima Allaudeen, MD

Palo Alto VA Health Care System, Palo Alto, CA
Medicine Department Despite a robust evidence base and well-established clinical guidelines for patients with HFrEF, a significant number of patients with this disease are not currently prescribed ACEI/ARB/ARNI and beta-blocker therapies at or near target doses proven to reduce the risk of cardiovascular events and mortality in randomized clinical trials.

Within the VA Palo Alto Health System we found that the minority of patients with HFrEF prescribed these therapies were receiving ACEI/ARB/ARNI (45.2%: 410 of 908) and beta-blockers (45.4%: 458 of 1008) at ≥50% of target doses. Limited general medicine and cardiology appointment availability as well as clinical inertia were identified as root causes of suboptimal dosing of guideline-directed medical therapy (GDMT).

We addressed these with implementation of a pharmacist driven Heart Failure Medication Titration Clinic through a shared practice agreement with general medicine physicians, initially at one clinical site with 190 total HFrEF patients. An academic detailing clinical dashboard including medication prescribing and LV ejection fraction data (obtained via natural language processing of imaging reports) is utilized by the on-site clinical pharmacist to identify actionable HFrEF patients on suboptimal GDMT. If felt appropriate for escalation of therapy, a patient’s primary care physician or cardiologist approves a referral to the clinic. The pharmacist then conducts regular clinic or telephone visits (typically every two to four weeks) with the patient to assess tolerance of therapy and eligibility for further dose escalation per an established titration algorithm that integrates recent symptoms, vital signs, and lab values.

In six months, patients referred to the Heart Failure Medication Titration Clinic have had their average ACE/ARB/ARNI dose escalated from 18.8%% to 35.4% of target dose and their average beta-blocker dose escalated from 52.1% to 81.3% of target dose. No adverse medication events or hospitalizations have occurred. There has been a corresponding increase in the overall percentage of this clinical site’s HFrEF patients on ACEI/ARB/ARNI (36.4% to 50.0%) and beta-blockers (39.4% to 46.1%) that are receiving ≥50% of target dose therapy.

These results suggest that clinical pharmacists can play a vital role in identifying and treating patients that are on suboptimal treatment for HFrEF via utilization of an academic detailing dashboard and pharmacist led medication titration clinics. Limitations of this quality improvement initiative include short duration of follow-up to date and performance of these interventions within an integrated health care system, which may not be generalizable to other health care delivery models. Next steps include addition of mineralocorticoid antagonist therapy to our titration algorithm and scaling these interventions to additional clinical sites within our health system. 
Improving Influenza Vaccination at Stanford Rheumatology Clinic


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Audra Horomanski, MD
Kate Kolstad MD PhD,
Melanie Buentipo
Ryan Marti PharmD
Nilushka Melnick
Gabriela Triant
Janice Lin MD
Medicine Department Abstract:
Background: Patients with rheumatologic diseases are at greater risk for complications of influenza infection due to immunosuppression from their disease and associated therapy. Prior studies have shown there are higher rates of hospitalization, intensive care admission, bacteremia, and death from influenza in this population. The influenza vaccination rate for Stanford Rheumatology Clinic in 2018/2019 was 62%. While this is above the overall national rate of 43.5%, it still leaves a high percentage of vulnerable patients without potential immunity.

Objective: Analyze the process of recording influenza vaccination status during patient visits and implement interventions with the goal of improving the vaccination rate from 62% to 70% over a period of one year.

Methods: With guidance from the Realizing Improvement through Team Empowerment (RITE ) cohort, we performed a root cause analysis and identified the process of obtaining and relaying vaccination information within the Rheumatology Clinic. We initiated several interventions, including making the vaccine available at the Stanford Cancer Center Pharmacy at the beginning of the flu season, creating a standard process for Medical Assistants to record vaccination information, and informing providers when patients “decline” or “plan to” receive vaccination. We tracked the cumulative vaccination rate throughout the 2019/2020 flu season.

Results: The root cause analysis revealed that there was no standard process for Medical Assistants to collect vaccine information on clinic patients. Furthermore, when this information was collected, it was not relayed to the provider or readily visible in EPIC. We initially instituted a process to inform providers when a patient declined the flu vaccine, but found that this made providers less likely to engage in a discussion with the patient, frequently citing concerns about time. We subsequently informed providers when patients “plan to” be vaccinated and found that they were more open to engaging in discussions with patients. However, despite these interventions, there was no significant difference in the flu vaccination rate compared to the prior flu season (62% vs 61%).

Conclusions: Although there was not an improvement in the vaccination rate this year, we learned several valuable lessons. Namely, there were serious flaws in how our clinic was collecting vaccination information and a breakdown in communication within the care team. We had also hypothesized that making the vaccine available at the Stanford Pharmacy would increase vaccination rates, but there was no difference in rate despite this being the earliest intervention. However, this was not a widely publicized resource until late in the season. These findings have spurred changes in our clinic workflow and initiated a project to better understand personal barriers to vaccination in rheumatology patients.
Improving long-term care for patients with drug and alcohol use disorders admitted to internal medicine


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Nadeem Abou-Arraj
Aparna Goel
Lisa Shieh
Amer Raheemullah
Medicine Department Over 20 million Americans qualify for diagnosis of substance use disorder (SUD), and over 15% of hospitalized patients have a SUD. Patients with SUD have higher rates of ED visits, readmission, costly resource utilization, and mortality. Internal medicine teams care for many patients admitted for complications of SUDs. These teams are well equipped to deal with the medical complications of SUDs but are not as well versed in treating the underlying SUDs themselves. Evidence is emerging that initiating pharmacotherapy for addictions at hospital discharge leads to decreased recidivism and decreased readmissions. Securing outpatient follow up is crucial to caring for patients with addictions. Addiction medicine consultation teams have been shown to facilitate the appropriate treatment of SUDs prior to discharge, leading to better outcomes. Criteria for early liver transplant in alcoholism is changing, though medicine teams often still function under the previous recommendation of six months of sobriety prior to transplant. Stanford has excellent addiction medicine and hepatology teams that are well versed in evidence-based treatment for SUDs. Yet, many patients admitted for complications of SUDs are not seen by these teams and do not receive appropriate follow up and pharmacotherapy for SUDs. Additionally, many internal medicine teams are not certain whether a patient with alcohol-induced liver failure is appropriate for transplant evaluation.
This project’s smart goal was to increase by 25% by 3/2020 the rates of appropriate consultations, pharmacotherapy prescription, and outpatient follow up reported by internal medicine residents for patients admitted with complications of SUDs. Consultation and follow-up algorithms were created with the input of addiction medicine and hepatology consultation teams. An educational intervention targeting internal medicine residents was performed at baseline and six months. A survey of internal medicine residents’ practice patterns and perspectives demonstrated significant increases in self-reported addiction medicine consultations obtained and pharmacotherapy prescribed at discharged, and a trend toward significance in arranging outpatient follow up for SUD treatment for patients admitted with complications of SUD. These results were evident at six month follow up after the second educational intervention and persisted at final survey six months later, without another educational intervention, demonstrating that the increases in desired outcomes were durable. The results were limited in that data were self-reported and survey response was low. This project demonstrates that an educational intervention can increase internal medicine residents’ self-reported rates of evidence-based interventions for patients admitted with SUDs.
Improving provider-nursing communication on an inpatient neurosurgery unit


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Leean Rodolfich, MSN, RN
Thomas Wilson, MD
Josh Dodson, RN
Jesus Navoa, PA
Corrine Petrushonis, RN-BC
Sammita Satyanarayan, MD
Angel Shew, MPH
Aaron Sy, MS
Neurosurgery Department Multiple communication methods allow for ineffective provider- nursing communication leading to staff burnout. The 2019 SCORE survey among neurosurgery staff showed poor perceptions of teamwork, with a subsequent needs assessment of Neurosurgery providers showing 65% of providers endorsing communication related burnout. Using free text responses from the needs assessment, we conducted a root cause analysis of communication breakdown between providers and nurses.  Main issues identified were proper identification of providers in Voalte, inconsistent provider assignment in Voalte, message volume burden, prioritization of messages, and expectations regarding message responses. We believed key drivers of these issues identification of appropriate provider, minimizing Voalte message fatigue, and clear escalation guidelines. Our interventions focused on minimizing Voalte message fatigue with increasing awareness of priority messaging, creating a logging sheet for non-urgent nursing needs, and implementing a rounding checklist during daily multidisciplinary rounds. After these interventions, the average number of Voalte messages per day shift decreased from 5.7 to 4.6 after implementation (p<0.05), and post-intervention survey data of neurosurgery providers showed communication-related burnout decreasing from 65% to 47%.

 
Improving Rapid Response Communication


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Wil Gibb
James Mitchell
Jeff Choi
Karen McIntyre
Paul Georgantes
Paul Mohabir
David Li
AJ Pedroza
Adjoa Boateng
Garrison Carlos
Swati DiDonato
Emergency Medicine Department  The rapid response team (RRT) is called to a patient’s bedside when a team member, typically the primary nurse, observes a deterioration in patient status. From 2011-2019, there were 4,206 RRT activations at Stanford Health Care. However, there is currently no standardized way to let primary physicians know that an RRT has been activated for their patient. We found that of internal medicine residents surveyed,  52% found their role in an RRT to be unclear, and 63% have missed an RRT on their patient because they were not notified. This lack of communication can delay appropriate patient care. Our team’s goal was to assess the current communication cycle of an RRT and to build an improved, standardized system.  Using a multidisciplinary approach, our team created a standardized RRT communication workflow which will assure that the primary resident team is notified promptly when an RRT is called on their patient. Having a standardized process for communication during critical events during a patient’s hospitalization is crucial for ensuring safe care.
Improving the efficiency and safety of Neuro-ICU to floor patient transfers


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Anna Janas MD PhD
Angie Murkins NP
Lili Velickovic Ostojic MD
Christina Mijalski MD
Zachary Threlkeld MD
Neurology Department Background: Transfer of patients from the Neuro-ICU to the floor is often delayed, even once an available bed is identified. Delays in transfer may result in unpredictable transfer timing that interferes with rounds and didactics, incomplete handoff between providers less familiar with the patient, occupation of ICU beds by patients who no longer require an ICU level of care, increased length of stay, and most importantly compromised patient safety. Models used by other services and institutions to address such delays include having the floor team round on floor-level patients who remain in the ICU, or having the ICU team be responsible for patients after transfer until provider handoff can be completed.

Current State: Our current state analysis revealed that between July 2018 and July 2019 the average total transfer time (from bed request to transfer completion) for Neuro-ICU patients was 11.2 hours.

SMART goal: To reduce the Neuro-ICU to Floor transfer time (from bed request to completion) from 11 hours to 3 hours by September 2020.

Interventions: We identified 3 key drivers that play a role in making the transfer process more efficient: prompt bed boarding, prompt signing of transfer orders, and prompt assessment of the patient by the accepting floor team. To address these key drivers we implemented a new transfer protocol for patients transferring from the Neuro-ICU to the Stroke floor. The protocol focuses on early (pre-rounding) bed boarding by the ICU fellow and attending, signing of transfer orders by the ICU team as soon as the patient is bed boarded, and the ICU team remaining the primary responsible team after transfer to floor until provider handoff is completed. This new protocol was implemented on March 2 , 2020.

Results: We performed a survey on provider compliance and satisfaction six weeks following implementation of the new protocol. 38 providers completed the survey. Of those, 79% were either very familiar or somewhat familiar with the protocol. The new protocol was implemented in a majority of transfers. Among providers who worked in the Neuro ICU or stroke floor since March 2 , 70% agreed that the new protocol improved efficiency of the transfer process.

Future Directions: Further analysis of the total transfer time will be performed at 3 month follow up. Pending the results of our efforts, we will explore expansion of the protocol to other Neurology services.
Improving the Quality and Ease of Outpatient Preoperative Evaluations


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Tara Ramaswamy, MD
Malathi Srinivasan, MD 
Medicine Department Background: Outpatient clinicians have variable approaches to preoperative consultation, including using different evidence sources that may not be fully up to date. Epic templates can help guide providers and offer current evidence to aid decision making.  Currently, residents and faculty at Stanford Internal Medicine (SIM) clinic do not have an evidence based Epic template for outpatient preoperative evaluation.

Target Goals: Our goals are to 1) understand current preoperative practices and viewpoints of medicine faculty and trainees, 2) quantify how many outpatient preoperative evaluations are performed per year (SIM East and West clinics), 3) create an updated, provider-friendly, evidence based Epic preoperative template, and 4) create improved curriculum for trainee education on perioperative care. We hope to achieve 80% provider utilization of developed tools as well as improved provider satisfaction based on survey data within 8 weeks of implementation.

Methods: We first queried Epic to quantify how many SIM clinic preoperative evaluations were completed between January 1, 2018 and January 1, 2019 based on visit diagnosis code. We then created a survey that was distributed to SIM attending clinic physicians, nurse practitioners, and residents to better understand current preoperative evaluation practices and areas for improvement. Using the results from our survey data, we created a new streamlined, evidence based Smartphrase within Epic to help providers complete the preoperative evaluation. We also created a new teaching module for perioperative management in primary care that was distributed to trainees in March 2020.

Results: Between January 1, 2018 and January 1, 2019, 191 preoperative evaluations were completed at Stanford Internal Medicine Clinic. Our pre-intervention survey consisted of a total of 34 responses  (15 attending physicians, 2 NPs, 11 residents, and 6  interns). All participants were internal medicine or family medicine trained. In the last year, 82% residents had completed between 1 and 10 evaluations (9/11) and 59% attendings/NPs had completed between 1 and 10 evaluations (10/17). 0/6 interns had completed any preoperative evaluations at time of survey collection. When queried what resources were utilized in completion of preoperative evaluations, 13/17 attendings/NPs used UpToDate, 8/17 used RCRI, 8/17 had their own Epic Smartphrase,  5/17 used colleagues, 4/17 used NSQIP, 3/17 used a pre-existing Epic Smartphrase, and 2/17 referred patient to anesthesia preoperative clinic. The residents, in contrast, utilized NSQIP (8/11),  RCRI (8/11),  UptoDate (6/11), referral to anesthesia clinic (5/11), individual Smartphrase (2/11), EPIC generated  Smartphrase (1/11), and MICA (1/11).  14/17 attendings/NPs and 8/11 residents wished for core education regarding critical issues in perioperative evaluation. 16/17 attendings/NPs and 7/11 residents wished for an evidence based Epic template to be created. Using this survey data as a guide, a primary care teaching module and a new Epic Smartphrase were created and piloted in March 2020 and April 2020, respectively. The module was distributed to all SIM residents and the template was piloted to 10 residents. Post-pilot survey results of residents were notable for the following: 3/10 residents felt the new template was “somewhat easier” than the current available resources and 7/10 residents indicated the new template was “much easier.” 8/10 residents felt the new template adhered to evidence based practice “very well.” 10/10 residents indicated they were likely to use the template in the future (1/10 somewhat likely, 9/10 very likely). 10/10 residents felt the educational module addressed evidence based guidelines “very well” and 8/10 residents felt the module helped increase their comfort level in performing outpatient preoperative evaluations.

Discussion: We identified a need in the outpatient setting for more perioperative education and an updated Epic template. Currently in preoperative evaluation, residents used risk scores (RCRI, NSQIP) more commonly than attendings/NPs. We developed a preoperative template that was user-friendly, felt to be evidence based, and highly likely to be used by providers in pilot testing.  We increased provider comfort in outpatient perioperative evaluation with more robust training.  We anticipate our template and educational interventions will ultimately save time, decrease provider workload,  increase provider satisfaction, benefit patients, and decrease avoidable day of surgery cancellations.
Increase effectiveness of intra-operative radiographs to rule out retained foreign objects


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Sarah N. Cheng MD
Jason Ni MD
Ankur Doshi MD
Marilyn Son RT(R)(ARRT)
Elizabeth Knoff RT(R)(CT)(QM)
H. Henry Guo MD, PhD
Radiology Department A retained foreign object (RFO) is a US Joint Commission ‘never event’ which may result in serious patient morbidity and mortality. Surgical sponges and needles are the most commonly retained items, although a multitude of other items are at risk of being left behind. An intraoperative radiograph is often utilized as a last line of defense for discovery of RFOs prior to surgical closure. However, intraoperative radiograph false negative rates have been reported up to 10-15%. The goal was to increase effectiveness of radiologists in evaluating for RFOs on intraoperative radiographs.

An anonymous survey sent out to radiologists collected perceived factors that reduced his or her confidence in the evaluation of RFOs. Recurrent themes that arose from the survey and workplace gemba were summarized into key drivers: radiographic technique to clearly show objects, radiologists' knowledge of the x-ray appearance of RFOs, surgical extent to be clearly marked by surgery for radiology technologists, and standard operation and communication workflow for intraoperative radiographs endorsed by all stakeholders.

A standard protocol was developed that provided critical information to the radiologist, including the type of procedure, exam indication, and specific missing item. A positive control reference radiograph of the missing item was obtained when applicable. A dedicated RFO dictation template was created for radiologist guidance and standardized documentation.

A 10-minute interactive teaching module to improve RFO detection included positive RFO cases, a recommended approach to an intraoperative radiograph, explanatory radiographs of commonly retained sponges and needles, along with pre- and post-training RFO detection performance testing.  Accuracy in detecting RFOs from intraoperative radiographs improved significantly from 62% at pre-testing baseline to 76% after module completion.

Using a Likert scale, radiology attendings and trainees were surveyed regarding their confidence in intraoperative RFO detection at different timepoints: before the start of the QI project, at 1-week increments during intervention roll-out, and after project completion. On a 5-point Likert scale with 5 being the most confident, average radiologist RFO detection confidence rating increased significantly after interventions from a baseline of 3.3 to 3.9. There was sustained increase in the confidence score for seven straight weeks at the end of the intervention period.

Several RFOs were successfully detected during the QI process, including less common items such as surgical patties and umbilical tape, with documented images demonstrating the crucial role of positive control reference images in the accuracy of RFO detection.
Increasing New Patient Access to Neurology Clinics using Patient-Initiated Late Cancellations


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Tarini Goyal
Chitra Venkatasubramanian
Neelam Goyal
Nina Bozinov
Nick Quiroz
Maram Mohamed
Suzanne Pritchard
Cessa Heinzmann
Neurology Department Problem statement/Background
Patient-initiated cancellations cause new patient slot in neurology clinics go unfilled, leading to decreased patient access and decreased clinical productivity. The highest rate of cancellations occur between 2-14 days before the appointment.

Current state/SMART goal
Every month, 40 out of 280 new patient slots (~14%) in neurology clinic are cancelled by patients within 2 – 14 days of their appointment. The average wait time for a new patient to be seen in neurology clinic is 4-6 months from referral. Currently, there is no systematic and effective method to fill these slots. This leads to decreased patient access, multi-month delays for new patient appointments, and reduced clinical productivity. Enhancing new patient access and improving clinical productivity is a key priority for the neurology department. The clinics have lost time in relative value units (RVUs) equivalent to nearly $2 million annually. We aimed to decrease unfilled new patient slots created by late (within 2-14 days) patient-initiated cancellations from 14% to 9% by March 2020.

Analysis/Intervention
After surveying new patient coordinators (NPCs) and observing their workflow, we learned that disorganized workflow, underutilized waitlist, and lack of protocol for filling newly opened slots were major contributors to unfilled new patient slots. We identified 4 key drivers necessary for an improved process: 1) following a standardized NPC workflow to fill slots, 2) routinely utilizing EPIC waitlist functionality, 3) manageable volume of incoming calls to NPCs, and 4) a systematic method for reducing late patient cancellations. Interventions targeted to these key drivers included: routinely checking insurance coverage (a common cause of cancellations), using a centralized waitlist, and reducing incoming call volume through automated recordings and an online FAQ section.

Results/Sustain plan
We reduced unfilled patient slots to 10% by March 2020. The sustain plan includes ongoing efforts to streamline NPC workflow by reducing incoming call volume. Moving forward, new patient access will include innovations such as telemedicine, given rapid conversion to telemedicine visits due to the COVID-19 pandemic.
Make a difference in pneumonia readmissions: Transitionalist Pathway, a multidisciplinary transitions of care approach


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Vittavat Termglinchan, MD
Kelly Zhang, BA
Kimberly Dong, PharmD, BCPD
Karen Nelson, MSW, MBA
Kristel Fallon, RN
Terese McManis, RN
John Shepard, MBA, MHA
Carlos Montalvo
Phyo Aung, PharmD, BCPS
Noah Fang, PharmD, BCPS
Ellen Tasaka, PharmD, BCACP
Alicia Wong, PharmD, BCPS
Neera Ahuja, MD
Charles Liao, MD
Medicine Department Background: The Centers for Medicare and Medicaid Services identified preventable hospital readmissions as one of the leading problems of the U.S. healthcare system. We developed a Transitionalist Pathway (Pathway) to improve transitions of care by using a multidisciplinary care team that focuses on the hospitalization and post-discharge care of the patient. This pilot focuses on patients with pneumonia, a condition with one of the highest readmission rates at our institution and nationwide.
Methods: The Pathway is available via our EPIC electronic medical record through an order set to all patients admitted to Stanford Health Care with a diagnosis of pneumonia. Once the Pathway order set is selected, the provider can choose services that include (1) high-risk readmission providers that specialize in patient education, post-discharge phone calls, and home visits, (2) transition of care pharmacists to provide medication reconciliation and education at discharge, (3) occupational therapists, and (4) social workers. We collected data on age, marital status, hospital length of stay, diagnosis-related group (DRG) weight, discharge location, and hospital readmissions and patient satisfaction survey results. Our primary outcome was all-cause 30-day readmission rates, and secondary outcomes were all-cause 7-day, 15-day and 90-day readmission rates, as well as patient satisfaction.
Results: From August 2017 to 2019, a total of 1,407 patients were admitted under general medicine with a diagnosis of pneumonia. 136 patients (10%) received the Pathway intervention. Pathway patients were significantly older than non-pathway patients (80 vs 71, p<0.001). There was no statistical difference in the hospital length of stay and DRG weight between the two groups. There was a 25% relative reduction in 30-day readmission rate in pathway patients when compared with non-pathway patients with a trend towards significance (12.5% vs 16.5%, p=0.23). Interestingly, pathway patients had a significantly lower 7-day readmission rate when compared with non-pathway patients (2.2% vs 8.3%, p<0.01), but there was a decremental gap between the two groups with almost similar readmission rates at 90-day post-discharge period (26.3% vs 26.7%, p=0.96). There was no statistical difference in patient satisfaction between the two groups.
Conclusion: Improving transitions of care through a multidisciplinary approach can provide a meaningful reduction in readmissions of patients with pneumonia. This approach could be adapted for other high-risk of readmission diagnoses to further optimize care and healthcare costs. In the future, it is important to explore methods to sustain this reduction. This may require improved post-discharge follow-up with outpatient primary care providers.
Measuring the Quality of a Quality Measure


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Shefali Dujari
Santosh Gummidipundi
Zihuai He
Carl A. Gold, MD
Neurology Department Introduction
Quality measures are vital to track and improve the quality of care provided. We have an increasing need for specialty-specific quality measurement sets that are clinically relevant, have robust beta testing for feasibility and reliability performed prior to publication, and allow for benchmarking performance internally and externally(1). Benchmarking is an essential part of the quality improvement process. It allows healthcare providers and organizations to compare their quality of care to top performers in the field, identify underlying drivers of high performance, and develop focused improvement efforts(2). To address this need, the AAN, Neurocritical Care Society, and Neurohospitalist Society jointly published the first Inpatient and Emergency Care Quality Measurement Set for neurology patients, which defines 12 quality measures related to the hospital care of patients with conditions such as status epilepticus and delirium (3,4).  Our goal for this project was to test the feasibility and reliability of one of the twelve measures, as well benchmark performance at our institution, which to our knowledge as not been done for any of the twelve measures.

Methods
The measure we decided to study was regarding the treatment of patients with bacterial meningitis with dexamethasone before or with the first dose of antibiotics. We used the Vizient Clinical Database and Resource Manager to identify non-pediatric patients admitted for bacterial meningitis to Stanford Hospital between October 2015 – June 2019. We then performed further chart review using the hospital electronic medical record to confirm the diagnosis of bacterial meningitis as well as obtain additional data regarding clinical presentation, exclusion criteria to receiving dexamethasone per the quality measure, laboratory work up, and treatment decisions. Exclusion criteria included hypersensitivity to corticosteroids, antibiotic treatment in the last 48 hours, recent neurosurgery or head trauma, or cerebrospinal fluid shunt, as outlined in the quality measure.

Results
We identified 79 patients using Vizient of whom 69 had a diagnosis of bacterial meningitis confirmed by chart review (PPV=87%). Of the 69 patients, 32 (46%) were female and 40 (58%) were white; median (IQR) age was 52 (39, 67). 56 patients were ineligible to receive dexamethasone per the quality measure – 27 patients had antibiotics in the last 48 hours, 37 patients had a recent head trauma or neurosurgery, and 18 patients had a CSF shunt. This left 13 patients eligible to receive dexamethasone. Five of these patients (38%) received dexamethasone. 

Conclusion
This study is one of the first efforts to test the feasibility, reliability, and performance of one of the 12 quality measures included in the AAN Inpatient and Emergency Care Quality Measurement Set(4). We found that during the 45-month study period, 81% of patients with bacterial meningitis were ineligible to receive dexamethasone per the quality measure at our institution, leaving only 13 patients eligible to receive dexamethasone. In our view, the relatively infrequent presentation, high rate of patients with exclusion criteria, and variable involvement of neurologists in these cases raises concern that this measure may be an unreliable indicator of the quality of care provided, especially at large institutions similar to ours. 38% of our patients with bacterial meningitis eligible for dexamethasone received this medication, suggesting room for improvement. However, without the ability to benchmark our institution’s performance against peer institutions, it is not known if 38% represents relatively excellent, average, or poor performance.

References
1. Kotter T, Blozik E, Scherer M. Methods for the guideline-based development of quality indicators – a systematic review. Implementation Sci 2012;7:21.
2. Ettorchi-Tardy A, Levif M, Michel P. Benchmarking: A method for continuous quality improvement in health. Health Policy. 2012 May; 7(4); e101-119.
3. Josephson SA, Ferro J, Cohen A, Webb A, Lee E, Vespa PM. Quality improvement in neurology: Inpatient and emergency care quality measure set - Executive Summary. Neurology 2017;89(7):730-735.
4. American Academy of Neurology. Inpatient and Emergency Neurology Quality Measurement Set. Available at: www.aan.com. Accessed Nov 17, 2019.
Methods to address challenges in implementing teleneurology during COVID-19​


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Jessica Ng, MD
Monica Liu BS
Hilary Wang MD,MBA
Sammita Satyanarayan MD
Jingjing (Jenny) Chen MD,MBA
Laurice Yang MD,MHA
Neurology Department Purpose
In the face of the COVID-19 pandemic, in-person clinic visits have been largely converted to video visits. Since telemedicine was not commonly utilized within the Stanford neurology department prior to the COVID pandemic, trainees and practicing neurologists have not had the experience nor training to conduct teleneurology visits. Transitioning to teleneurology in an effective manner requires prompt implementation of changes discussed below.

Method
We have identified five main areas of focus which form the major challenges and barriers: 1) Need for structured visits, 2) Logistical challenges, 3) Concern about not meeting patients’ expectations, 4) Lack of experience, and 5) Technical issues. Our proposal for quickly addressing these issues include creating a centralized platform to share feedback, forming a teleneurology workgroup, and writing best practice guidelines for video visits. 

Result/Anticipated result
First, we have assembled interested medical students, residents and fellows into a teleneurology workgroup under the guidance of an attending neurologist and meet weekly to discuss implementation of teleneurology visits, ongoing research, and education efforts. Next, in order to troubleshoot issues that arise during teleneurology visits, we have distributed an anonymous survey to collect feedback from residents and fellows. Using the results, we have provided real time changes shared in daily department emails.
Given that a neurology exam is the most novel aspect of a teleneurology visit, we have most recently conducted a webinar featuring five neurology subspecialists and how they have adapted to teleneurology exams. To measure success, we prepared a post-webinar survey to assess attendee’s comfort level in conducting a teleneurology visit before and after the webinar. From the 16 responses from attending, fellows, residents and medical students, the majority have shifted from extremely uncomfortable and somewhat uncomfortable with teleneurology exam skills before the webinar to somewhat comfortable after the webinar. Additionally 57% responded that they are extremely likely to incorporate skills from the session to future telenvisits.

Conclusion
We believe these measures and actions have had an immediate beneficial impact on Stanford’s practice of outpatient neurology. But as the landscape shifts to the growing practice of telemedicine, further research and development is necessary to smoothly incorporate video visits into the field of neurology in a post-COVID world. 
Modifying Post-operative Opioid Prescribing Practices: an Institutional Intervention


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Ashley Titan
Kayla Pfaff
Alexis Doyle
Ioana Baiu

Angela Lee

Andrew Shelton
Mary Hawn 

Surgery Department Introduction:
Over-prescribing of opioid medications has contributed to the epidemic of narcotic addiction in the United States. Opioid overdose is now the leading cause of injury-related deaths nationwide, resulting in more than 47,000 deaths in 2017. More than 10 million Americans admit to abusing opioids during their lifetime and many were initially exposed during the postoperative period. We hypothesized that the implementation of institutional opioid-prescribing guidelines would be associated with a significant decrease in the amount of opioids prescribed and associated variability without negatively impacting patient care.

Methods:
We developed opioid-prescribing guidelines for the 26 most common general surgery procedures and implemented them at our institution. We compared the number of post-operative opioid prescriptions over a 6-month period before and after implementation. Differences in oral morphine equivalents (OMEs) were assessed using the 2-sample t test. The number of patient phone calls following prescription was used as an initial measure of impact on patient care associated with both time periods.

Results:
Data analysis is currently on-going. We have collected 10 patients in each cohort who underwent laparoscopic cholecystectomy.  Within this preliminary cohort collection, there is a statistically significant decrease in amount of OMEs prescribed post-operatively (40.0 ± 3.5 vs. 16.7 ± 1.7, p<0.0001). There has been no difference in the number of outpatient phone calls between time periods.

Conclusion:
Initial data collection indicates that formalized opioid-prescribing guidelines are associated with a decrease in the number of narcotics prescribed, as well as with a decrease in the variability in the number of tablets prescribed. This preliminary data supports that surgeon education using institutional guidelines may facilitate efforts to minimize narcotic over-prescription, and in turn reduce the number of circulating opioids among the population at large. We plan to continue our analysis for the rest of the pre- and post-implementations cohorts at Stanford. 
Nocturnal Awakening Prevention (NAP) Protocol


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Ioana Baiu MD MPH
Clark Owyang MD
Joseph Forrester MD MSc
Surgery Department Introduction: Noise levels in Surgical Intensive Care Units (SICU) are consistently above recommended standards.  Clinical Practice Guidelines for adult patients in the ICU recommend the implementation of sleep-promoting protocols (SPP) as a means of decreasing delirium.  Objective: We aimed to create a multiprong protocol to improve sleep hygiene in the SICU. Methods: Following review of the literature, discussions with SICU nurses, nurse managers, anesthesiology, surgery and critical care attendings as well as residents and fellows, a protocol was created and launched as an orderset on Epic entitled NAP Protocol. Success of the intervention is measured using Richmond Agitation-Sedation scale (RASS) and qualitative assessment of sleep by bedside RN. Results: 338 uses logged in Epic over 5-month study period.  Protocol is currently uesd across all Surgical ICU, Medicine ICU, and surgical floors. Conclusion: A Nocturnal Awakening Prevention Protocol can be successfully implemented through a multidisciplinary approach using the hospital EMR.  Preliminary subjective data suggests a positive impact in preventing delirium among hospitalized patients.
Optimization and Cost Savings with Reduction of Negative Immunohistochemical Reagent Controls


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Jason V. Scapa, MD
Yasodha Natkunam, MD, PhD
Sebastian Fernandez-Pol, MD, PhD
Megan Troxell MD, PhD
Pathology Department Background: Current tissue pathology diagnoses rely heavily on ancillary studies including immunohistochemistry. Like much of lab testing, immunohistochemistry requires both positive and negative controls on each tissue for every run when using the biotin-based methodology. However, with the advent of modern polymer-based detection, the College of American Pathologists (CAP) has acknowledged that this method is sufficiently free of background reactivity. Thus, negative reagent controls (NRC) may be omitted at the discretion of each lab following appropriate validation. After performing our own validation, we examined the cost and quality outcomes of optimizing our immunohistochemistry NRC.

Methods: We recently transitioned to exclusively using polymer-based detection in our large academic care center that processes 100,000 immunohistochemistry orders per year. We developed a validation plan to discontinue the majority of NRC as permitted by the CAP Checklist. Based on faculty input, we eliminated automatic NRC orders for most antibodies except for H. pylori, Her2/neu, BRAF V600E, HHV8, spirochetes, toxoplasmosis, and herpes simplex and varicella viruses. Pathologists could still order an NRC for any block as needed. Following validation, we retrospectively examined quality metrics including cost, volume, and labor in the first half of the year after implementation (July 7, 2019 to December 31, 2019) as compared to the corresponding weeks in 2018.

Results: We completed validation of 50 cases reviewed by pathologists to evaluate the NRC slides for background staining. All 50 samples lacked background staining or had expected endogenous pigment that matched the hematoxylin and eosin section. Based on reagent, instrument, and labor costs, we estimated saving $14.50 per NRC slide. In the first half of the year after implementation, we reduced the number of immunohistochemistry NRC from 8,110 in 2018 to 1,609 in 2019, corresponding to an 80.2% decrease in NRC in that 6 month period.  We extrapolated that this would save $196,000 and over 360 labor-hours for our immunohistochemistry lab each year.

Conclusion: Elimination of a large majority of negative controls is both feasible and cost-effective in labs employing polymer-based detection. We found no difference in quality or accuracy of our diagnostic interpretation after selectively omitting NRCs in our practice. Applying this protocol can save substantial healthcare dollars and lab resources including diagnostic tissue, reagents, and both technologist and pathologist time and effort. 
Pneumocystis Pneumonia Prophylaxis Prescribing Patterns in Dermatology


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Maggie Moses, MD
Joanna Tu, MD
Dermatology Department Purpose
Dermatologists often prescribe prolonged courses of oral glucocorticoids for a number of skin conditions, such as immunobullous diseases, autoimmune connective tissue diseases, and drug eruptions. Additionally, oral glucocorticoids are frequently employed within our supportive dermatoncology clinics. Pneumocystis Pneumonia (PCP) can be a serious complication of prolonged oral glucocorticoid use with a high mortality rate, however there are limited data and no clear guidelines on appropriate PCP prophylaxis use. We aimed to review Stanford Dermatology PCP prophylaxis prescribing practices, develop an intervention that would engage both residents and faculty to the need for PCP prophylaxis and conduct post-intervention analysis on the strength of the intervention.
 
Methods
To assess our current state, we performed an IRB-exempt non-randomized chart review of dermatology visits at Stanford between 1/1/2020 through 2/29/2020. Patients met inclusion criteria if they were ≥ 18 years of age and if they had oral prednisone listed as an active outpatient medication. We then reviewed those patients who were prescribed ≥20mg/day of prednisone for ≥ 30 days to see if they were prescribed PCP prophylaxis. During the course of this review, we held several QI brainstorming sessions within the residency program to elicit feedback on barriers to prescribing PCP prophylaxis and also on possible solutions.

Results/Anticipated Results
We reviewed 1016 charts, with 105 patients who met inclusion criteria. Within that cohort, 20 patients were eligible to receive PCP prophylaxis as outlined above. We had a 60% success rate in prescribing practices with 12/20 of those patients on appropriate prophylaxis, with 1/8 of the patients not on PCP prophylaxis  declining treatment. As a result of our residency QI brainstorming sessions, it was determined that conflicting data in the literature may contribute to lower rates of PCP prophylaxis prescriptions, and one proposed intervention was a formal presentation of the literature on the topic along with our own departmental data to engage the entire department to devise our own policy regarding PCP prophylaxis. This was presented at our bi-annual Morbidity & Mortality (M&M) Grand Rounds conference with robust faculty and resident engagement. Outcomes of this conference included a decision to utilize a dedicated task force of residents and faculty to cull more data and to devise a departmental policy with the support of more department-specific data.

Conclusions
We are excited to continue the work on this project and will be performing post-intervention analysis in the summer to fall of 2020. We found that engaging the entire department through use of M&M conference was extremely beneficial as it captured a wide audience and allowed for expert feedback from some of the leaders in our field and those who have deep experience with immunocompromised patients. 
Preliminary Results of an Intervention to Improve HIV PrEP Administration & STI Screening for MSM in the Stanford Internal Medicine Clinics


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Erik Eckhert MD MS
Wendy Caceres MD
Medicine Department Men who have sex with men (MSM) are disproportionately impacted by the epidemic of STIs in the San Francisco Bay Area and across the country. In 2013, the San Francisco Department of Public Health estimated that MSM are 63, 28 and 9 times more likely than their heterosexual counterparts to contract syphilis, gonorrhea, and chlamydia respectively. For MSM who have multiple sexual partners or who have every had an STI, the CDC recommends triple site gonorrhea/chlamydia screening, as well as blood tests for HIV +/- syphilis (depending on additional risk factors) every 3 months. The vast majority of MSM on HIV pre-exposure prophylaxis (PrEP) fall into this category, and the nature of PrEP administration provides a unique opportunity for providers to get patients into screening early and often. However, most providers are failing to adequately screen MSM in the Stanford Internal Medicine Clinics (SIM-E and SIM-W) and across the country. In this Quality Improvement initiative, we performed a retrospective cohort study of all MSM receiving PrEP through the SIM clinics in order to determine the percent of patients receiving the CDC recommended standard of care. A subsequent root cause analysis informed a multi-pronged intervention to address this healthcare disparity gap. 
Preventing Unnecessary Admissions to SICU by developing a Multidisciplinary Clinical Pathway for Trauma Patients with Isolated Rib Fractures


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Joshua Jaramillo
Aussama Nassar
Lisa Knowlton
Javier Lorenzo
Einar Ottestad
Jean-Louis Horn
Ankur Bharija
Christopher J. Wolff
Andre V. Coombs
Surgery Department Problem Statement/Background:
Trauma admissions for rib fractures occur frequently and can be time and resource intensive.  Current trauma clinical guidelines may over-utilize Surgical Intensive Care Unit (SICU) resources in order to provide care for these patients.  We sought to update the care pathways in order to reduce overutilization of SICU resources while providing equivalent care on the trauma unit utilizing I-ICU level of care.


Target State (SMART Goal):
To prevent unnecessary SICU admissions for patients with isolated rib fractures by creating a clinical pathway that utilized I-ICU level of care on the Trauma K7 unit, saving total costs of >$500,000 annually (June/20 – June/21). 

Root Cause Analysis:
Current versions of admission protocols called for SICU admission from ED based strictly on age and number of rib fractures and did not allow for clinical correlation.  The unnecessary admissions to the SICU is associated with increased cost (up to 500K/FY) and a negative impact on patient and provider experience.  Admission to an ICU bed and subsequent transfers of care add additional layers of complexity to a hospital stay, which may lead to worse outcomes and/or longer lengths of stay.
Our proposition has several targets:
1. Replace current SICU admission criteria which is solely based on age and number of rib fractures (which can be overly sensitive for increased morbidity) with clinical judgement.
2. Utilizing more specific physiological and clinical parameter correlation at the time of presentation may help to better identify patients at need of the SICU.

Interventions:
Development of an interprofessional, multidisciplinary clinical pathway in coordination with leaders from Trauma, Anesthesia, Geriatrics and Respiratory therapy and nursing for patients with isolated rib fractures to be managed in an I-ICU care setting on the trauma floor with updated epic order sets and Stanford Trauma Guidelines.   We will also monitor for balancing measures (re-admissions to SICU, response teams activations, etc)

Results:
I-ICU level of care compared to intensive care provides equivalent care for measures important for patients with isolated rib fractures.  For example, intermediate compared to intensive provides 3:1 nursing with q2 hour vital checks vs 1-2:1 with q1 hour, respectively.  Intermediate also provides greater emphasis on early mobilization and discharge planning compared to intensive while maintaining same level of pain management.  Using Stanford financial data, intermediate care saves >$4,100/day compared to intensive care, which leads to an estimated cost saving >$541,000/year. After implementation we will prepare a run chart analysis.

Key Learning:
Re-evaluation of hospital processes is vital to quality improvement.  Subtle changes in a protocol requires involvement from multiple specialties including nursing and physician teams.  Involvement in these teams early help to develop an all-encompassing pathway that is more likely to succeed once implemented.  Selection of measurable outcomes is important and helps to qualify important change.
Sign, Seal, Deliver: Pre-Addressed Advance Directive Packets to Increase Completion Rates


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Michael Genualdi
Meera Sheffrin
Sylvia Tee
Medicine Department Background: Engaging patients in the advance care planning (ACP) process can be challenging given time constraints in primary care visits, cultural norms, and reluctance to talk about end of life issues. However, when patients do participate in advance care planning with their providers, it becomes more likely that their wishes will be known and followed. An integral component of this process is to identify and communicate patients’ goals and then document them in a manner that is accessible to all healthcare team members.

Methods: The Stanford Senior Care clinic does not have a formal procedure for initiating ACP discussions with our patients. Our goal is to have ACP documented for all patients, defined as having either an advance directive or POLST uploaded in the EMR. We assessed the baseline rate of patients with ACP documentation, and developed a QI intervention as to further improve this rate.

Established patients without ACP documentation were identified by chart review one week prior to their scheduled follow up appointment, and an email was sent to providers listing their upcoming patients who fit these criteria. During the clinic visit, patients were provided with a pre-addressed, stamped envelope containing a copy of an advance directive, a one page FAQ on advance directives and POLST forms, and a letter explaining the importance of ACP.

Patients were encouraged to fill out the form and mail it back to us. Patients are then followed up via chart review in monthly intervals to determine if ACP documentation had been uploaded to our EMR.

Results: At baseline before the intervention, 67% of the patients had either had ACP documentation. The pre-addressed envelope intervention was started in Oct 2019. Currently, 73 patients have been provided with the packets, and 33 have returned some form of ACP on follow up at 6 month follow up chart check. The rate of ACP documentation in Nov 2019 was 68%.

Conclusions: We found that both patients and their family members/caregivers were appreciative of the discussions we had about ACP and were amenable to completing ACP documentation. As we engage with more patients over the coming months we hope to see a continued trend that validates our approach, as first outlined in the PREPARE trial, using patient-facing information sources and easy to read advance directive forms coupled with in person discussion to increase the percentage of our patients who have their healthcare wishes documented.
Standardization of Discharge Instructions for
Surgical Patients: Faster, Safer, Better


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Ioana Baiu MD MPH Surgery Department Introduction: Epic EMR allows for personalization of protocols, which can lead to heterogeneity and inacuracies in information that should otherwise be standardized and verified.  Inacurate discharge instructions were identified as one of the areas of improvement in the Department of Surgery. Objective: We aimed to create a standardized process for discharge instructions that still allows for individualization for each surgical service and operation, that can be easily updated online in the future. Methods: We worked with faculty from each of the 15 general surgery services to create service-specific discharge instructions. Within each service up to 6 discharge templates for various operations were created, reviewed and approved by each attending. These were integrated with Epic’s function that automatically imports these instructions in the discharge AVS. Results: Residents report a much faster and streamlined discharge process and comfort with updated information.  Attendings aware of discharge instructions patients receive. Patients note satisfaction with upgraded instructions. Conclusion: Epic EMR can be used to standardize and streamline an otherwise complex discharge process to allow for homogeneity and accuracy of information while allowing for individualization for each post-operative care plan. 
Streamlining ICU care for ALS patients receiving tracheostomy and gastrostomy


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Connie Wu, MD
Nick M Murray MD
Eric Bernier RN
Christine Wachira DNP, RN, MPA, NE-BC
Francesca Heinzmann BS
Leslie Bennett RN
Neelam Goyal MD
Michelle Cao DO
Karen Hirsch MD
Zachary Threlkeld MD
Neurology Department Title: Streamlining ICU care for ALS patients receiving tracheostomy and gastrostomy

Authors: Connie Wu MD, Nick M Murray MD, Eric Bernier RN, Christine Wachira DNP, RN, MPA, NE-BC, Francesca Heinzmann BS, Leslie Bennett RN, Neelam Goyal MD, Michelle Cao DO, Karen Hirsch MD, Zachary Threlkeld MD

Background: Amyotrophic Lateral Sclerosis (ALS) is a progressive neuromuscular disorder resulting in dysphagia and progressive respiratory failure. In order to treat these complications and prolong life, ALS patients may pursue enteral nutrition and invasive mechanical ventilation, and are thus frequently admitted to the ICU for percutaneous endoscopic gastrostomy (PEG) tube placement and/or tracheostomy. However, intensive care unit (ICU) admissions for such procedures, whether elective or unplanned, are frequently associated with delays, which prolong length of stay (LOS). Longer ICU LOS results in higher costs and may increase the rate of ICU-associated complications.

Current State: Our current state analysis showed that between January 2019 to February 2020, the average neuro-ICU length of stay for ALS patients admitted for tracheostomy or PEG tube placement was 6.9 days.

SMART goal: To reduce mean ICU length of stay for ALS patients admitted for tracheostomy and PEG placement from 7 days to 5 days by December 2020.

Proposed Interventions: We identified the following potential interventions: consistent inpatient workflow pathway to implement safe and comfortable respiratory support during hospitalization and on discharge, education and expectation management with patients and caregivers pre-operatively and post-operatively, establishing and sustaining goal-concordant care, administration of perioperative sedation and analgesia tailored to the unique needs of patients with neuromuscular disease, and safe discharge pathway with clear transition of care to the outpatient setting.

Next Steps: We plan to create and educate all health care providers for patients with ALS on a standardized consensus guideline and care pathway. We will develop a patient and caregiver education tool detailing expectations and relevant action items to complete during the hospitalization and post-procedure care to expedite safe discharge. We will continue to engage additional experts and stakeholders throughout this process.
Ultrasound Training for Lumbar Puncture in Neurology



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Eric Rider, MD
Sarada Sakamuri, MD
Neurology Department Problem Statement/Background
Ultrasound is a tool with proven clinical benefit in lumbar puncture; however, neurology residents are not currently trained to incorporate it into clinical practice.

A standard bedside lumbar puncture relies exclusively on physical exam and knowledge of anatomy. However, technical limitations such as increased body habitus or abnormal anatomy can lead to failed attempts, redirections, and delayed care. Ultrasound (US) is an established adjunct to performing lumbar puncture correctly that has been shown to increase success rates, decrease the number of attempts, and minimize traumatic taps.1 Additionally, ultrasound can be used as a tool to help trainees improve understanding of anatomy.

SMART Goal
We created a session teaching basic ultrasound skills and understanding of lumbar anatomy required to perform lumbar punctures prior to July 1, 2020. The goal of this skills session was to serve as a model to be implemented as part of Neurology Bootcamp for the incoming class of PGY2 neurology residents.

Interventions
Two groups of residents participated in a voluntary two-hour training session in February 2020

Residents were given a basic introduction to ultrasound techniques, a review of lumbar anatomy, and hands-on practice identifying relevant landmarks.

Attitudes towards ultrasound, confidence in identifying anatomical landmarks, and use of ultrasound were assessed before and after the session using a Likert scale survey.

Results
All residents surveyed believed that ultrasound could be a helpful tool in any lumbar puncture
After the training session, all residents agreed that ultrasound was easy to use
After the training session, all residents strongly agreed that they would be able to identify relevant anatomical landmarks to perform an LP with ultrasound, if a machine were available
Nearly all residents (87%) agreed that using ultrasound would not significantly prolong the overall duration of LP procedure

Key Learning
After the hands-on ultrasound skills session, neurology residents:
were more confident in their ability to identify relevant anatomical landmarks in lumbar puncture
felt that ultrasound could be a helpful tool in performing successful lumbar punctures
Felt that ultrasound was easy to use and could be easily incorporated into practice, if machines were available
were enthusiastic about gaining more experience with US

Next Steps:
Dedicated ultrasound training for LP during Neurology Bootcamp for incoming PGY2 neurology residents

References:
1. Soni, et al, Neurology Clinical Practice 2016;6:358-368 










 
Understanding Life after Hospitalization: A Geriatric Trauma Quality Improvement Pilot


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Kristie Hsu, BS
Ankur Bharija, MD
Nannette Storr-Street, RN, MS, AGCNS-BS
Matthew Mesias, MD
Medicine Department BACKGROUND: Trauma from a fall or motor vehicle accident is a leading cause of morbidity and mortality among older adults. In response, Stanford Health Care implemented a multidisciplinary Geriatric Trauma Care Pathway in November 2018 for hospitalized older adults under the trauma service with a focus on improving inpatient process, quality, and utilization outcomes. Our quality improvement pilot aims to assess the long-term outcomes of these patients.
METHODS: A medical student trained in QI methodology conducted semi-structured phone interviews (n=12) with 7 patients and 5 caregivers (surrogate respondent when patient unavailable) 6 months after admission to Stanford’s geriatric trauma pathway. We aggregated patient and caregiver perspectives regarding level of physical recovery (including self-reported recovery and changes to Katz ADLs), psychological recovery, number of emergency department visits and hospitalizations since discharge, and services that were helpful or missing during their recovery.
RESULTS: At 6-month follow-up, 7/12 (58%) interviewees reported incomplete physical recovery from the trauma (self-reported 66% recovery on average); they identified pain, ADL dependence, and reduced walking tolerance as areas yet to recover. 2 (17%) reported incomplete psychological recovery from the trauma; they felt “afraid to cross the street” and “my mortality more.” 8 (67%) received PT. 6 (50%) received OT. 7 (58%) had additional ED visits and 3 (25%) had additional hospitalizations after discharge. All interviewees were independent with ADLs before trauma; at 6-month follow-up, 3 (25%) required assistance for 1 or more ADLs. Interviewees identified family support, PT, OT, follow-up medical appointments, and psychological counseling as most helpful to their recovery. Services felt to be missing included PT and OT (“I just found my own exercises online”), transportation (“I don’t want to burden my family to drive me”), and difficulty finding paid caregivers (“the process was too cumbersome”).
CONCLUSIONS: In this pilot, a majority of interviewees reported incomplete physical recovery 6 months after geriatric trauma despite most feeling psychologically recovered, receiving PT, and without additional hospitalizations after discharge. Patient and caregiver perspectives demonstrated QI opportunities in transitions of care, including more robust PT and OT, additional caregiver support, and transportation services.

Research

Abstract Title & Poster

All Authors

Department

Abstract

Analyzing Impact of an Institutional Protocol for MRI in Patients with Legacy Cardiac Rhythm Devices


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Collin J. Culbertson MD
Laurel Jakubowski MD
Jingjing Chen MD MBA
Max Wintermark MD
Paul Wang MD
Angela Tsiperfal MS RN ACNP CNS
Rosalie Geronimo DNP RN NEA-BC CNL
Teresa Nelson
Connie Lund
Carl A. Gold MD MS
Neurology Department Background: Prior to 2018, patients with older pacemakers or implantable cardioverter defibrillators, also called “legacy” devices, could not receive MRI scans at SHC. Data from large studies published in 2017 showed no significant safety issues with MRI in patients with legacy devices. In response, a committee with representatives from Neurology, Neuroradiology, and Cardiac Electrophysiology was formed and updated SHC policy to allow MRI with a standardized safety protocol, starting in August 2019. For this study, we prospectively tracked all SHC patients with legacy devices undergoing MRI and attempted to estimate the impact of MRI on patient care.

Methods: The project was granted Chart Review exemption from Stanford IRB (#52411). Radiology technicians prospectively recorded all legacy device MRI scans. Data was pulled monthly from Radiant and compiled for review. Patient charts were reviewed in STARR/Epic to extract clinical and device data and determine the impact of MRI on clinical care.

Results: A total of 14 MRI scans were performed on 11 unique patients with legacy devices from August 2019-March 2020. In 8 patients (73%), MRI expanded treatment options or significantly changed management. In 5 patients (45%), MRI confirmed a suspected diagnosis and/or changed the diagnosis meaningfully. In 3 patients (27%), the availability of MRI avoided a more invasive procedure. There were no patient safety events. In 2 patients (18%), earlier MRI may have avoided a delay in appropriate treatment.

Conclusions:With successful implementation of a multidisciplinary SHC protocol, we now safely offer MRI to patients with legacy devices. Amongst this initial cohort, MRI frequently added crucial information or expanded treatment options, possibly changing the diagnosis or management. In the future, we hope to expand weekend/evening access for inpatients including emergency cases, as well as offer the service to outpatient Neuroscience clinics and other departments.
Antibiotic Clinical Decision Support Tool Improves Management of Beta-Lactam Allergies


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Theresa Dunham, MD
Danielle Fasani, PharmD
Elizabeth Lipper, MD
Bonnie Halpern-Felsher, PhD
Anne Liu, MD
Medicine Department Introduction: Antibiotic allergies are associated with suboptimal antibiotic use, treatment failures, longer hospitalizations, and multidrug resistant organisms. SHC providers report insufficient knowledge and confidence in managing antibiotic allergies, often resulting in poor documentation and classification of allergies.
Methods: 55 residents, pharmacists, and attendings/fellows chose actions, grouped into risk-stratified categories, in six clinical vignettes both with and without a clinical decision support tool (CDST), preceded and followed by surveys.
Results: All providers recently encountered patients who needed an antibiotic possibly related to a listed allergy. At baseline, 80% of providers were at most “moderately” confident in taking an antibiotic allergy history, while the use of the CDST increased confidence in doing so for 89%. The CDST significantly increased confidence in determining when antibiotics are related for 98% of providers (paired t=5.38, p<0.0001). Participants were overall more likely to choose the correct action, categorized as having equal or lesser risk, in all clinical vignettes with the use of the CDST compared to without (chi-square 21.7587, p<0.00001). 95% of participants would use the CDST in the future.
Conclusion: This tool increased confidence and improved decision-making in managing antibiotic allergies. This tool allows for increased safety and improves antibiotic selection as indicated by influencing users’ choices. Implementation of this tool should be piloted on SHC services with high antibiotic use and burden. A prospective analysis could be performed to assess for changes in patterns of antibiotic prescribing, efficacy of antibiotic treatment, adverse reactions to antibiotics, and healthcare costs among patients with listed antibiotic allergies. 
Characterizing Interruptions to Attending Rounds on an Academic General Medicine Service


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Julia Armendariz, MD
Carla Tamayo, MD
Justin Slade, MD
Ilana Belitskaya-Levy, PhD
Caroline Gray, PhD
Nazima Allaudeen, MD
Medicine Department Background: Daily attending rounds is a cornerstone of teaching and patient care for medicine services in academic health centers. The literature and local experience show that interruptions in healthcare are common, and suggest there are adverse effects such as increased risk of errors and incomplete work, and decreasing decision-making accuracy. There is also literature to support that interruptions during teaching diminishes a trainee’s capacity to learn and retain information. To our knowledge, no study has yet characterized the types of interruptions that occur during attending rounds.
Methods. This study utilized a mixed method design: a prospective observational study to characterize interruptions, and a qualitative study to elucidate the impact of interruptions on workflow and the educational value of rounds.
Results. A total of 30 attending rounds were evaluated resulting in 378 observed interruptions, averaging 12.6 (range 1-22, median 13) interruptions per rounding episode. The most common sources of interruptions were from bedside nursing staff (25%), but the most common topic of interruption was consultant recommendations (21%). Most interruptions occurred during patient presentations (76%), and the most common method of interaction was text message (24%). For the qualitative portion of our study, team members described how interruptions impacted their work flow and education in addition to proposing solutions.
Conclusions. Interruptions to attending rounds are common and diverse in their characteristics. The qualitative portion of our study suggested many similar concerns and descriptive solutions. Next steps include interventions to decrease the quantity and frequency of interruptions.
Cost Transparency Affected Expensive Drug Prescribing and IV to PO Substitution


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Rebecca Linfield, MD
Bo Wang, MD
Janjri Desai, PharmD, MBA
Lisa Shieh, MD, PhD
Medicine Department Healthcare costs in the United States continue to increase, largely driven by the high cost of pharmaceuticals. Cost transparency, the act of showing the price of drugs to providers, has been proposed as a method of reducing healthcare costs, but its effectiveness has not been studied on a large scale. By tracking the volume of the top 50 medications in the Stanford Health Care network before and after the introduction of price transparency in the electronic medical record on August 1, 2017, with a second group on June 27, 2018, we sought to determine if this intervention would generate at least a 10% decrease in the orders of expensive medications (greater than $200 per dose) and at least a 10% decrease in intravenous (IV) prescriptions when the oral substitute was available. We show only a 5% decrease in the volume of expensive medications ordered in the 12 months following the intervention but did note a 25% decrease in IV medications during the same time frame, with the decrease in IV volumes roughly matched by increase in PO volumes. This led to ~$225K in cost savings. We believe that cost transparency can be a low-intensity intervention to decrease unnecessary prescribing.
Decreasing Provider Discordance in Code Status Ordering and Interpretation at SHC


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Emily Shearer
Jason Batten
Mukund Ramkumar
Kimberly Kopecky
Haley Manella
Lisa Shieh
Stephanie Harman
Winnie Teuteberg
David Magnus
Medicine Department Background: Stanford currently has five code status orders available for patients: Full Code, Partial Code, DNR/DNI, DNR/DNE, and DNR/C. These code status orders are meant to reflect patients’ wishes regarding limitation of life-sustaining treatments.
Local Problem: Despite the importance of correct ordering and interpretation of code status orders in achieving goal-concordant care for patients, particularly near the end of life, previous qualitative work undertaken at Stanford has shown there may be variation in ordering and interpretation of code statuses.
Methods: In this quality improvement project, we employed qualitative interviewing among 24 physicians and nurses at SHC across five departments to identify problems with our current code status options. These interviews revealed SHC’s current code status options operate in three domains: interventions, level of care (treatment unit), and philosophy of care. From these insights and from our qualitative interviews, we devised eight hypothetical patient scenarios that represent areas of confusion among providers in the current code status system at Stanford. We then used these scenarios to assess provider concordance among 54 nurses and physicians in a) code status ordering and b) code status interpretation for patients with given clinical scenarios. From these qualitative and quantitative results, we worked with the Stanford Epic Informatics team and the Stanford Design School to develop a new code status ordering menu for our electronic health record.
Results: Our results show significant discordance among providers at our institution in both a) code status ordering and b) code status interpretation for patients across eight identified problematic clinical scenarios.
Conclusions & Future Steps: There is currently significant discordance among providers at SHC.  Testing of our eight patient scenarios against our newly developed code status options, as well as cognitive interviewing with providers to assess their views of the new options, are needed to see if our newly devised system 1) decreases discordance in code status ordering and interpretation, and 2) is acceptable to providers at Stanford.
Discomfort from povodone-iodine ocular antiseptic swabs


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Victor Eng
Ryan Shields
Theodore Leng
Steven Sanislo
Darius Moshfeghi
Sandeep Randhawa
Stephen Smith
Ophthalmology Department Discomfort from povodone-iodine ocular antiseptic swabs

Victor Eng1, Ryan Shields2, Theodore Leng1, Steven Sanislo1, Darius Moshfeghi1, Sandeep Randhawa2, Stephen Smith1

1Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA
2Beaumont Eye Institute, William Beaumont Hospital, Royal Oak, MI

Background: The use of povodone-iodine (PI) has become the standard of care for disinfecting the ocular surface prior to anti-VEGF intravitreal injections (IVI). However, use of PI as prophylaxis commonly causes severe irritation and sensitivity that may last for days after injection. Aggressive irrigation of the adnexa after IVI reduces the severity of perioperative pain.

Objective: To assess 1) the prevalence and severity of ocular pain after IVI and 2) methods for alleviating discomfort (e.g. additional irrigation, over-the-counter NSAIDs, hot/cold packs)

Methods: Patients with a history of receiving anti-VEGF IVI were surveyed in-person in March 2020

Results:
Survey response rate was high (>95%). A total of 104 patients (53% male; current age 75.1 ± 12.4 years) participated in the survey. 70% reported usually experiencing discomfort after IVI with 33% having experienced at least one episode of perioperative pain rated above 8/10. Pain was not significantly associated with the total number of intravitreal injections a patient had received (p = 0.44). Roughly half of patients (46%) ask for extra rinsing of the eye after injection procedures. Patients also reported alleviating pain and irritation with artificial tear drops (34%), over-the-counter NSAIDs (19%), and cold and/or hot compresses (23%). 16% of patients said that the pain affected their decision to continue receiving injections. 80% would be interested in a less-irritating alternative to povodone-iodine swabs.

Conclusions:
Postoperative pain after use of povodone-iodine is common among Stanford patients with a substantial percentage of patients resorting to self-treatment with artificial tear drops, over-the-counter NSAIDs, or hot/cold compresses. Providers should actively offer extra rinsing to patients who may be unaware or hesitant. These findings demonstrate a possible market for a less-irritating antiseptic swab as well as the value of upcoming extended-release anti-VEGF agents that permit longer intervals between dosing.
Effect of Brief Education Course on Provider Utilization of Telehealth Video Visits During the SARS-CoV-2 Pandemic

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Katherine Thomas MD (PM&R, PGY-3)
Molly Timmerman DO (PM&R Attending)
Orthopedic Surgery Department BACKGROUND: With the unfolding of the SARS-CoV-2 pandemic, many healthcare organizations have advocated the telehealth video visit as a method for fulfilling their mission of healthcare delivery while minimizing risk of infection for both patient and provider. Furthermore, video visits offer additional clinical insight not available through telephone visits. Despite organizations’ new-found interest in telehealth video visits, many physicians are reluctant to use telehealth video software. This reluctance may be due to inexperience using the software or negative preconceived opinions regarding video visits. For example, a survey of physicians in 2015 showed that only 5% had ever used video visit software(1) and a 2019 survey showed that 31% of physicians were not willing to have a video visit with their patients (2). Given the relatively recent onset of the SARS-CoV-2 pandemic, there is a need for novel, evidence-based methods of quickly augmenting provider utilization of telehealth.

OBJECTIVE: The primary study aim is to evaluate the effectiveness of a virtually delivered lecture, which provides brief instruction on how to perform telehealth video visits, to improve provider utilization of telehealth video visits during the SARS-CoV-2 pandemic. Specifically, our SMART goal is to decrease the number of physicians doing 0 video visits weekly by 50% over the course of 1 month (from March 30, 2020 to April 30, 2020).

METHODS: 17 Physical Medicine and Rehabilitation (PM&R) attendings and residents at the VA Palo Alto Health Care System (VAPAHCS) were emailed an anonymous pre-intervention survey to assess their baseline utilization of the VAPAHCS’ video visit software (Virtual Care Manager).  A 45-minute virtually delivered PowerPoint lecture was then presented, which provided a brief description of the required video visit equipment and reviewed how to use the telehealth video visit software, maintain HIPPA compliance during video visits, bill for video visits, as well as assist patients in troubleshooting the video visit software. A PDF of the lecture was also made available to all providers after the PowerPoint lecture. The providers were then emailed an anonymous post-intervention survey regarding their utilization of the video visit software 1 month after the lecture.

RESULTS: Surveys were completed by 12/17 PM&R resident and attending physicians. Survey results indicate that providers’ perceived importance of video telehealth visits significantly increased, by approximately 2-fold, as a result of the SARS-CoV-2 pandemic (p-value: 0.0004). Furthermore, data show that just prior to the lecture, approximately 91% of physicians reported doing 0 video visits in an average week. One month after the lecture was given, there was a significant decrease to only 33% of providers reporting doing 0 video visits weekly (p-value: 0.008), which exceeded our original SMART goal.

CONCLUSIONS: Although the study is limited by a small sample size, our findings suggest that the SARS-CoV-2 pandemic has significantly increased providers’ perceived importance of video telehealth visits. Results of the current study further show that a short, virtually delivered lecture regarding how to perform video visits can effectively increase providers’ utilization of this software. Utilization of this software for patient visits is beneficial as it offers additional clinical insight not available through telephone visits, while minimizing risk of COVID-19 infection for both patient and provider.

FOOTNOTES:
1. “Telehealth Index: 2015 Physician Survey.” American Well, June 2015. http://go.americanwell.com/rs/335-QLG-882/images/Telehealth-Physician-Survey-eBook.pdf
2. “Telehealth Index: 2019 Physician Survey.” American Well, July 2019. https://static.americanwell.com/app/uploads/2019/04/American-Well-Telehealth-Index-2019-Physician-Survey.pdf
Evaluation of seizure risk in neonates after cardiopulmonary bypass in the absence of deep hypothermic cardiac arrest


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Rebecca Levy
Elizabeth Mayne
Amanda G Sandoval Karamian
Mehreen Iqbal
Natasha Purington
Rajani Kaimal
Kathleen Ryan
Courtney Wusthoff
Neurology Department Objective: The American Clinical Neurophysiology Society suggests continuous EEG (cEEG) for seizure detection after neonatal surgery involving cardiopulmonary bypass (CPB). Early reports described seizures in 21% of children after CPB, with recent estimates ranging 3-12%. Seizures have been associated with deep hypothermic cardiac arrest (DHCA), bypass duration, and age. This study characterizes seizure prevalence in a neonatal cohort after CPB without standard DHCA.
Methods: Single-center chart review of all infants from July 2017 through June 2019 monitored with cEEG for 48 hours after CPB, as per institutional guideline. Clinical and EEG variables were recorded for univariate and multivariate analyses.
Results: 12 of 112 (10.7%) patients had seizures on cEEG; 5 (42%) had status epilepticus. All 12 had subclinical seizures; 2 also had electroclinical seizures. Median time from bypass end to first seizure was 28.1 hours [IQR 18.9-32.2 hours, range 6-52 hours]. Only 2 patients underwent DHCA; neither had seizures. Highly predictive risk factors include: post-op paralysis, abnormal brain imaging, prematurity, delayed sternal closure, bypass time, critical illness pre-op (number of codes, oxygen or ventilator dependence), and lactate peak peri-op. These confirm many findings in the literature.
Conclusions: Seizure prevalence in our cohort was analogous to other reports, despite minimal DHCA in our group. Among infants with seizures, time to first seizure ranged from 6-52 hours after end of CPB, suggesting a window of highest yield for cEEG. Modeling risk factors in our sample had high accuracy and can be used as a calculator to predict risk in future patients. 
Improving Influenza Vaccination at Stanford Rheumatology Clinic


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Audra Horomanski, MD
Kate Kolstad MD PhD,
Melanie Buentipo
Ryan Marti PharmD
Nilushka Melnick
Gabriela Triant
Janice Lin MD
Medicine Department Abstract:
Background: Patients with rheumatologic diseases are at greater risk for complications of influenza infection due to immunosuppression from their disease and associated therapy. Prior studies have shown there are higher rates of hospitalization, intensive care admission, bacteremia, and death from influenza in this population. The influenza vaccination rate for Stanford Rheumatology Clinic in 2018/2019 was 62%. While this is above the overall national rate of 43.5%, it still leaves a high percentage of vulnerable patients without potential immunity.

Objective: Analyze the process of recording influenza vaccination status during patient visits and implement interventions with the goal of improving the vaccination rate from 62% to 70% over a period of one year.

Methods: With guidance from the Realizing Improvement through Team Empowerment (RITE ) cohort, we performed a root cause analysis and identified the process of obtaining and relaying vaccination information within the Rheumatology Clinic. We initiated several interventions, including making the vaccine available at the Stanford Cancer Center Pharmacy at the beginning of the flu season, creating a standard process for Medical Assistants to record vaccination information, and informing providers when patients “decline” or “plan to” receive vaccination. We tracked the cumulative vaccination rate throughout the 2019/2020 flu season.

Results: The root cause analysis revealed that there was no standard process for Medical Assistants to collect vaccine information on clinic patients. Furthermore, when this information was collected, it was not relayed to the provider or readily visible in EPIC. We initially instituted a process to inform providers when a patient declined the flu vaccine, but found that this made providers less likely to engage in a discussion with the patient, frequently citing concerns about time. We subsequently informed providers when patients “plan to” be vaccinated and found that they were more open to engaging in discussions with patients. However, despite these interventions, there was no significant difference in the flu vaccination rate compared to the prior flu season (62% vs 61%).

Conclusions: Although there was not an improvement in the vaccination rate this year, we learned several valuable lessons. Namely, there were serious flaws in how our clinic was collecting vaccination information and a breakdown in communication within the care team. We had also hypothesized that making the vaccine available at the Stanford Pharmacy would increase vaccination rates, but there was no difference in rate despite this being the earliest intervention. However, this was not a widely publicized resource until late in the season. These findings have spurred changes in our clinic workflow and initiated a project to better understand personal barriers to vaccination in rheumatology patients.
Improving the Quality and Ease of Outpatient Preoperative Evaluations


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Tara Ramaswamy, MD
Malathi Srinivasan, MD 
Medicine Department Background: Outpatient clinicians have variable approaches to preoperative consultation, including using different evidence sources that may not be fully up to date. Epic templates can help guide providers and offer current evidence to aid decision making.  Currently, residents and faculty at Stanford Internal Medicine (SIM) clinic do not have an evidence based Epic template for outpatient preoperative evaluation.

Target Goals: Our goals are to 1) understand current preoperative practices and viewpoints of medicine faculty and trainees, 2) quantify how many outpatient preoperative evaluations are performed per year (SIM East and West clinics), 3) create an updated, provider-friendly, evidence based Epic preoperative template, and 4) create improved curriculum for trainee education on perioperative care. We hope to achieve 80% provider utilization of developed tools as well as improved provider satisfaction based on survey data within 8 weeks of implementation.

Methods: We first queried Epic to quantify how many SIM clinic preoperative evaluations were completed between January 1, 2018 and January 1, 2019 based on visit diagnosis code. We then created a survey that was distributed to SIM attending clinic physicians, nurse practitioners, and residents to better understand current preoperative evaluation practices and areas for improvement. Using the results from our survey data, we created a new streamlined, evidence based Smartphrase within Epic to help providers complete the preoperative evaluation. We also created a new teaching module for perioperative management in primary care that was distributed to trainees in March 2020.

Results: Between January 1, 2018 and January 1, 2019, 191 preoperative evaluations were completed at Stanford Internal Medicine Clinic. Our pre-intervention survey consisted of a total of 34 responses  (15 attending physicians, 2 NPs, 11 residents, and 6  interns). All participants were internal medicine or family medicine trained. In the last year, 82% residents had completed between 1 and 10 evaluations (9/11) and 59% attendings/NPs had completed between 1 and 10 evaluations (10/17). 0/6 interns had completed any preoperative evaluations at time of survey collection. When queried what resources were utilized in completion of preoperative evaluations, 13/17 attendings/NPs used UpToDate, 8/17 used RCRI, 8/17 had their own Epic Smartphrase,  5/17 used colleagues, 4/17 used NSQIP, 3/17 used a pre-existing Epic Smartphrase, and 2/17 referred patient to anesthesia preoperative clinic. The residents, in contrast, utilized NSQIP (8/11),  RCRI (8/11),  UptoDate (6/11), referral to anesthesia clinic (5/11), individual Smartphrase (2/11), EPIC generated  Smartphrase (1/11), and MICA (1/11).  14/17 attendings/NPs and 8/11 residents wished for core education regarding critical issues in perioperative evaluation. 16/17 attendings/NPs and 7/11 residents wished for an evidence based Epic template to be created. Using this survey data as a guide, a primary care teaching module and a new Epic Smartphrase were created and piloted in March 2020 and April 2020, respectively. The module was distributed to all SIM residents and the template was piloted to 10 residents. Post-pilot survey results of residents were notable for the following: 3/10 residents felt the new template was “somewhat easier” than the current available resources and 7/10 residents indicated the new template was “much easier.” 8/10 residents felt the new template adhered to evidence based practice “very well.” 10/10 residents indicated they were likely to use the template in the future (1/10 somewhat likely, 9/10 very likely). 10/10 residents felt the educational module addressed evidence based guidelines “very well” and 8/10 residents felt the module helped increase their comfort level in performing outpatient preoperative evaluations.

Discussion: We identified a need in the outpatient setting for more perioperative education and an updated Epic template. Currently in preoperative evaluation, residents used risk scores (RCRI, NSQIP) more commonly than attendings/NPs. We developed a preoperative template that was user-friendly, felt to be evidence based, and highly likely to be used by providers in pilot testing.  We increased provider comfort in outpatient perioperative evaluation with more robust training.  We anticipate our template and educational interventions will ultimately save time, decrease provider workload,  increase provider satisfaction, benefit patients, and decrease avoidable day of surgery cancellations.
Make a difference in pneumonia readmissions: Transitionalist Pathway, a multidisciplinary transitions of care approach


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Vittavat Termglinchan, MD
Kelly Zhang, BA
Kimberly Dong, PharmD, BCPD
Karen Nelson, MSW, MBA
Kristel Fallon, RN
Terese McManis, RN
John Shepard, MBA, MHA
Carlos Montalvo
Phyo Aung, PharmD, BCPS
Noah Fang, PharmD, BCPS
Ellen Tasaka, PharmD, BCACP
Alicia Wong, PharmD, BCPS
Neera Ahuja, MD
Charles Liao, MD
Medicine Department Background: The Centers for Medicare and Medicaid Services identified preventable hospital readmissions as one of the leading problems of the U.S. healthcare system. We developed a Transitionalist Pathway (Pathway) to improve transitions of care by using a multidisciplinary care team that focuses on the hospitalization and post-discharge care of the patient. This pilot focuses on patients with pneumonia, a condition with one of the highest readmission rates at our institution and nationwide.
Methods: The Pathway is available via our EPIC electronic medical record through an order set to all patients admitted to Stanford Health Care with a diagnosis of pneumonia. Once the Pathway order set is selected, the provider can choose services that include (1) high-risk readmission providers that specialize in patient education, post-discharge phone calls, and home visits, (2) transition of care pharmacists to provide medication reconciliation and education at discharge, (3) occupational therapists, and (4) social workers. We collected data on age, marital status, hospital length of stay, diagnosis-related group (DRG) weight, discharge location, and hospital readmissions and patient satisfaction survey results. Our primary outcome was all-cause 30-day readmission rates, and secondary outcomes were all-cause 7-day, 15-day and 90-day readmission rates, as well as patient satisfaction.
Results: From August 2017 to 2019, a total of 1,407 patients were admitted under general medicine with a diagnosis of pneumonia. 136 patients (10%) received the Pathway intervention. Pathway patients were significantly older than non-pathway patients (80 vs 71, p<0.001). There was no statistical difference in the hospital length of stay and DRG weight between the two groups. There was a 25% relative reduction in 30-day readmission rate in pathway patients when compared with non-pathway patients with a trend towards significance (12.5% vs 16.5%, p=0.23). Interestingly, pathway patients had a significantly lower 7-day readmission rate when compared with non-pathway patients (2.2% vs 8.3%, p<0.01), but there was a decremental gap between the two groups with almost similar readmission rates at 90-day post-discharge period (26.3% vs 26.7%, p=0.96). There was no statistical difference in patient satisfaction between the two groups.
Conclusion: Improving transitions of care through a multidisciplinary approach can provide a meaningful reduction in readmissions of patients with pneumonia. This approach could be adapted for other high-risk of readmission diagnoses to further optimize care and healthcare costs. In the future, it is important to explore methods to sustain this reduction. This may require improved post-discharge follow-up with outpatient primary care providers.
Measuring the Quality of a Quality Measure


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Shefali Dujari
Santosh Gummidipundi
Zihuai He
Carl A. Gold, MD
Neurology Department Introduction
Quality measures are vital to track and improve the quality of care provided. We have an increasing need for specialty-specific quality measurement sets that are clinically relevant, have robust beta testing for feasibility and reliability performed prior to publication, and allow for benchmarking performance internally and externally(1). Benchmarking is an essential part of the quality improvement process. It allows healthcare providers and organizations to compare their quality of care to top performers in the field, identify underlying drivers of high performance, and develop focused improvement efforts(2). To address this need, the AAN, Neurocritical Care Society, and Neurohospitalist Society jointly published the first Inpatient and Emergency Care Quality Measurement Set for neurology patients, which defines 12 quality measures related to the hospital care of patients with conditions such as status epilepticus and delirium (3,4).  Our goal for this project was to test the feasibility and reliability of one of the twelve measures, as well benchmark performance at our institution, which to our knowledge as not been done for any of the twelve measures.

Methods
The measure we decided to study was regarding the treatment of patients with bacterial meningitis with dexamethasone before or with the first dose of antibiotics. We used the Vizient Clinical Database and Resource Manager to identify non-pediatric patients admitted for bacterial meningitis to Stanford Hospital between October 2015 – June 2019. We then performed further chart review using the hospital electronic medical record to confirm the diagnosis of bacterial meningitis as well as obtain additional data regarding clinical presentation, exclusion criteria to receiving dexamethasone per the quality measure, laboratory work up, and treatment decisions. Exclusion criteria included hypersensitivity to corticosteroids, antibiotic treatment in the last 48 hours, recent neurosurgery or head trauma, or cerebrospinal fluid shunt, as outlined in the quality measure.

Results
We identified 79 patients using Vizient of whom 69 had a diagnosis of bacterial meningitis confirmed by chart review (PPV=87%). Of the 69 patients, 32 (46%) were female and 40 (58%) were white; median (IQR) age was 52 (39, 67). 56 patients were ineligible to receive dexamethasone per the quality measure – 27 patients had antibiotics in the last 48 hours, 37 patients had a recent head trauma or neurosurgery, and 18 patients had a CSF shunt. This left 13 patients eligible to receive dexamethasone. Five of these patients (38%) received dexamethasone. 

Conclusion
This study is one of the first efforts to test the feasibility, reliability, and performance of one of the 12 quality measures included in the AAN Inpatient and Emergency Care Quality Measurement Set(4). We found that during the 45-month study period, 81% of patients with bacterial meningitis were ineligible to receive dexamethasone per the quality measure at our institution, leaving only 13 patients eligible to receive dexamethasone. In our view, the relatively infrequent presentation, high rate of patients with exclusion criteria, and variable involvement of neurologists in these cases raises concern that this measure may be an unreliable indicator of the quality of care provided, especially at large institutions similar to ours. 38% of our patients with bacterial meningitis eligible for dexamethasone received this medication, suggesting room for improvement. However, without the ability to benchmark our institution’s performance against peer institutions, it is not known if 38% represents relatively excellent, average, or poor performance.

References
1. Kotter T, Blozik E, Scherer M. Methods for the guideline-based development of quality indicators – a systematic review. Implementation Sci 2012;7:21.
2. Ettorchi-Tardy A, Levif M, Michel P. Benchmarking: A method for continuous quality improvement in health. Health Policy. 2012 May; 7(4); e101-119.
3. Josephson SA, Ferro J, Cohen A, Webb A, Lee E, Vespa PM. Quality improvement in neurology: Inpatient and emergency care quality measure set - Executive Summary. Neurology 2017;89(7):730-735.
4. American Academy of Neurology. Inpatient and Emergency Neurology Quality Measurement Set. Available at: www.aan.com. Accessed Nov 17, 2019.
Modifying Post-operative Opioid Prescribing Practices: an Institutional Intervention


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Ashley Titan
Kayla Pfaff
Alexis Doyle
Ioana Baiu
Angela Lee
Andrew Shelton
Mary Hawn 
Surgery Department Introduction:
Over-prescribing of opioid medications has contributed to the epidemic of narcotic addiction in the United States. Opioid overdose is now the leading cause of injury-related deaths nationwide, resulting in more than 47,000 deaths in 2017. More than 10 million Americans admit to abusing opioids during their lifetime and many were initially exposed during the postoperative period. We hypothesized that the implementation of institutional opioid-prescribing guidelines would be associated with a significant decrease in the amount of opioids prescribed and associated variability without negatively impacting patient care.

Methods:
We developed opioid-prescribing guidelines for the 26 most common general surgery procedures and implemented them at our institution. We compared the number of post-operative opioid prescriptions over a 6-month period before and after implementation. Differences in oral morphine equivalents (OMEs) were assessed using the 2-sample t test. The number of patient phone calls following prescription was used as an initial measure of impact on patient care associated with both time periods.

Results:
Data analysis is currently on-going. We have collected 10 patients in each cohort who underwent laparoscopic cholecystectomy.  Within this preliminary cohort collection, there is a statistically significant decrease in amount of OMEs prescribed post-operatively (40.0 ± 3.5 vs. 16.7 ± 1.7, p<0.0001). There has been no difference in the number of outpatient phone calls between time periods.

Conclusion:
Initial data collection indicates that formalized opioid-prescribing guidelines are associated with a decrease in the number of narcotics prescribed, as well as with a decrease in the variability in the number of tablets prescribed. This preliminary data supports that surgeon education using institutional guidelines may facilitate efforts to minimize narcotic over-prescription, and in turn reduce the number of circulating opioids among the population at large. We plan to continue our analysis for the rest of the pre- and post-implementations cohorts at Stanford. 
Nocturnal Awakening Prevention (NAP) Protocol


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Ioana Baiu MD MPH
Clark Owyang MD
Joseph Forrester MD MSc
Surgery Department Introduction: Noise levels in Surgical Intensive Care Units (SICU) are consistently above recommended standards.  Clinical Practice Guidelines for adult patients in the ICU recommend the implementation of sleep-promoting protocols (SPP) as a means of decreasing delirium.  Objective: We aimed to create a multiprong protocol to improve sleep hygiene in the SICU. Methods: Following review of the literature, discussions with SICU nurses, nurse managers, anesthesiology, surgery and critical care attendings as well as residents and fellows, a protocol was created and launched as an orderset on Epic entitled NAP Protocol. Success of the intervention is measured using Richmond Agitation-Sedation scale (RASS) and qualitative assessment of sleep by bedside RN. Results: 338 uses logged in Epic over 5-month study period.  Protocol is currently uesd across all Surgical ICU, Medicine ICU, and surgical floors. Conclusion: A Nocturnal Awakening Prevention Protocol can be successfully implemented through a multidisciplinary approach using the hospital EMR.  Preliminary subjective data suggests a positive impact in preventing delirium among hospitalized patients.
Understanding Life after Hospitalization: A Geriatric Trauma Quality Improvement Pilot


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Kristie Hsu, BS
Ankur Bharija, MD
Nannette Storr-Street, RN, MS, AGCNS-BS
Matthew Mesias, MD
Medicine Department BACKGROUND: Trauma from a fall or motor vehicle accident is a leading cause of morbidity and mortality among older adults. In response, Stanford Health Care implemented a multidisciplinary Geriatric Trauma Care Pathway in November 2018 for hospitalized older adults under the trauma service with a focus on improving inpatient process, quality, and utilization outcomes. Our quality improvement pilot aims to assess the long-term outcomes of these patients.
METHODS: A medical student trained in QI methodology conducted semi-structured phone interviews (n=12) with 7 patients and 5 caregivers (surrogate respondent when patient unavailable) 6 months after admission to Stanford’s geriatric trauma pathway. We aggregated patient and caregiver perspectives regarding level of physical recovery (including self-reported recovery and changes to Katz ADLs), psychological recovery, number of emergency department visits and hospitalizations since discharge, and services that were helpful or missing during their recovery.
RESULTS: At 6-month follow-up, 7/12 (58%) interviewees reported incomplete physical recovery from the trauma (self-reported 66% recovery on average); they identified pain, ADL dependence, and reduced walking tolerance as areas yet to recover. 2 (17%) reported incomplete psychological recovery from the trauma; they felt “afraid to cross the street” and “my mortality more.” 8 (67%) received PT. 6 (50%) received OT. 7 (58%) had additional ED visits and 3 (25%) had additional hospitalizations after discharge. All interviewees were independent with ADLs before trauma; at 6-month follow-up, 3 (25%) required assistance for 1 or more ADLs. Interviewees identified family support, PT, OT, follow-up medical appointments, and psychological counseling as most helpful to their recovery. Services felt to be missing included PT and OT (“I just found my own exercises online”), transportation (“I don’t want to burden my family to drive me”), and difficulty finding paid caregivers (“the process was too cumbersome”).
CONCLUSIONS: In this pilot, a majority of interviewees reported incomplete physical recovery 6 months after geriatric trauma despite most feeling psychologically recovered, receiving PT, and without additional hospitalizations after discharge. Patient and caregiver perspectives demonstrated QI opportunities in transitions of care, including more robust PT and OT, additional caregiver support, and transportation services.