6th Annual UC Davis Healthcare Quality Forum
March 16, 2016
UC Davis Health System Education Building
Podium
Presentations
Submitted Tracking Number: 287 Abstract Title: Response: Establishing a new patient care protocol to improve outcomes for patients with ruptured abdominal
aortic aneurysm Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Samuel Clarke soclarke@ucdavis.edu MD, MAS Assistant Professor, Department of Emergency Medicine Learner Additional Participants
Name Degrees Title Role
Kathleen Behan RN, MS Clinical Quality and Safety Mentor David Dawson MD Professor, Division of Vascular Surgery Mentor Christine
McBeth DO Resident, Department of Emergency
Medicine Learner William Pevec MD Professor and Chief, Division of Vascular
Surgery Mentor Samuel
Turnipseed MD Assistant Professor, Department of
Emergency Medicine Mentor Introduction: Response: Ruptured abdominal aortic aneurysm (rAAA) is the 13th most common cause of death in the United
States, and overall mortality is greater than 90%. Endovascular repair of the aorta (EVAR) has become the
preferred operative strategy for managing rAAA, as there is evidence to suggest improved mortality in comparison
to traditional “open” repair. At UC Davis, EVAR requires the rapid deployment of operating room (OR) and Cath
Lab Team (CLT) staff, as well as preparation of a specific operating room (OR 45) with equipment to support both
endovascular and traditional operative approaches. An analysis of our institutional performance at UC Davis over
the past five years has shown substantial variability both in time to diagnosis and time to OR 45 readiness. In order
to address these issues, an interdepartmental and interdisciplinary group from the Departments of Vascular
Surgery, Anesthesia, and Emergency Medicine endeavored to create a new process of care that would streamline
the diagnosis and disposition of these critically ill patients. Methods: Response: We devised a new treatment protocol based on work performed at other academic institutions showing
that a protocol-driven approach to EVAR for rAAA repair leads to improved mortality. After achieving initial
consensus on our protocol, we performed two full-scale simulations in the Emergency Department (ED) and OR
45. We used data collected during these simulations to further refine the protocol. Additionally, we developed an
order set in the electronic health record to standardize the initial workup and approach to resuscitation for these
patients. We also conducted point of care ultrasound training with the emergency medicine residents to improve
their skills at detecting AAAs, and did on-site training with ED, OR and CLT staff to ensure their familiarity with
the protocol. Results: Results: Response: We conducted two full-scale simulations of the protocol on September 15th and December 9th, 2015.
Our initial simulation revealed critical issues around the coordination of staff to prepare OR 45 emergently. These
issues were addressed through revisions to the protocol and further staff training, and our second simulation
session resulted in substantially improved coordination of care (time from ED arrival to start of case in OR 45 was
29 minutes). Since initiating this process we have also had one actual rAAA case present to UC Davis. The patient,
an 83-year-old man, was transferred from an outside hospital with a 7.5 centimeter rAAA. The time from ED
arrival to the start of the EVAR case was 45 minutes, and the patient was discharged to a skilled nursing facility
on post-operative day four after a successful repair. Discussion: Response: Although this project is still early in its implementation, it has already proved to be a successful
collaboration between multiple departments. We believe it represents an important step towards improving the care
for patients presenting to our hospital with rAAA, and that we hope that it will pave the way for UC Davis to
become a leading institution in the management of this disease. Submitted Tracking Number: 245 Abstract Title: Response: Improving Asthma Care in a Pediatric Teaching Clinic Through the Use of a Practice Improvement
Module Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Julia Lee jshlee@ucdavis.edu MD PGY 3 Mentor Additional Participants
Name Degrees Title Role
Albina Gogo MD Pediatric attending Mentor Ulfat Shaikh MD, MPH Pediatric attending Mentor Daniel Tancredi PhD biostatistician Mentor Introduction: Response: Standardized systematic approaches to asthma management result in increased compliance with asthma
care guidelines, creation of asthma action plans, documentation of asthma severity, appropriate prescription for
controller medication, and decreases in medical service utilization. There is significant variation asthma
management in the outpatient setting. Our objective was to increase appropriate care for asthma in our pediatric
teaching clinic, including spirometry testing, monitoring asthma control, and provision of asthma action plans. Methods: Response: Our strategy for quality improvement addressed three domains. The first domain was provider education
which included teaching the national asthma care guidelines in terms of diagnosis and management, and making
those guidelines readily available on a central resident resource website as well as visual aid in clinic with key
national guideline messages. This domain also included feedback on individual results every two months after
each chart review in addition to feedback on group results every six months. The second domain was a
systems-based intervention which included several electronic health record (EHR) modifications such as creation
and universal sharing of a standardized asthma action plan and standardized asthma history template, creation of a
flowsheet to document asthma control scores and creation of a pediatric asthma controller medication order-set.
The third domain consisted of patient education through reformatting the standardized asthma control questionnaire
and asthma action plan to increase understandability to patients with low health literacy as well as encouraging
providers to review written asthma action plans and appropriate inhaler technique with patients and their parents.
After a series of outpatient based interventions, chart reviews were done every two months using Education in
Quality Improvement for Pediatric Practice (EQIPP), a practice improvement module created by the American
Academy of Pediatrics. At the end of each chart review, data from the EQIPP questionnaire was entered into the
EQIPP Asthma module and then entered into SAS program for statistical analysis. Results: Response: Several key measures showed statistically significant improvements over the course of the
interventions, specifically use of a standardized instrument to determine current level of control, use of national
guidelines for treatment, providing written asthma action plans, and providing asthma self-management education.
We noted statistically significant improvement in influenza immunization in months during which patients face the
highest risks for influenza. Discussion: Response: Our University-based teaching clinic serves a large proportion of underserved children, who are at
highest risk for complications related to asthma. Standardization and the use of EHRs improved adherence to
national clinical guidelines for pediatric asthma. Utilizing existing resources provided by the American Academy
of Pediatrics, namely the asthma EQIPP module, allowed us to monitor process measures over the course of our
intervention. The use of an established practice improvement module allowed us to identify practice goals for
improvement, collect and analyze our group performance data over time, assess the impact of each change and
re-design our process based upon feedback provided by the practice improvement module. Submitted Tracking Number: 281 Abstract Title: Response: Improving Patient-Clinician Communication in Advanced Cancer: A Cluster Randomized Trial Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Paul Kaesberg pkaesberg@ucdavis.edu M.D. Clinical Professor Mentor Additional Participants
Name Degrees Title Role
Camille Cipri n/a n/a Mentor Richard Kravitz M.D. Professor Mentor Daniel Tancredi PhD Professor Mentor Guibo Xing n/a n/a Mentor Introduction: Response: The “Values and Options in Cancer Care (VOICE)” study is an RCT testing the effect of patient and
physician communication training on the quality of communication regarding aspects of their care in patients with
advanced cancer. Poor communication between providers and patients with advanced cancer has been associated
with unrealistic patient expectations regarding curability, survival time and the benefits of chemotherapy. We
hypothesized that a combined intervention targeting both oncologists and their patients would increase patient
participation discussions and physician responsiveness to patients’ emotions while promoting discussions about
prognosis and treatment choices Methods: Response: Oncologists were randomized to receive a video on communication, mock patient interviews regarding
an advanced cancer situation, identification of 4 communication goals, and feedback to the physician (intervention
group) or no training (control group). Up to 10 patients of intervention-group physicians received communication
training, with follow-up phone calls. Up to 10 patients of control physicians received the NCI book “Coping with
Advanced Cancer.” The primary outcome was the Quality of Communication in Advanced Cancer Score, an
aggregate of four measures matched to the four key goals of communication training and assessed using audio
recordings of enrolled patients’ first encounter with the study oncologists. Four specific communication skills were
assessed: ENGAGING patients and caregivers to identify and ask questions, express concerns and opinions, and
request clarifications; RESPONDING to patients’ emotions, expressed as direct concerns and indirect cues;
INFORMING patients about the disease, prognosis and treatments then checking understanding using an
“ask-tell-ask” approach; and BALANCED FRAMING that presents the positives and negatives of
recommendation. Results: Response: 281 patients were allocated to intervention (n=139) or control (n=142); 205 (73.0%) had an enrolled
caregiver. Sixteen patients were withdrawn. The intervention had a significant effect in increasing the composite
primary outcome (p=0.02). The intervention produced statistically significant increases in ENGAGING (p=0.03)
and trending effects in RESPONDING (p=0.10) and INFORMING (p=0.11), while no effects were observed in
FRAMING. There were only 8 instances of balanced framing in the entire dataset. Discussion: Discussion: Response: A combined intervention directed conversations to a more patient- centered focus where patients asked
more questions and were more assertive; physicians were more responsive to patients’ emotions and discussed
prognosis and treatment choices with greater frequency. Patient activation behaviors were influenced by the
intervention. Other behaviors - responding to patients’ emotions, discussing prognosis and balanced framing of
decisions – may be more difficult to influence, and in the case of prognosis and framing, may not be appropriate at
every visit and difficult for even the most activated patient to elicit in physicians. There was a notable paucity of
framing talk during the encounters; often, treatment decisions were presented as a fait accompli or requiring a
simple assent rather than considering alternatives. Few patients selected prognosis to discuss in the visit with their
doctor, and perhaps they didn’t want to discuss it at all. The intervention group experienced no decline in patients’
ratings of their care or their relationships with their physicians. Submitted Tracking Number: 269 Abstract Title: Response: Navigating Sickle Cell Pain so Crisis Doesn't Mean an ED Visit Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Kerri Stuart kstuart@ucdavis.edu RN, MSN Nurse Manager Mentor Additional Participants
Name Degrees Title Role
Debra Burgess RN, BSN, HCA Quality Nurse Mentor Natalie Merilus RN, BSN CNIII Learner Calene Roseman RN, MSN Admin Nurse Learner Ted Wun MD Divison Chief Hem Onc Mentor Introduction: Response: Over 100,000 people in the U.S. are affected by sickle cell disease (SCD) which increases morbidity
and mortality. People with SCD have a genetic blood disorder and frequently suffer from acute vaso- occlusive
crises (VOCs) causing severe painful episodes. Individuals with SCD most commonly seek pain management for
sickle cell crisis (SCC) in the emergency department (ED) and are frequently admitted for continued therapy to
control pain. Impacted ED waiting rooms can result in long wait times to receive therapy despite the best triage
practices. In some cases patients leave without being seen. Within our facility we found that 10 patients with SCD
were responsible for 50% of admits for management of VOCs and 15 patients were responsible for 75% of ED
utilization for SCC. The average time to first narcotic was 2:51 from ED triage. The current system does not
provide adequate access for care and could be more efficiently delivered in an outpatient setting. The aim of this
project was to provide a treatment alternative for SCD and prompt access for pain management of VOCs while
improving the patient experience. This also serves to decompress overburdened EDs and reduce hospital
admissions. Methods: Response: An outpatient infusion center model of care was developed to provide an alternative environment for
treatment to patients with SCD and SCC. Patients receive scheduled appointments for management of chronic
issues and have the option to call in for management of their acute VOCs rather than waiting to be triaged for care.
Services offered included short term pain management and IV hydration, exchange transfusion, blood product
administration and phlebotmychelation therapy. Hours of operation are from 8am to 8pm, weekdays. Data
collected included time to first narcotic, pain score, average visit time, and discharge status from the Infusion
Center. Success was measured by providing administration of narcotics within 1 hour of chair time, adequate pain
control resulting in discharge home, and reduction in ED utilization and unnecessary hospitalization. A SCD nurse
navigator was hired to provide clinical care in the infusion center and manage care. Results: Results: Response: 163 SCD patients were treated at the Cancer Center during the pilot study. The average time to
narcotic in the Infusion Room was 1:04 verses 2:51 in the ED, a 62.7% reduction. The average time to pain control
was 6:33 with 93% of patients discharged home (3% transferred to ED and 4% transferred as direct admit for
continued therapy). The most common services provided was pain management with IV hydration for SCC (63%),
Desferal infusion (17%) and exchange transfusion (13%). There was a downward trend noted in ED utilization and
hospitalization for the pilot group. Discussion: Response: The Infusion Center model provides a quality experience for management of VOCs and a more
efficient use of healthcare resources. It is a preferred alternative for receiving care than going to the ED. Outcomes
are promising to demonstrate a decline in ED utilization, hospitalization and unplanned readmission. More research
and analysis is needed to evaluate the cost benefit of the model. Submitted Tracking Number: 263 Abstract Title: Response: Osteoporosis Overtreatment in the UC Davis Health System Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Joshua Fenton jjfenton@ucdavis.edu MD, MPH Associate Professor Mentor Additional Participants
Name Degrees Title Role
Anna Lee Amarnath MD, MPH Medical Consultant Learner Peter Franks MD Professor Mentor John Robbins MD, MSH Professor Mentor Introduction: Response: The U.S. Preventive Services Task Force (USPSTF) recommends dual x-ray absorptiometry (DXA)
screening for women aged >=65 years and for younger women at increased risk. However, for women to benefit
from screening, clinicians must appropriately select women for drug treatment based on the presence of clinically
important DXA abnormalities and patient risk. DXA reports at UCDHS routinely include T-scores for anatomic
sites, such as the lateral lumbar spine, that the International Society for Clinical Densitometry (ISCD) does not
recommend for osteoporosis diagnosis. We hypothesized that UCDHS women are frequently prescribed
osteoporosis drugs based on non-diagnostic DXA abnormalities. Methods: Response: We performed a retrospective cohort study of electronic health records (EHR) and radiology records for
treatment naïve women aged 40-85 years receiving initial screening DXA within UCDHS from January 1, 2006
through December 31, 2011. We classified women based on the presence of >=1 of six risk factors. We used
natural language processing to abstract T-scores from EHR radiology reports. For each site, we classified T-scores
as normal(T>-1.0), osteopenia (-2.5 Results: Response: Of 6,150 women who received initial DXA screening, 31.1% received new osteoporosis drug treatment.
Overall, 14.2% of women had mainsite osteoporosis, 32.8% had non-mainsite osteoporosis, while the remainder
had no osteoporosis (either isolated osteopenia or normal T-scores). Most women with mainsite osteoporosis
(73.5%) received new drug therapy, as did nearly half with non-mainsite osteoporosis (47.7%). Nevertheless,
because non-mainsite osteoporosis or isolated osteopenia occurred commonly, women with non-mainsite
osteoporosis accounted for 50.3% of new prescriptions, while women without osteoporosis accounted for 15.8%.
Of the 6,150 DXAs, 60.1% were performed on women aged 40-64 years without osteoporosis risk factors who
may not have been recommended for screening by the USPSTF. Of the 1,912 women who initiated new drug
treatment, 66.4% had DXAs either without osteoporosis or non-mainsite osteoporosis. Discussion: Discussion: Response: Within UCDHS, two-thirds of new osteoporosis drug prescriptions were potentially inappropriate
because the osteoporosis diagnosis was based on DXA abnormalities considered non-diagnostic by international
guidelines. Of these prescriptions, half were provided to younger women without risk factors who may not have
merited screening in the first place. Based on study findings, radiologists have ceased interpreting including lateral
lumbar T-scores on UCDHS DXA reports. Additional efforts are needed to ensure that screening is not frequently
performed on younger, lower-risk women. Submitted Tracking Number: 265 Abstract Title: Response: PAIN MANAGEMENT BUNDLES IN THE EMERGENCY DEPARTMENT FOR OLDER
PATIENTS WITH HIP FRACTURE Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Katren Tyler krtyler@ucdavis.edu MD Associate Professor Mentor Additional Participants
Name Degrees Title Role
Dane Stevenson MD Learner Geriatric Emergency Medicine Fellow Introduction: Response: Fragility hip fracture are common presentations to EDs and are associated with a high risk of
complications. Guidelines illustrate the value of multidisciplinary geriatric fracture programs for managing hip
fractures. Implementing pain management bundles in the ED is a key part of geriatric fracture programs. Our
institution introduced a multidisciplinary geriatric fracture program (GFP) for fragility hip fractures in January
2014 and we describe opioid dosing, administration of the fascia iliaca compartment block (FICB) and
development of delirium in the first 154 patients admitted through the ED. Methods: Response: Patients were prospectively enrolled in the GFP and included in the GFP database. Patients less than 65
years of age, peri-prosthetic fractures, and patients whose fracture mechanism were not ground level falls are
excluded from the GFP and were never included in the database. Demographic data and clinical information
including MRN, name, sex, age and other parameters are collected into the database prospectively. The GFP
database includes the number of shifts delirium is identified by RNs using the Confusion Assessment
Method–ICU. Analgesic doses for the first 24 hours were hand tabulated from the electronic medical record and
24-hour morphine equivalence was calculated using a standard table. Results: Response: From January 2014 to October 2015, 153 patients were enrolled in the GFP database. Of these, 75
(49%, 95% CI 41-57%) patients received FICB in the ED. Of the 78 (51%) patients with hip fractures who did not
receive a FICB, 36 received less than two doses of opioids in the first 24 hours of their admission. After excluding
patients who received less than two doses of opioids in the initial 24 hours of their hospital stay, patients who did
not have an FICB in the ED had a median 24-hour ME dose of 16.3 mg (IQR 10.1-23.8) and 21/42 (50%, 95%CI
34-66%) had delirium. Patients who had a FICB performed in the ED had a median 24-hour ME dose of 12.5mg
(IQR 5.0–20.4) and 27/75 (36%, 95%CI 25-48%) had delirium. Discussion: Response: A multimodal pain pathway introduced in the ED as part of a multidisciplinary hip fracture clinical
pathway reduces the opioid dose in the first 24 hours of the hospital stay, and may reduce the rate of delirium
during hospitalization. Poster
Presentations
Submitted Tracking Number: 299 Abstract Title: Response: Acute heart failure admission from skilled nursing facilities versus community: an evaluation of
mortality risk and other clinical outcomes Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Sukhi Sidhu Sukhi.Sidhu@ucsf.edu Pharmacy Intern Learner Additional Participants
Name Degrees Title Role
Sarah Bajorek Pharm.D. Pharmacist Mentor Tiffany Pon Pharm.D. Pharmacist Mentor Tiffany Tang Pharmacy Intern Learner Christine Tran Pharmacy Intern Learner Charisma Urbiztondo Pharmacy Intern Learner Introduction: Response: Current studies on heart failure (HF) patients discharged to skilled nursing facilities (SNF) show a
30-day readmission rate secondary to HF exacerbation of 27-43% as compared to other studies of 23% for patients
discharged to the community, suggesting that patients may not be adequately managed at SNFs. The objective of
this study is to assess whether patients admitted for acute decompensated HF (ADHF) from SNFs have a higher
mortality risk and worse clinical outcomes compared to those from the community. Methods: Response: This was a single-center, retrospective chart review of patients aged >18 admitted for ADHF from SNF
(intervention) or community (control). Patients with the following criteria were excluded: LVAD, incomplete data,
prisoners, pregnant, cognitively impaired on treatment, and fluids entirely removed by hemodialysis. Primary
endpoint was mortality risk according to the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC)
score that categorizes patients into six risk groups that represent increasing 3-year mortality rates (1:0-16, 2:17-20,
3:21-24, 4:25- 28, 5:29-32, 6:33+). The intervention group was matched to the control group by age, sex, ejection
fraction (EF), and ethnicity. Secondary endpoints were clinical decompensation, length of hospital stay, 30-day
readmission rate, and in-hospital mortality rate. Results: Response: Of the 111 patients who met inclusion criteria, 64% (33/51) of SNF patients and 61% (32/53) of
community patients were classified within the MAGGIC risk groups 3-5 (p=0.5), suggesting that majority of
patients admitted for ADHF have a 3-year mortality risk of 30- 54%. Compared to patients from community, fewer
SNF patients with reduced EF were on beta-blockers (BB) (68% vs 86%, p=0.15) and renin- angiotensin
aldosterone (RAAS) inhibitors (23 vs 36%, p=0.32) prior to admission. Thirty-day readmission rate (20% vs 15%,
p=0.48) and in-hospital mortality (16% vs 4%, p=0.03) were also higher in the SNF cohort. During hospitalization,
SNF patients also required more loop diuretic therapy (p=0.02) and vasopressor utilization (13% vs 6%, p=0.2)
than community patients. Average net intake/output was also higher in SNF patients (-7L vs -4.7L, p=0.26). Discussion: Discussion: Response: Although patients from the community were more likely to be on mortality-reducing medications
(BB/RAAS inhibitors) PTA, three-year mortality rates between groups were similar. Despite not meeting statistical
significance, readmission rates, vasopressor use, and average net intake/output were higher in the SNF group,
which may have clinical significance. Both in-hospital mortality and loop diuretic utilization were significantly
higher in SNF patients; this further suggests SNF patients may be more acutely decompensated and require higher
levels of care. One possible reason for these results may be inappropriate management of SNF patients with suboptimal medication regimens, which indicates potential need for educating local SNFs regarding appropriate
management of heart failure. Further study, however, with larger sample sizes is needed to see if a true statistically
significant difference in all clinical outcomes exists. Submitted Tracking Number: 278 Abstract Title: Response: An Educational Program About Operating Room Fires Aimed at Effecting Behavior Change in
Anesthesia Residents Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Brian Pitts bpitts@ucdavis.edu M.D., M.S. Associate Professor, Anesthesiology and Pain Medicine Mentor Additional Participants
Name Degrees Title Aubrey
Yao M.D. Assistant Professor, Anesthesiology and Pain
Medicine Role
Mentor Introduction: Response: Operating room fires are rare events that have devastating medical, legal, and economic consequences.
Although the etiologies and events leading to operating room fires is well described in the literature, inadequate
anticipation and communication by the operative team continues to represent a significant contributor. At The
University of California Davis Medical Center, the Surgical Time Out is an important pause that occurs in the
immediate preoperative period after the patient enters the operating room but before surgery begins. The goal of
this pause is to eliminate wrong site and wrong person surgery, as well as to identify the patient care plan using a
team-based approach. Together, Nurses, anesthesiologists, surgeons, and the patient systematically review relevant
concerns before the start of surgery. We observed that in many instances where the risk of operating room fire was
higher than normal (i.e. airway and ENT cases), team members did not always mention or discuss a plan to
minimize the risk of fires. To improve awareness and increase communication about the risk of operating room
fires, we developed an inquiry-based educational intervention that used video-based learning and high fidelity
simulation. Methods: Response: Because anesthesiologists play a pivotal role in the care and safety of the patient during surgery, we
developed an educational intervention for first-year anesthesia residents to not only deliver the knowledge required
to minimize operating room fires, but also assess the application of that knowledge in a simulated clinical setting.
Perceptions, knowledge, and prior experience was measured using survey questionnaires both before and after the
intervention. Results: Response: Both knowledge and confidence levels regarding the recognition and management of operating room
fires increased after the intervention (knowledge: 75% vs. 90%, N=8). The simulation was positively perceived by
both participants and observers ( rating 4.9 out of 5, N = 8). A surgical pause was performed; recognition and
management was achieved in less than 1 minutes. Reported barriers to real-life implementation: 1) production
pressure, 2) lack of knowledge, and 3) no cases with risk factors. At one month, 86% reported having mentioned
the risk of airway fires in the O.R. during the surgical pause compared to less than 2% before the intervention. Discussion: Discussion: Response: Educational interventions that increase the awareness of operating room fires have the potential to
reduce patient morbidity and mortality. However, a gap exists between delivering an educational program and
measuring its intended effect in clinical situations. The ultimate goal of effective instruction is to produce change
that can be translated into the real world. Achieving this goal remains a major challenge in medical education today.
Simulation- based training combines medical knowledge with clinical practice in high acuity scenarios that
promote experiential learning and critical thinking. Here we describe an educational approach that takes advantage
of the unique capabilities of various learning environments to expand the learner’s awareness and skill in reducing
the risk of operating room fires. Submitted Tracking Number: 309 Abstract Title: Response: Analysis and Educational Program To Reduce the Overuse of Neurodiagnostic Imaging in the Workup
of Cerebrovascular Accidents (CVA) Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Derek Holder dholder@ucdavis.edu MD MS Resident Physician PGY4 Learner Additional Participants
Name Degrees Title Role
Mustafa Ansari MD Resident Physician PGY3 Learner Glen Jickling MD Attending Mentor Katherine Park MD Resident Physician PGY3 Learner Dionne Swor DO Resident Physician PGY3 Learner Introduction: Response: There is a perception of overuse of neurological imaging in the Neurology Department and the
Emergency Departments in the workup of Cerebrovascular Accidents. It is not uncommon for patients to receive
multiple imaging studies with the same clinical questions regarding the etiology of the patient's symptoms. There
are burdens placed on neuroradiology and nursing staff, as well as limited scanner time. There is also additional
added anxiety for patients and exposure to anxiolytics and side effects associated with them during extra studies.
These studies have significant cost as well as risks such as extra contrast exposure and increased time away from
nursing and physician staff, which can be dangerous, particularly in the immediate period after a stroke. Our
project seeks to educate and implement strategic methods of reducing redundant neurological imaging studies. Methods: Response: Our project has two phases. The first involves education and implementation of tools to help providers
make educated decisions for best practice in patient care. We have educated neurology and emergency department
residents on an accepted algorithm for workup in acute and chronic stroke, avoiding redundant studies. We also
adjusted our department's order sets to avoid unnecessary "default" unnecessary studies. The second phase involves
analysis of pre-implementation patterns and compares to post-project implementation rates of imaging. There are
also ongoing discussions to implement physician notifications (via EMR flags) to limit unnecessary studies that had
recently been performed. Results: Response: We have calculated the rate and number of imaging studies performed in the first day of a patient's
admission from a group of patients collected from 2005-2015. There were an average of 5.24 studies per patient,
which included CT Head, CT Angiography Head or Neck, MRI Brain, MR Angiography Brain or Neck, and
Carotid Ultrasound. The education program recommends at most 3-4 studies per patient from the above list. Our
analysis efforts are ongoing on a group of patients collected after education efforts were started in order to
compare pre and post- education imaging rates. Our team was able to collaborate with IT as well as neuroradiology
to discuss changes in order sets and the possibility of implementing EMR Flags in the future, to remind physicians
of all services of order redundancy (For instance, a reminder that CT Angiography with contrast is more sensitive
and specific than MR Angiography without contrast, and that ordering a MR Angiogram after a CT Angiogram
may be unnecessary). Discussion: Response: Our analysis ofimaging rates is ongoing, as are efforts to continue and educate other services of
recommended imaging modalities for the workup of acute and chronic stroke. We continue to evaluate the data of
post-education rates of imaging orders as well as their patient value impact as well as ways of notifying ordering
providers of standard of care in neuro-imaging in real-time, including the use of EMR Flags, which will require
inter- departmental discussion and agreement. We are hopeful the current project will help solidify norms of
clinical practice and ensure patients high quality of care. Submitted Tracking Number: 262 Abstract Title: Response: Antimicrobial Stewardship-Guided Protocol for Surgical Prophylaxis of Appendicitis in Children Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Alexandra Yonts abyonts@ucdavis.edu MD Resident Physician (Pediatrics) Learner Additional Participants
Name Degrees Title Role
Jamie
Anderson MD Resident Physician (Surgery) Learner Shinjiro Hirose MD Associate Professor, Pediatric Surgery Mentor Linda
Shutzman Resident Physician (Surgery) Learner Associate Professor, Pediatric Infectious
Disease Mentor MD Jean Wiedeman MD,PhD Introduction: Response: Acute appendicitis is the most common pediatric surgical condition, occurring in 9-12/10,000 children.
Most cases(50-75%)present as appendicitis without perforation (“uncomplicated”). Evidence and federal advisory
committee guidelines suggest a single pre-operative administration of antibiotics,given within 1 hour of incision, is
all that is required. The goal of this study is to educate providers regarding these guidelines and illustrate that
standardization of local practices in compliance with said guidelines will maintain or improve local quality
outcomes, without increasing negative events. Methods: Response: This was an IRB approved retrospective cohort study. An EMR order set for surgical admissions was
designed and enacted in January 2015 and antibiotic dosing guidelines were disseminated and discussed in person
with Pediatric Surgery attendings/residents.Guidelines included limiting antibiotics to only pre-operative use and
dictating which antibiotics should be used (Ceftriaxone and Metronidazole). EMR charts were identified by ICD
9/10 codes. Additional inclusion criteria included “uncomplicated appendicitis” as defined by UC Davis Pediatric
surgeon and age 0-18 years. Historical cohort (N=96) included cases from 1/2013-12/2014. Interventional cohort
(N=50) included cases from 1/2015-1/2016. Primary endpoints include surgical providers’compliance with
guidelines, cost of antimicrobials (based on representative average wholesale prices), length of stay in hours and
frequency of surgical site infection (SSI). Secondary endpoints include rates of re-admission, post-discharge ED
visit, re-operation, fever, abscess, C. difficile infection or abdominal CT scan within 30 days of discharge. T-tests
were used to compare pre/post variables via Excel. Results: Response: Initial results show that the majority of providers (70%) were adherent to the guidelines following the
educational intervention (vs 10.4% in historical cohort,(p Discussion: Discussion: Response: The use of an EMR order set, as well as in person education about national guidelines for antimicrobial
use in pediatric uncomplicated appendicitis, leads to improved adherence to guidelines. When these guidelines are
followed, less antibiotics are used and associated costs are decreased, and length of stay is shortened without
increasing any negative outcomes or complications of appendicitis. Next steps include continuing to educate
providers, in particular, new surgery residents, in regards to these guidelines and improve dissemination of
guidelines by adding them to the CRC website for reference. Submitted Tracking Number: 301 Abstract Title: Response: Assessing the appropriateness of venous thromboembolism prophylaxis and clinical consequences of
over-prophylaxis Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Calvin Diep calvin.diep@ucsf.edu Pharmacy Intern Learner Additional Participants
Name Degrees Hien Lu Title Role
Pharmacy Intern Learner Patricia Parker PharmD Pharmacist Mentor Tiffany Pon PharmD Pharmacist Mentor Introduction: Response: Implementation of the venous thromboembolism (VTE) risk assessment tool into the electronic
medical record (EMR) at UC Davis Medical Center (UCDMC) improved rates of VTE chemical prophylaxis;
however, adverse effects of inappropriate chemical prophylaxis have not been evaluated. The American College of
Chest Physicians recommends against chemical prophylaxis in patients with low VTE risk and patients with
bleeding risks. The purpose of this study was to evaluate the effectiveness of the UCDMC VTE tool in promoting
appropriate VTE prophylaxis and to assess consequences of over-prophylaxis. Methods: Response: This was a single-center retrospective chart review from 06/01/2015-09/01/2015. This study included
patients > 18 years who were hospitalized for greater than 48 hours. Patients on comfort care, receiving
therapeutic anticoagulation, or who were pregnant were excluded. Patients categorized as low, moderate, or high
risk for VTE were identified by the EMR VTE tool. Inappropriate prophylaxis was defined as the use of chemical
prophylaxis in the following populations: 1) low risk 2) moderate risk with exception(s) to chemical prophylaxis
3) high risk with exception(s) to chemical prophylaxis. Exceptions to chemical prophylaxis were defined by the
VTE tool and included known risk factors for bleeding. The primary endpoint was rate of VTE chemical
prophylaxis in the above populations. Secondary endpoints included in-hospital major and minor bleeding events.
Descriptive statistics were used for analysis. Results: Response: A total of 4,041 patient days were reviewed. Chemical prophylaxis was administered in 38%, 40% and
21% of patient days in low risk, moderate risk with exceptions, and high risk with exceptions groups, respectively.
The majority of low risk patients had no exceptions (88%). “Active bleeding” was the most common exception in
moderate risk patients (38%) while “thrombocytopenia” was most common in high risk patients (51%). Major
bleeding occurred at a rate of 0.27% (2/733). Both of these patients were categorized as moderate risk and had
“active bleeding” exceptions. One of the two bleeding events was fatal, where the patient had two exceptions
(“active bleeding” and “cirrhosis”). Discussion: Discussion: Response: This study suggests inappropriate utilization of VTE chemical prophylaxis in terms of overprophylaxis at UCDMC as it was given in up to 40% of patients in these populations, potentially increasing
bleeding risk. Compared to high risk patients, moderate risk patients were more likely to be inappropriately
exposed to chemical prophylaxis and have an “active bleeding” exception, which potentially led to the observed
bleeding events. Furthermore, the VTE tool creates the exception for “active bleeding” based only on changes in
hemoglobin and hematocrit, which may have led to providers overlooking this exception. Bleeding events were not
observed in low risk patients likely because they were less likely to have any exceptions. Educating providers on
how to appropriately utilize the tool and potentially creating a more obvious alert for specific exceptions (e.g.
“active bleeding”)may reduce the rate of inappropriate chemical prophylaxis administration and the associated
bleeding risks. Submitted Tracking Number: 303 Abstract Title: Response: Beyond the code sheet: a novel instrument for evaluating code blue team performance Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Samuel Clarke soclarke@ucdavis.edu MD, MAS Assistant Professor, Department of Emergency Medicine Learner Additional Participants
Name Degrees Title Role
Aaron Bair MD, MS Director, Center for Health and
Technology Mentor Zoya
Derebenskiy BA, BS Quality and Safety Analyst Learner Amy Doroy RN Nurse Manager, Medical Intensive
Care Unit Mentor Kevin Floyd RN, BSN,
CCRN Clinical Nurse Educator Mentor Joleen Lonigan RN Nurse Manager, Patient Care
Resources Mentor Introduction: Response: Documentation of in-hospital Code Blue cardiac/respiratory arrest emergencies supports real-time care,
process improvement, and legal accountability. Currently, the “code sheet” serves as the primary documentation for
what is often a chaotic and complex event. Vital aspects of leadership, organization, and team communication are
generally not evident from the code sheet. In order to strengthen the capture of subtle features of Code Blue events,
an interdisciplinary and interprofessional group from the recently reorganized Code Blue Committee developed a
novel reporting instrument. Our objective was to document key leadership and communication behaviors of the
Code Blue Team that may help or hinder resuscitation. Methods: Response: The reporting instrument was developed over multiple iterations via group consensus. It contains items
relating to the clinical circumstances of the code, as well as items relating to leadership, organization, and
communication during and after the code (based on a Likert 1-5 scale with 5 being the highest performance). The
instrument also contains space for narrative comments to provide further detail. This instrument is filled out by
specifically trained members of the Code Blue Team (nurses from either the Medical Intensive Care Unit or Rapid
Response Team). We used summary statistics and standard deviation (SD) for reporting our results. Results: Response: We collected data from adult Code Blue events that occurred between July 1 and December 31, 2015.
During this time there were 94 Code Blue calls. We received complete reporting instruments for 40 (43%) of the
events. These occurred in: ICU (n=16), Telemetry Unit (n=11), Med/Surg Unit (n=10), and non-inpatient unit
(n=3) settings. Residents served as code leaders in 41% of codes (n = 16), and fellows in 33% (n = 13). For team
organization, the mean score for appropriate distribution of labor (i.e. assigning roles such as chest compressions,
airway management, medication administration) was 3.8 (SD 1.7), and for equipment positioning (e.g. defibrillator
visible to team leader, adequate space for activity) was 3.8 (SD 1.2). For team leadership, the mean score for
clinical decision-making (establishment and execution of plan) was 3.9 (SD 1.3), and for team communication (e.g.
use of closed-loop communication, sharing of plan with team) was 3.6 (SD 1.3). Debriefing was performed after
75% of events (n = 30). Major themes from the narrative comments clustered around several factors: a)
overcrowding, b) a need for more clearly defined roles within the team, c) difficulty with technical skills (e.g.
central line placement), and d) barriers to performing effective debriefing after codes. Discussion: Response: We believe that this reporting instrument is an important step towards a better understanding of the
complex and dynamic nature of team interactions during Code Blue events. As we refine the reporting process, and
further integrate the results into our quality assurance process, we anticipate that it will result in improved
outcomes for our most vulnerable patients. Submitted Tracking Number: 268 Abstract Title: Response: Central line blood stream infection reduction in Oncology patients using Chlorhexidine gluconate
bathing. Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Valerie Sawhill vsawhill@ucdavis.edu RN-BC, MSN Clinical Nurse lll , Quality & Safety Champion Mentor Additional Participants
Name Degrees Title Role
Laurie Brunton RN Clinical nurse lll Learner Nicole Mahr RN,MSN Clinical nurse lll Mentor Wilson Yen RN Nurse Manager Davis 8 Mentor Introduction: Response: Oncology patients are at risk for infections. Oncology patients need central venous access for the
chemotherapy treatment. When there is a central line in place there is a risk that the bacteria from the skin can
migrate to the insertion site entering the blood stream causing a Central Line Blood Stream Infection (CLABSI).
The NHSN benchmark for CLABSI is 2. Davis 8 CALBSI rate has been above the NHSN benchmark of 2 for
more than 4 consecutive quarters Q1 2014-Q1 2015. The infections occur several days to weeks after insertion
suggesting that maintenance care should be considered. Most of the infections are caused by bacteria that normally
grows on the skin. The patients on Davis 8 either showered or were washed in bed with 2% CHG liquid soap. This
method of cleaning the skin has been found to be insufficient to remove bacteria from the skin and does not
penetrate the skin to provide a protective shield from bacteria. The goal of the project was to reduce the CLABSI
rate to the NHSN benchmark by the end of 2015. Methods: Response: The Nurse Manager, Clinical Nurse III (CNIII) group, the Infection Prevention nurse, and the Quality &
Safety Nurse Champion met to analyze the problem. The decision was made to implement an intervention to reduce
infections. The Q&S Champion and CNIII nurses taught the nurses about the problem by reporting the infection
rate and cause of CLABSI. The nurses were instructed by video and demonstration on how to bathe patients with
CHG wipes. The patients were educated on infection prevention and how to use the CHG wipes after showering.
Signs describing how to use the CHG wipes were placed in each patient room to remind nurses and patients about
the use of the CHG wipes. Patient education on CHG bathing was placed in the Bone Marrow Transplant patient
education binder. The Q&S Champion and IP nurse reported monthly to the CNIII group and staff the infections
for the month. The Q&S Champion asked the nurses if there were any barriers to CHG bathing and addressed the
identified barriers.The Q&S Champion continued to encourage the nurses and patients to use the wipes. The CNIII
nurses audited the charts for nurse documentation of CHG bathing. They also coached nurses on CHG bathing and
documentation. We measured our infection rate using the Infection Prevention data of hospital acquired infections.
The monthly infection report was reviewed in daily huddles with staff and posted in the nursing unit. Results: Response: The CLABSI rate was decreased to reach the benchmark in Q2 and Q3 of 2015. The project decreased
the number of CLABS by having patients use the CHG wipes. This project showed that when nurses involve
patients in their care there are good outcomes. Discussion: Response: The project showed the patients risk of infection reduces with daily bathing with the CHG wipes. The
next step for D8 is for the nurses to pay close attention the integrity of the central line dressings. Submitted Tracking Number: 307 Abstract Title: Response: Collaborative care for achieving a cure in patients with chronic Hepatitis C infection Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Patricia Poole plpoole@ucdavis.edu PharmD Pharmacist Specialist Mentor Additional Participants
Name Degrees Title Role
Jessica Gomez PharmD Staff Pharmacist II Learner Kathleen Haight Pharm.D. Staff Pharmacist II Mentor Thomas Harper CPhT Pharmacy Technician III Mentor Rebecca
Hluhanich PharmD Staff Pharmacist II Mentor Vinh Nguyen Pharm.D. PGY-2 Ambulatory Care Resident
Pharmacist Learner Introduction: Response: Approximately 4 million people in the United States are estimated to be infected with hepatitis C. Over
time, chronic Hepatitis C can cause serious health problems including liver failure, and is the leading cause of liver
cancer and liver transplantation. Following the long-awaited FDA approval of direct acting antiviral medications to
treat chronic Hepatitis C in December 2013, there was insufficient capacity within UC Davis specialty clinics to
provide treatment to all interested patients. Additionally, there was insufficient expertise within the specialty clinics
to navigate the complicated authorization process, mitigate drug interactions and adherence barriers, and coordinate
care among providers. The addition of clinical pharmacists and clinical pharmacy technicians to the existing
specialty clinic staff was mobilized to bridge this gap in access and quality. Methods: Response: Clinical pharmacist staff were imbedded into hepatology and infectious disease specialty clinics from
January 2014 to December 2015 to co-manage patients with Hepatitis C (HCV) under a collaborative practice
agreement. The pharmacists participated in HCV regimen selection, patient education, lab ordering and
monitoring, side effect management, adherence support, care coordination and documentation of patient outcomes.
Clinical pharmacy technicians supported the prior authorization, patient assistance, medication delivery and
adherence support functions. Resident pharmacists were layered with experienced clinicians to extend care and
meet the academic learning mission. The patient experience was analyzed by stage of disease, treatment
progression, prescription payment assistance, and clinical outcome of achieving a cure. Patient and provider
satisfaction was assessed by written surveys. Results: Response: Over the 24 month period of the project, over 900 patients with HCV were referred to the clinical
pharmacist co-management panel. Of 488 patients who completed the full course of treatment and surveillance,
92% achieved a cure. The pharmacy team continues to monitor approximately 500 patients who are in some stage
of pre- treatment work up, active treatment monitoring, or post-treatment surveillance. The pharmacy technicians
secured financial assistance for patients’ prescription treatment in excess of $3 million dollars in the second year of
the program. Patient satisfaction scores each quarter rated the pharmacy staff and UC Davis Specialty pharmacy
favorably, with 93% strongly agreeing that staff were compassionate, friendly and helpful, and 98% rating the UC
Davis Specialty pharmacy as 9 or 10 with a score of 10 as the "best possible" during the most recent quarter. UC
Davis medical providers also rated the clinical pharmacy team efforts favorably. Discussion: Response: The integration of clinical pharmacists and pharmacy technicians into UC Davis specialty clinics
expanded access to Hepatitis C specialty care through clinical and payor interventions. Cure rates for chronic
hepatitis C infection are impressive at 92%, including a high proportion of difficult-to-treat patients. Patient and
provider satisfaction remain high, endorsing the high quality of care provided by the clinical pharmacy team. The
integration of resident pharmacists as learners yields a high quality opportunity for future practitioners to gain
specialized clinical expertise. As the model is also self-sustaining through prescription revenues, expansion to
other specialty clinics continues with a similar model. Submitted Tracking Number: 256 Abstract Title: Response: Creating a Culture of Safety through a Geriatric Hip Fracture Interprofessional Team Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Philip Wolinsky prwolinsky@ucdavis.edu MD Professor, Orthopedic Surgery Mentor Additional Participants
Name Degrees Title Role
Calvin Hirsch MD Professor, General Internal Medicine Mentor Christina Slee MPH Director, Quality and Safety Learner Katren Tyler Associate Professor, Emergency Medicine Mentor MD Introduction: Response: In 2013, the UC Davis Medical Center (UCDMC) created a co-managed model of care for geriatric hip
fracture patients involving orthopedic surgery (OS) and internal medicine (IM). The program developed a focus on
patient safety through three strategies: 1) developing standardized geriatric-friendly order sets, 2) cohorting of
patients on the orthopedics service, and 3) using weekly interprofessional huddles to identify patient safety
concerns and escalate them to the UCDMC Patient Safety Events Committee. Methods: Response: Standardization in care was established with EMR-generated order sets for the emergency department
(ED) admission, fascia iliac compartment block (FICB) administration in the ED, the inpatient admission, and
post-op care. Cohorting was used to sort patients to the service most skilled at managing them (orthopedics vs
medicine) based on comorbidities and potential complications. Lastly, a weekly interprofessional huddle was used
to identify system-level patient safety concerns requiring institutional review by the Patient Safety Events
Committee (PSEC). Results: Response: Between January 1, 2014, and November 30, 2015, 189 patients were enrolled in the GFP. Between
2014 and 2015, 24.7% more hip fracture patients received IM consults (p < .05), and uptake of the FICB order set
in the ED increased by 18.8% (p = NS). In the cohorted population, length of stay and incident delirium remained
unchanged between 2014 and 2015. Three patient safety events were brought to PSEC and escalated to
interprofessional teams who established or reinforced nursing-resident-attending communication guidelines,
designed training to improve management of high-risk medications, and expanded the GFP pathway to
non-geriatric patients at high risk for complications. Discussion: Response: The complexity of GFP patients required a multi-pronged approach to patient safety. The order sets
have succeeded in directing medical staff to best practices, including alternatives to opioid use such as the FICB.
Medically unstable patients are routinely assigned to medicine for pre-op optimization, allowing 50% of patients to
be cohorted on the orthopedic service. PSEC has increased the visibility of medical co-management challenges
across the institution and highlighted the value of interprofessional participation in patient safety. Specific areas of
improvement include improving inter-service transfers for patients who do not need critical care, expanding
co-management to other at-risk patients (ie, end-stage renal disease patients on dialysis), and breaking down silos
between services. One future goal of the collaborative care model is to consolidate GFP admissions to medicine to
a non-academic service with a small number of rotating attending providers in order to optimize
medicine-orthopedic cooperation through greater familiarity with the GFP. Submitted Tracking Number: 297 Abstract Title: Response: Decreasing Fluoroscopy Time for Percutaneous Coronary Intervention Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Brad Stauber bstauber@ucdavis.edu DO Fellow, Cardiovascular Medicine Learner Additional Participants
Name Degrees Title Role
Wendy Foster BS Project Manager Mentor Garrett Wong MD Assistant Clinical Professor Mentor Introduction: Response: Continued advances in interventional cardiology have led to an ever growing number of patients each
year undergoing procedures with fluoroscopy. While patients benefit from these necessary diagnostic and
interventional studies, the price paid is exposure to ionizing radiation and its side effects. As a quality measure, the
cardiac catheterization laboratory at UC Davis reports data to the National Cardiovascular Data Registry (NCDR).
We have known that compared to hospitals in the United States, our average fluoroscopy time required to perform
percutaneous coronary intervention (PCI) is approximately double the national average. Although we aim to deliver
safe and quality healthcare, there is always room in improve our standards. Decreasing fluoroscopy minutes during
PCI is one such area that can be improved. The aim of this project has been to decrease the mean fluoroscopy time
to perform these interventions of the 2014-2015 academic year. Methods: Response: All PCI procedures over the course of the third quarter of 2014 until the second quarter of 2015 were
reported to the NCDR including data regarding fluoroscopy time (minutes) and history of coronary artery bypass
grafting (CABG). Several interventions were employed at the beginning of Q3 2014. Firstly, individual operators
were informed of their averages on a quarterly basis. Additional efforts were put in place including a push to use
fluoroscopy images when possible instead of cineradiography (which increases radiation dose and time), and strong
consideration of whether a right heart catheterization needed to be performed in addition to the left heart
catheterization + PCI (which also increases fluoroscopy time). Finally, trainees were given the opportunity to hone
their techniques in a simulation lab to help improve skills while fluoroscopy is being used. Results: Response: Mean fluoroscopy time for all-comers from 18.6 minutes in the third quarter of 2014 to 16.6 minutes by
the second quarter of 2015 (11% decrease). When accounting for history of CABG, an improvement in fluoroscopy
time was when looking at patients with and without a history of CABG. Discussion: Response: On a per capita basis in the United States exposure to radiation has more than doubled since the 1980’s.
Risks from have been well described in the literature for decades, including (but not limited to) tissue injury,
cancer, and reproductive effects. As radiation exposure increases, risks also increase. This can affect not only
patients but all persons in the laboratory, including physicians, nurses, and technicians. With steps in place to
actively decrease fluoroscopy time, we saw a 11% decrease in mean time over the period of one year.
Improvements can be attributed to several aspects of the intervention. Radiation awareness with culture aimed at
decreasing fluoroscopy time seemed to make a difference. Furthermore, as with any training institution, less
decreasing fluoroscopy time seemed to make a difference. Furthermore, as with any training institution, less
experienced trainees can improve skills in a simulation lab to help minimize time under ionizing radiation. With
our averages still above national average, next steps will include continued use of simulation lab, review of
fluoroscopy time after each case, and continued awareness with aim for decreased ionizing radiation exposure
while maintaining high quality studies. Submitted Tracking Number: 311 Abstract Title: Response: Decreasing Postoperative Pulmonary Complications after Spine Surgery Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Adam Wegner amwegner@ucdavis.edu M.D., Ph.D. PGY-3 Resident, Orthopaedic Surgery Learner Additional Participants
Name Degrees Title Role
Yashar
Javidan M.D. Assistant Profession, Department of Orthopaedic
Surgery Mentor Eric
Klineberg M.D. Co-Director of the Spine Center, Associate
Professor, Department of Orthopaedic Surgery Mentor Rolando
Roberto M.D. Chief of Spine Service, Executive Vice Chair,
Professor of Orthopaedic Surgery Mentor Introduction: Response: Spine surgery inflicts a significant physiological challenge onto the patient, necessitating prolonged
ICU stays for postoperative management and monitoring, and limitingmobility due to pain and activity restrictions.
Early mobilization and respiratory care are paramount to recovery after spine surgery in order to decrease the risk
of pulmonary postoperative complications (PPC’s) such as pneumonia, pulmonary embolism, and prolonged
intubation, all of which contribute to increased overall morbidity and prolonged ICU and total hospital lengths of
stay. These complications tax the healthcare system’s limited financial and physical resources and negatively affect
the patient experience. The UC Davis Spine Center has identified a higher than expected rate of postoperative
pulmonary complications (PPCs) after spine surgery, according to NSQIP data. By improving postoperative
pulmonary care, we hypothesize that we can decrease the risk of PPC's after spine surgery. Methods: Response: A new spine postoperative order set will be constructed to implement consensus treatment protocols to
maximize pulmonary care through improved orthotic production and use, early physical therapy, early respiratory
therapy, and DVT prophylaxis. Implementation will require cooperation between multiple departments involved in
the multidisciplinary care of postoperative spine patients. We will use NSQIP PPC data as our primary outcome, as
well as secondary measures such as time to first mobilization, time to receive orthotic, rate of DVT prophylaxis,
and time to respiratory. Results: Response: It is expected that the number of PPCs will decrease with improved pulmonary care, and that patients
will receive their orthotics faster, receive optimal pulmonary care through respiratory therapy, mobilize earlier, and
receive DVT prophylaxis at a higher rate than before implementation of a new spine postoperative order set. It is
also expected that training of residents and staff on these new procedures will result in improved communication
and care coordination. Discussion: Discussion: Response: We hypothesize that early mobilization and improved pulmonary care will decrease the rate of PPCs. It
is expected that certain aspects of these new protocols may elucidate new systemic barriers to optimal care of
postoperative spine patients that we will address through fine-tuning of the order set or systemic policy changes to
decrease postoperative complications, improve the patient experience, and decrease costs. Submitted Tracking Number: 264 Abstract Title: Response: Early Quality Benefits to Participation in The American College of Surgeons' Optimal Surgical Care of
the Child Pilot Project Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Suzyn Daniel skdaniel@ucdavis.edu BSN, MBA, RN, CNOR Pediatric NSQIP Administrative Nurse Learner Additional Participants
Name Degrees Title Role
Diana
Farmer MD, FACS,
FRCS Chair Department of Surgery, UC Davis
Children's Hospital Mentor Shinjiro
Hirose MD Chief, Division of Pediatric General,
Thoracic and Fetal Surgery Mentor Greg
Maynard MD Clinical Professor of Medicine, and Chief
Quality Officer Mentor Karen
Semkiw BSN, MPA,
RN Children's Program Manager Mentor Christina
Slee BSJ, BA,
MPH Director, Quality and Safety Mentor Introduction: Response: UC Davis Children’s Hospital became a pilot site for the ACSs’ Level 1 Children’s Surgery Center.
The program’s intent optimizes principles and resource standards for quality-improvement, safety processes, data
collection and process verification. Participation initiated substantial changes, resulting early quality benefits under
the direction of the newly formed Children’s Surgery Performance Improvement and Patient Safety (CSPIP) in
collaboration with the Quality Departments prior to receiving our first risk- adjusted report. Methods: Response: The CSPIP formed, meeting monthly reviewing surgical program performance and safety events
intra-operatively, within 48 hours, to 30 days post-operatively guiding ACS program requirements. Pediatric
physician chairs redefined credentialing/privileges, formally engaging in peer review, event assessment, analysis,
education/improvement recommendations. A program nurse manager was hired attending to data and project
management. The hired Surgical Case Reviewer consulted with IT for data automation to improve abstraction
efficiency. Hospital-wide quality projects in collaboration with the CSPIP provided real-time data further
enhancing early benefits. Results: Response: Early quality benefits initiated enhanced efficiency: data automation and decreased need for follow-up
phone calls; safety: pediatric surgeon credentialing/privileging designation, adverse event analysis resulting
equipment, medication & practice changes and increased daily & on-call pediatric specialized care; and
performance: “Case Status” added to OR HUDDLE, and formation of additional pediatric-transition unit increasing
open-bed efficiency in the ED. Discussion: Response: Participation in the pilot ACS initiated a multifaceted approach guided by the multidisciplinary CSPIP.
In monitoring our pediatric surgical program, early benefits initiated improvement in efficiency, patient safety and
performance. Submitted Tracking Number: 273 Abstract Title: Response: Enhanced Recovery Protocols Reduce LOS in Elective Colorectal Surgery Patients: An ACS NSQIP
Project Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Kimberly Brink kkbrink@ucdavis.edu RN, BSN Surgical Case Reviewer, NSQIP Mentor Additional Participants
Name Degrees Title Role
Christine
Cocanour MD, FACS,
FCCM Professor of Surgery, NSQIP Surgeon
Champion Mentor Professor of Surgery, Former NSQIP
Surgeon Champion Mentor James Holcroft MD Vijay Khatri MBChB, FACS,
MBA Professor, NSQIP Director Mentor Anne Marder RN, BSN Surgical Case Reviewer, NSQIP Mentor Introduction: Response: The goal of the Enhanced Recovery Program is to improve patient outcomes, increase hospital
efficiency and value, and decrease provider variability in the care of the colorectal surgical population by
decreasing surgical stress, length of stay, and complication rates. This program is intended to accelerate recovery
while still successfully meeting discharge criteria. Using NSQIP data, the average length of stay in 2013 for a
routine elective colectomy patient at UCDMC was 6.02 days, and for a routine elective proctectomy patient, 9.45
days. Methods: Response: The Enhanced Recovery Program is a multimodal, patient focused approach to rehabilitation in the
post-operative colorectal patient. This paradigm has focused elements in the patient's journey through surgery,
including pre-operative, intra-operative, and post-operative care processes. Targeted interventions include patient
education, pre-operative fluid intake and nutrition status, use od multi-modal approaches to pain control,
maintaining intra- operative fluid balances, and early mobilization and nutrition post- operatively. Length of stay
and post-operative occurrences are evaluated using NSQIP abstracted data. Results: Response: The Enhanced Recovery Program was initiated in mid-2014 targeting elective colorectal patients that
met NSQIP inclusion criteria. With the above protocols initiated, the average length of stay was reduced to 5.37
days in colectomy patients, and 5.53 days for proctectomy patients. In addition, there was a reduction in morbidity
events in this population placing UCDMC in the top 10% of participating hospitals for urinary tract infections and
surgical site infections. Discussion: Response: Although the case volume for these 3 years is small, the reduction in length of stay and overall
morbidity for this population of patients is notable. It is expected that this trend will continue and these best
practices will be implemented in other surgical departments. Submitted Tracking Number: 279 Abstract Title: Response: Evaluating cancellations of surgeries that occurred on the day of or one day before intended operation
date at the Children’s Surgery Center of UC Davis Medical Center Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Joseph Baek wbaek@ucdavis.edu M.D. Anesthesiology Resident Physician (PGY-3) Learner Additional Participants
Name Degrees Title Role
Tzu-Ang Li Undergraduate
student Undergraduate student Learner Niroop
Ravula M.D. Assistant Clinical Professor of
Pediatric Anesthesiology Mentor Introduction: Response: The cancellation of scheduled surgeries pose numerous problems including potential harm to patients,
patient dissatisfaction, and a waste of scarce resources. These problems are especially magnified when the
surgeries are cancelled on the day of or one day before the surgery. We have looked at reasons for cancellations
and preventable causes at the Children’s Surgery Center (CSC) at UC Davis Medical Center (UCDMC). Methods: Response: We looked all the surgery cancellations that occurred in a ten-month period from 1/1/2015 to
10/30/2015 at CSC. The data was collected by the UCDMC Perioperative Performance, Safety, & Quality
Improvement Team. We then singled out cancellations that occurred on the day of or one day before the planned
operation date. From those, we focused our study on the canceled cases that could have been prevented. We divided
the data into four categories by reasons: 1) surgical, 2) medical, 3) anesthesia-related, 4) patient-related. From the
surgery category, we deemed the cancellation preventable if the reasons were either “surgery previously
performed” or “patient reevaluated, surgery not needed.” From the medical category, the cases were preventable if
the provider wanted “more evaluation needed” before surgery. From the patient- related category, cancellations
were selected as preventable for the following reasons: not-NPO, insurance reasons, no longer wants surgery,
unable to reschedule, or other miscellaneous reasons. There was no preventable cancelled cases from the
anesthesia category. Results: Response: In the 10-month period from 1/1/2015 to 10/30/1015 at the CSC, there was a total of 3073 cases
scheduled and 305 cancelled cases. 123 of those cancellations were on the same day or one day before the planned
operation date. We will call these cancellations “near-day cancellations.” Out of 123, 55 of them were deemed
preventable. 56.4% (31 cases) of the near-day preventable cancellations were due to surgical reasons; two main
reasons being “surgery previously performed” and “surgery not needed.” Patient-related reasons were the second
most common near-day preventable cancellations (38.2%). There was a variety of patient-related reasons, but the
two most common ones are insurance and “patient no longer wants surgery” categories. Discussion: Discussion: Response: Nearly 20% of all the cancelled cases were deemed preventable. Many were cancelled because the
surgery was either not needed or already performed, and of insurance and consent issues. Per UCDMC
perioperative services, the contribution margin of each cancelled cases was roughly about $6000; that is roughly
$360,000 in preventable loss of revenue for the hospital. Many could have been prevented if patients were sent to
the preoperative assessment clinic to be medically optimized. These added steps will improve patient satisfaction
score, reduce unnecessary cost to the hospital, and decrease burden to patients’ families. Submitted Tracking Number: 277 Abstract Title: Response: Evaluation of appropriate venous thromboembolism (VTE) prophylaxis in hospitalized pregnant
women undergoing cesarean section. Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Natalie Wessel nwessel@ucdavis.edu DO, MPH Resident Physician, PGY3 Learner Additional Participants
Name Degrees Vincent Cagonot
Ronnie
Delmonte Title Role
PharmD candidate Learner PharmD candidate Learner Laurie Finta MD, FACOG Medical Director of Maternity Services Mentor Tiffany Pon PharmD,
BCPS Assistant Professor of Clinical
Pharmacy Mentor Denise Roach PharmD Clinical Services Supervisor Mentor Introduction: Response: Venous thromboembolism (VTE) is a leading cause of maternal mortality. Studies have shown
pregnant women have a 4-5 fold increase in VTE risk compared to women who are not pregnant and hospitalized
pregnant women undergoing c-section are at an even higher risk. Consensus regarding appropriate chemical VTE
prophylaxis during pregnancy is lacking. Three organizations currently provide different recommendations: the
American Congress of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and
Gynaecologists (RCOG), and the American College of Chest Physicians (ACCP). In 2013, ACOG District II
piloted the Safe Motherhood Initiative (SMI) to reduce maternal mortality. The SMI combines elements from these
guidelines to create new recommendations for prophylaxis, where patients undergoing c-section who have
additional risk factors for VTE qualify for chemical prophylaxis. University of California, Davis Medical Center
(UCDMC) currently has no VTE prophylaxis protocol for the OB population. The purpose of this study is to
evaluate chemical VTE prophylaxis practice for women undergoing c-section at UCDMC and compare it to the
SMI recommendations, with the hypothesis that current practice at UCDMC is insufficient. Methods: Response: This was a single-center retrospective chart review of pregnant women undergoing c- section from
05/01/13-09/01/15. The study included pregnant women aged 18 and older undergoing c-section who met criteria
for chemical VTE prophylaxis according to the SMI. Exclusion criteria included treatment with anticoagulation
prior to admission. Primary endpoints were rate of mechanical or chemical prophylaxis order placement and
chemical VTE prophylaxis administration. Secondary endpoints were incidence of VTE within 6 weeks after
c-section and VTE-associated mortality. Results: Results: Response: A total of 626 charts were reviewed. The rate of mechanical prophylaxis was 94.5% (580/614).
Chemical prophylaxis was ordered in 4.6% (28/614) of patients and in those patients 98.1% (262/267) of doses
ordered were administered. The incidence of 6-week post-partum VTE was 0.81% (5/614). There were zero cases
of VTE-associated mortality. Discussion: Response: Recommendations for chemical VTE prophylaxis in pregnant women are based only on observational
evidence and therefore remain controversial due to lacking consensus. However, the results of this study suggest
failure to utilize any guideline or protocol for chemical prophylaxis in the OB population at UCDMC may be
problematic. Only 4.6% of patients who met criteria for chemical prophylaxis according to the SMI actually
received it. And, despite high compliance to mechanical prophylaxis (94.5%), 0.81% patients did develop VTE
within 6 weeks of c-section; this is 2-4-fold higher than nationally reported rates of 0.2-0.4%. It is unclear how
many women would need to receive chemical prophylaxis to prevent one VTE associated maternal death.
Nonetheless, VTE remains a major cause of maternal mortality on a population level, and women at increased risk
need to be identified. At UCDMC, one strategy to improve rates of chemical prophylaxis would be to include the
OB population into the existing EMR-based VTE risk-assessment tool. Submitted Tracking Number: 325 Abstract Title: Response: Exploring Staff Perceptions of A Newly Implemented Endotracheal Tube Assist Device in the MICU Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Andrea Rosato alrosato@ucdavis.edu RN MS Student Learner Additional Participants
Name Degrees Title Role
Beverly Schacherbauer RN MS Student Learner Carel Troutman RN MS Student Learner Introduction: Response: An increased number of lip/facial pressure ulcers were observed in intubated patients in the Medical
Intensive Care Unit (MICU), which were attributed to standard tape securing protocols. This prompted review of
evidence based practice of ETT stabilization, changes in policy and the trial of the Anchor Fast Endotracheal Tube
Assist Device (ETAD) beginning November 17, 2015. Prior to the trial, the Airway Management Protocol was
revised to allow for either taping or ETAD based on nursing discretion. Data were collected at 45 days post
implementation by the MICU leadership and evidenced potential issues with the ETAD. This included device
failures, minor skin breakdown, inconsistent practice and documentation patterns, and confusion about device
indications within the interdisciplinary team. The project aims is to understand the staff’s perceptions of the ETAD
after the initial trial period via Survey Monkey. Information obtained from this project will help guide and inform
future staff education and potentially clarify protocols specific to the utilization of the device. Methods: Response: Based on the results of the 45-day post implementation data, a survey was created to explore the
potential barriers to implementation in the MICU. The survey consisted of eighteen questions that focused on four
specific domains: benefits of the ETAD, decision making on ETAD appropriateness, training and knowledge
surrounding the ETAD, and confidence in utilization of the ETAD using a combination of Likert and open-ended
answers. Demographic information on the survey participants will be collected including gender, years of ICU
experience, and shift worked. The survey was reviewed by the MICU Nurse Manager and three subject matter
experts for content validity. The survey will be sent to all MICU nursing staff via work email. The data will be
collected, analyzed, and presented to the Nurse Manager with recommendations for the next area of focus. Results: Response: Prior to ETAD implementation, two full thickness lip/facial ulcers were associated with standard ETT
taping protocols. At 45-day post implementation of ETAD, full thickness ulcers were not present, although there
was a stage 1 ulcer and 3 skin tears reported. Preliminary survey data shows 43% of nurses disagree that the device
prevents pressure sores. Discussion: Discussion: Response: Nurse perception’s of the ETAD’s effectiveness are inconsistent with pressure ulcer data indicating a
need for further staff education in the next PDSA cycle. The unit could consider providing rates of pressure ulcer
findings to align nursing perceptions to the outcome data. Additional findings will be used to determine how best
the MICU Leadership team can promote the safe and effective use of the ETAD, address staff concerns and
uncertainty, and provide supplemental education. Submitted Tracking Number: 260 Abstract Title: Response: Implementation of integrated hematopathological services: to improve patient care and reduce cost. Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Ananya Datta Mitra adattamitra@ucdavis.edu MD PGY-1 Learner Additional Participants
Name Degrees Title Role
Saba Ali MD PGY-3 Learner Dennis Dwyre MD Faculty Mentor Jeffery Gregg MD Faculty Mentor Hooman Rashidi MD Faculty Mentor Adam Stelling MD PGY-4 Learner Introduction: Response: Clinical Problem : Effective management of patients with hematologic malignancies depends upon
prompt and precise diagnosis. Arriving at a differential diagnosis can often be challenging due to overlapping
clinical manifestations in several malignant and non-malignant conditions. Planning appropriate treatment
according to disease stage and patient prognosis requires the integration of a spectrum of diagnostic tests including
clinical analysis, peripheral smear evaluation and trephine bone marrow (BM) biopsies which undergo multi-stage
testing for determining histologic subtype, molecular and immnophenotypical profiles, degree of maturation or
point of maturation arrest. The cumulative interpretation of these results is the fundamental basis for providing
ethically reliable diagnoses and high quality patient care. Diagnostic delay as well as the potential for repeated
bone marrow biopsies due to specimen inadequacy or poor quality can be tormenting and take a tremendous toll on
the quality of life for both patients and their families. As clinicians, we responsibly guide and support the patients
and their families throughout the diagnostic period, anxiously waiting for the final diagnosis which will ultimately
drive therapy. Although pathology results are not the only important aspect of a diagnostic workup, for patients it
often does answer one of the most important questions of all: “Do I have cancer?” Irrespective of the answer, the
anguish of the wait is no less arduous. And sadly, if the answer is “yes,” then this is just the start of an extensive
long journey involving treatment options and prognostic measures. We are in the process of implementing some
changes in the BM biopsies which not only has markedly decreased turn-around time (TAT) but also has allowed
molecular studies in the clot section. Methods: Response: Project Description: We propose developing and implementing diagnostic interventions in terms of
improvement in the quality of BM sampling within the next 6- 8 months, with constant follow-up, monitoring and
amendment in the sampling techniques, and technician work flow for a total duration of 18 months. It is a new
aspect of an existing project involving the coordinated effort of Hematopathology division in the Department of
Pathology and Laboratory Medicine and the Hematology-Oncology division of the department of Internal
Medicine. Results: Results: Response: Metrics: Patient data including hematological diagnosis, demographics, clinical parameters, and
management, will be collected through utilization of the EPIC/LIS. Clinical outcomes will include time to
diagnosis, time to initiation of anticancer therapy, total hospitalization, length of stay in Hematology-Oncology
service, number of repeat biopsies and estimated cost savings. Time to diagnosis will be defined as the time of
collection of BM sample to the date of the first BM biopsy result. Discussion: Response: We will compare patients with hematological malignancy who received BM results with and without
the rapid decalcification technique every 6 month interval starting from July 1st 2013 till June 30th 2016. Submitted Tracking Number: 310 Abstract Title: Response: Implementing AUA Guidelines for Office Cystoscopy Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Robert Lurvey rlurvey@ucdavis.edu M.D. Resident Learner Additional Participants
Name Degrees Title Role
Roger Low M.D. Professor Mentor Introduction: Response: Antibiotic overuse presents a risk of adverse event on both the individual and community level.
Previously, it was standard policy in our department to provide all patients undergoing cystourethroscopy with
peri-procedural antibiotics. This practice did not appear consistent with the American Urological Association
(AUA) guidelines on antibiotic prophylaxis. Our goal was to review the antibiotic guidelines with the department
and to quantitate the decrease in antibiotic use. Methods: Response: The AUA guidelines were reviewed with clinic staff, all residents, and pertinent faculty through e-mail
and discussion at our weekly case conference in June of 2015. Signs listing the AUA guidelines were also posted
in the two cystoscopy suites. In addition, as part of a separate change in billing practices, physicians were asked to
place an order in EMR if antibiotics were given. Residents were also asked to separately document in their
procedure notes if antibiotics were provided and a reason why. Previously, antibiotics were given as part of
standard operating procedure without an EMR order. Between June 10, 2015 and October 7, 2015, nursing staff
kept a log of cystoscopies performed in a single cystoscopy sweet and whether the patient received antibiotics.
Separate chart review was performed by a single resident of all cases logged where antibiotics were provided to
identify if they were provided within guidelines. Results: Response: A total of 200 cystoscopies were logged. 77 patients (39%) received peri-procedural antibiotics. On
chart review, the majority of patients received antibiotics due to advanced age or manipulation. One patient
received antibiotics due to patient request. Six patients had no identifiable reason for receiving antibiotics and three
received antibiotics in the log despite EMR documentation to the contrary. Overall, it appears 5% of patients
received antibiotics contrary to guidelines. Discussion: Response: By implementing and reinforcing the AUA guidelines for antibiotic prophylaxis, we decreased our
antibiotic use by over 60%. Over-antibiotic use was seen in only 5% of our patients. Prior studies by Herr et al
found less than 4% rate of symptomatic bacteriuria after cystoscopy without antibiotics. Further studies will need
to better define the exception guidelines as laid out by the AUA. Submitted Tracking Number: 321 Abstract Title: Response: Improving Breast Cancer Screening Rates in the Primary Care Clinics Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: vaihere sagues vasagues@ucdavis.edu Operations Analyst Learner Additional Participants
Name Degrees Title Role
HEALTH MANAGEMENT AND
EDUCATION CARE
COORDINATION N/A Learner PCN/HBC LEADERSHIP TEAMS CLINIC MEDICAL
DIRECTORS;
ASSISTANT
DIRECTORS Mentor DEPARTMENT OF
RADIOLOGY N/A Learner PCN/HBC PRIMAR CARE
CLINICS PRACTICE
MANAGERS; PHYSICIANS,
AND CLINICAL SUPPORT
STAFF Learner IT REPORT AND REGISTRY
TEAMS ANALYSTS Learner Introduction: Response: The aim was to integrate a team-based care model to improve clinical quality measures across all
primary care clinics. We started with a focus on the breast cancer screening measure, using evidence-based
guidelines and national benchmarks. Methods: Response: We redesigned MA/LVN workflow to engage patients at point-of-care. Our first priority was building a
strong collaborative effort with the Department of Radiology. Having access to schedule into radiology templates
allowed our care teams to increase the scheduling rate at check-out and overall patient satisfaction. We developed
training resources for Clinical Support Staff to learn how to review a patient’s chart (HM, Surgical History, Media,
and Imaging), pend a mammography screening order, schedule from the order at point-of-care, and document
using overrides if mammography screening was done at an external facility. To help MA/LVNs identify eligible
patients, we developed weekly reports that look ahead of the schedule and look back for missed opportunities,
including whether the order was placed, if a modifier/override was added, or an appointment was made. Another
method was leveraging technology to help us with patient outreach, such as MyChart messages and using an
automated call system, called "EmmiPrevents." To keep this effort at the forefront, data is shared at monthly
meetings for the entire care team. Incentives were also utilized to build up friendly competition between clinics.
We rewarded clinics the “Most Improved” and “Highest Performer” on a quarterly basis with pizza luncheons or a
catered breakfast. The CDC provides patient-friendly flyers that were ordered to raise awareness in all of the
clinics. To continue our momentum and further engrain workflows, we developed a refresher training presentation
at the 1-year anniversary in November 2015. We presented it to the ‘Back-Office Lead’ meeting and they used the
at the 1-year anniversary in November 2015. We presented it to the ‘Back-Office Lead’ meeting and they used the
PowerPoint presentation as a template at their designated Clinic site. Results: Response: As a result of continuous focus since November 2014, the combined PCN and HBC Primary Care
collaborative has improved from 61.4% (November 2014) to 66.1% (December 2015) in the mammography
screening rate measure. Discussion: Response: As the healthcare industry moves toward value-based care, the care team model is an integral part of
our long-term success with clinical quality measures and clinical quality improvement projects. This project
engaged all staff levels in the QI process and reinforced a common purpose. Next steps include the utilization of
this team-based model and a similar implementation approach for new clinical quality measures. Submitted Tracking Number: 304 Abstract Title: Response: Improving Patient and Visitor Hand Hygiene: A Missed Opportunity for Infection Prevention Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Andrew Liman aliman@ucdavis.edu BA Medical Student II Learner Additional Participants
Name Degrees Title Role
Ulfat Shaikh MD Director for Healthcare Quality Mentor Jean
Wiedeman MD Pediatrics Infectious Diseases Attending
Physician Mentor Introduction: Response: Healthcare systems regularly enforce employee hand hygiene as a key component of infection
prevention. However, there is less information on the importance of patient/visitor hand hygiene and whether or
not they are compliant with current policies. The purpose of this pilot study was to measure patient and visitor
knowledge, perceptions, and self-reported behaviours around hand hygiene, and implement an intervention to
improve these measures. Methods: Response: A pilot study was conducted on the Pediatric ward of the University of California, Davis Medical
Center. English-speaking families of patients over the age of 3 were asked to complete a survey. One adult from
each family was given a pre-survey. Patients over the age of 7 were also given a pre-survey, although they were
not asked to self-report behaviour. The next day, participants were given a post-survey to assess for change. To
assess for response bias, the first two weeks of the study consisted only of surveys with no intervention (baseline
group). Subsequently, the intervention was added between the pre/post surveys where patients and their families
were invited to the playroom for an interactive and educational hand hygiene activity (intervention group).
Within-group changes were compared between groups. Results: Response: 235 surveys were completed representing 130 unique families, but only 39 families remained long
enough to participate in both pre/post surveys, with 8 of these families also participating in the activity. 10 patients
participated long enough to complete both surveys, with 5 of them also participating in the activity. When
comparing the family intervention group (N=8) to the family baseline group (N=31): knowledge of minimum hand
washing time increased from 25% to 75% (baseline group decreased from 32% to 26%); reported hand washing
increased from an average of 3.5 points to an average of 4.0 points, out of 4 possible points with 1 point awarded
for each situation in which hand washing was reported (baseline group increased from 3.6 to 3.8); perception that
infectious agents are found on the hands increased from an average of 8.9 points to an average of 9.8 points, on a
10-point scale (baseline group increased from 8.9 to 9.0); perception that infections acquired at a hospital can lead
to serious illness increased from an average of 9.4 points to an average of 10.0 points, on a 10-point scale (baseline
group decreased from 9.6 to 9.5). When comparing the patient intervention group (N=5) to the patient baseline
group (N=10): perception that infectious agents are found on the hands increased from an average of 7.4 points to
an average of 8.8 points, on a 10-point scale (baseline group decreased from 7.8 to 7.3). Discussion: Discussion: Response: This pilot project supports scaling up the study to collect a larger sample. The work facilitates more
discussion on patient and visitor hand hygiene, a novel approach to infection control. Submitted Tracking Number: 251 Abstract Title: Response: Improving the Documentation of Complications to Support Accurate Reporting of AHRQ Patient
Safety Indicators Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Tessie Kaithathara tfkaithathara@ucdavis.edu RN, MSN Quality and Safety Administrative Nurse Mentor Additional Participants
Name Degrees Title Role
Jennifer
Erickson RN, MSN,
MBA Quality and Safety Administrative
Nurse Mentor Bobbi Henk RN, MSN,
CPHQ Quality and Safety Administrative
Nurse Mentor Calene
Roseman RN, MSN Quality and Safety Administrative
Nurse Mentor Johanna Sanders RN, BSN Quality and Safety Administrative
Nurse Mentor Greg Woolf Quality and Safety Administrative
Nurse Mentor RN, MS Introduction: Response: Introduction: The Patient Safety Indicators (PSIs) were developed by the Agency for Healthcare
Research and Quality (AHRQ) to provide information on potential in-hospital complications and adverse events
following surgeries, procedures, and childbirth. Each PSI has its own set of technical specifications and is
monitored displayed by The University HealthSystem Consortium (UHC) in a risk adjusted format with a peer
comparison ranking. The pre-intervention (2011) UCDMC PSI overall composite rate per 1000 exceeded the UHC
comparison group with a rate of 5.03 vs 4.61 for the UHC comparison group. The pediatric patient safety indicators
(PDI) also significantly exceeded the UHC comparison group with a composite rate of 9.87 vs the UHC
comparison group rate of 6.54. Methods: Response: Methods: The approach implemented included three main modes of intervention: 1) Automated trigger
reports were developed to search the Electronic Medical Record for PSI related documentation. These reports were
reviewed, and if determined a possible valid PSI existed, the documenting provider was contacted to verify the PSI
and review related documentation strategies. 2) After coding, but prior to Health Information Management (HIM)
billing a case with a potential PSI, the case was emailed to the Q&S nurses for review and validation. If a potential
valid PSI was determined the documenting provider was contacted to verify the PSI and discuss appropriate
documentation. 3) Medical staff departments and nursing leaders were educated, via group presentations, regarding
appropriate PSI related documentation. PSIs were also reviewed with nursing unit staff in weekly quality unit
rounds. Due to the complexity of most of the PSIs, this education was specific to each identified PSI. In addition,
process improvement and root cause analyses were utilized with select medical staff departments. Results: Results: Response: Results: For select adult patient safety indicators there was a significant overall improvement of 63%.
However, due to a decrease in case volume, PSI 17, 18 and 19 decreased in performance despite the number of
reportable cases being reduced or remaining unchanged. For select pediatric patient safety indicators there was also
a significant overall improvement of 35%. Children’s hospital physician and nursing leadership were very engaged
in the PDI review process and are largely responsible for the significant improvement. Discussion: Response: Discussion: Implementing a multi-modal improvement process was effective in reducing the number of
reported PSI/PDI cases and improving the accuracy of documentation related to procedure and patient care related
complications. Improvement in these select PSIs was a significant contributing factor in UCDMC UHC Scorecard
moving from 2 stars in 2012 to 4 stars in 2014. This movement was related to the scorecard safety domain
indicator, which showed a 52.8% improvement. This improvement in the PSIs raised the safety domain ranking
from 93 in 2012 to 9 in 2014. Submitted Tracking Number: 323 Abstract Title: Response: Improving Timely Inpatient Lab Results and Minimizing Order Cancellations on an Academic
Medical/Surgical Ward Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Kanal Singh kanal.singh@va.gov M.D. Chief Resident of Quality and Patient Safety Mentor Additional Participants
Name Degrees Title Role
Introduction: Response: Timely and clear communication of lab is a necessity to facilitate effective patient care in an inpatient
setting. Even a small, teaching facility such as the VA Hospital in Mather, CA is 45 Medical/Surgical beds, ~80%
of which are occupied/day) is no exception to this. A problem was identified several years earlier: morning labs
results were late, resulting in delays in patient care and hospital discharges. Labs at this institution are collected by
phlebotomists (preferred methods) at two specified times/day, or otherwise by a nurse (if workload allows). The
Medicine service and laboratory collaborated to develop a new quality standard targeting all routine morning labs
(e.g. BMP) result by 8 AM. This strategy, did improve the efficiency of lab staff in processing and resulting
morning labs. However, to ,maintain this cutoff time an unofficial policy was adopted by staff that if a test could
not be obtained or resulted in time, it would be cancelled (without notification of primary team or nursing staff)
with the implication that the provider could reorder if needed. This resulted in frustration among the inpatient
medical service, and potentially delayed patient care/flow. Due to this, we developed a subsequent QI project
attempting to minimize lab test cancellations (goal of at least 25% reduction) and improve communication between
lab and medical staff. Methods: Response: Using the VA QI model (VA-TAMMCS) we observed and analyzed the process of inpatient lab
collection by the phlebotomy service. We noticed multiple reasons for lab cancellations, such as patient refusal,
hard sticks, and last minute lab orders (“add-ons”) that significantly increased the workload of the phlebotomists.
We implemented use of a “missed lab” card which the phlebotomist would deliver to the patient’s nurse,
communicating inability to collect a sample and the reason behind it. We hypothesized if notified an RN could
obtain the necessary blood sample before 8AM, avoiding any cancellations. Results: Response: Two months of data collection (November –December 2015) showed the majority of lab cancellations
were due to “add-ons” (109, and 112 respectively), which is mainly due to provider error (e.g. lab orders not placed
the evening prior by the residents/interns). Additionally, “missed lab” cards now identified the reasoning behind
the inability to obtain the labs in the first place. However, despite some nurses attempting to obtain samples when
phlebotomy could not, the project did not result in any decrease in the overall number of cancelled labs. Discussion: Discussion: Response: Interestingly, we see that the attempts at quality improvement (such as time cutoffs for labs) can have
potential downsides—particularly when a a metric is targeted (e.g. 8AM lab result time) at the expense of clinical
care. Additionally, while out QI project did not result in its desired effect, it did allow us to understand the
reasoning behind lab cancellations in more detail. Future direction of this project will include resident education
about "add-on" labs, and we will consider re-evaluating the need for a morning cutoff time for lab results. Submitted Tracking Number: 315 Abstract Title: Response: In & Out on Photopheresis: Does vascular access choice improve procedural efficiency and patient
safety? Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Grace Monis gmonis@ucdavis.edu MD, PhD Transfusion Medicine Fellow Learner Additional Participants
Name Degrees Title Sarah
Barnhard MD Assistant Clinical Professor, Pathology and
Laboratory Medicine Role
Mentor Introduction: Response: Per the American Society for Apheresis Guidelines (2013), extracorporeal photopheresis (ECP) is “a
therapeutic procedure in which buffy coat...is treated extracorporeally with a photoactive compound and exposed to
ultraviolet A light and subsequently reinfused to the patient.” Our apheresis service uses the CELLEX
Photopheresis System manufactured by Therakos (Raritan NJ). From 2013 to 2015 our ECP procedures grew by
43% (160 to 282 per year) while our clinic capacity remained the same. Therefore, we continue to seek
opportunities to improve our workflow efficiency. In December 2015, two of our ECP patients had repeat
instrument alarms during their procedures necessitating treatment times nearing 3 hours. This reduced bed and
nurse availability. We investigated the cause and established previously unpublished safe procedural run time
ranges for the various vascular access types compatible with ECP. We also identified novel trends in procedure run
times between vascular access devices, an important consideration when recommending vascular access for a new
patient. Methods: Response: Per Therakos bulletin CLX #09, “post-reinfusion hemolysis…may occur as a result of excessive heat in
the centrifuge chamber. Factors include duration of treatment, length of system downtime between treatments, and
ambient room temperature.” Optimization of venous access to allow collection and return rates > 15 ml/min is the
only specification noted. We searched PubMed for published ECP adverse events and safe procedure run time
reference ranges, but no literature was available. We performed a retrospective cohort analysis of 68 procedures
performed across 19 patients in 2015. Thirty two (32) procedures were performed using double-lumen vortex ports
(DL-VP), 13 double lumen tunneled apheresis catheters (DL- TAC), 10 single lumen vortex ports (SL-VP), and 13
procedures with peripheral IV's (PIV). No adverse events were reported. Total run time was recorded. Procedures
were stratified by vascular access type. Reference ranges were established by the mean +/- 1 standard deviation.
Means were compared using the two-sample student’s T- test. Results: Response: The mean procedure run times were: DL-VP 104 +/- 10 mins, DL-TAC 102 +/- 12 mins, SL-VP 142
+/- 10 mins, PIV 143 +/- 14 mins. A comparison of the means revealed no statistical significance between DL-VP
and DL-TAC (p=0.6835) or SL-VP and PIV (p=0.7827). However, DL- VP and DL-TAC independently compared
with SL-VP and PIV mean run times were statistically significant (p Discussion: Discussion: Response: We will use these data to recommend DL-VP or DL-TAC access on all eligible new patients referred
for ECP. In addition, our proposed reference ranges for each vascular access type will ensure that physicians are
immediately consulted when patients fall outside the procedure run times so we can help trouble shoot the issue
and ensure ongoing patient safety. Our established reference ranges will be incorporated into departmental policies
and procedures in the near future. Submitted Tracking Number: 257 Abstract Title: Response: Increasing Awareness and Advance Directive Completion Rates in the Primary Care Setting Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Ashley Clark akclark@ucdavis.edu BS Medical Student Learner Additional Participants
Name Degrees Title Role
Brian Swanson M.D Adult Medicine Physician Mentor Introduction: Response: The PSDA of 1991 first brought attention to the importance of advance directives. Since the
implementation of the act little has been done to educate, encourage and implement this initiative highlighting the
need for efforts focused on improving interventions to increase completion rates. The purpose of this project is to
test a model to increase AD completion rates, and thus providing more complete patient centered care. The aim is to
improve completion rates by 25% over the three-month implementation period. Methods: Response: To improve completion rates in the primary care setting records will be reviewed of patients 65 and
older that have a physical or follow up scheduled during the 3-month implementation period. If the patient has an
AD, it will be noted. If the patient does not, their chart will be flagged for education. Educational information and a
letter explaining the intent will be sent out to patients a week prior to their scheduled appointment. A discussion,
10-15 minutes in length, will take place between the patient and the practitioner. If the patient is prepared, he/she
will be assisted in completing the AD form. If the patient declines, a note will be made for follow-up. The “study”
portion of the project is the calculation of the compliance rates before and after implementation of the project to
determine the effectiveness of the education provided. Results: Response: Tentative data: Patients 65 and older received educational information at their appointment every
Tuesday in the implementation period. Unfortunately, most appointments are scheduled only a few days prior, not
providing enough time to mail information. Additionally, the time burden on the provider limited the intervention.
Fifteen patients opted to complete their form, which was a total increase of 25%. End-of life issues are not easy
topic to discuss for multiple reasons, particularly due to the time constraint in a primary care setting. Patients were
also quick to say that their family members knew what they would want. A lot of education was focused on these
misconceptions. Due to the scheduling pattern of the patient panel forms were not mailed in advance. If the patient
was appropriate the discussion was attempted if the patient was prepared, but this did not allow for multimodal
intervention. Discussion: Response: The goal of a 25% increase in AD completion rates was met and patients were satisfied with the
education provided. Patients were willing to complete their ADs, but they needed time to discuss the information
with family. Having a process in place for the primary care provider was an important step in maintaining this
important issue at the forefront of providers minds. Whether it is monthly or annually, their needs to be an
intervention with the patient population that can benefit most. It is the provider’s responsibility to initiate these
discussions and to update forms as needed. Utilizing the students to continue the AD discussions will benefit the
patients, the practice, as well as the student because it will help develop skills in discussing end-of-life issues. Submitted Tracking Number: 258 Abstract Title: Response: Increasing Colorectal Cancer Screening Rates at CommuniCare, Davis Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Anastasia Warde anastasiacwarde@gmail.com Medical Student (MS3) Project Co-coordinator Learner Additional Participants
Name Degrees Title Role
Betsy Meux MD Attending Physician Mentor Yolanda Mora Clinic Manager Mentor Sonia Moreno Patient Services Representative Mentor Introduction: Response: Colorectal cancer (CRC) is the second most common cause of cancer death in the U.S. (1). Globally, it
is the third most common cancer among women and second most common among men, with an average lifetime
risk of 5%. Ninety-percent of colorectal cancers occur in patients older than 50 years (1). Because CRC tends to
develop slowly, and in a predictable manner, it is highly preventable through regular screening, which is able to
detect asymptomatic, early stage disease (4). However, in the U.S., screening rates remain below national goals (1).
Screening is recommended for everyone over age 50, but only 65.1 % of U.S. adults between 50-75 years were
screened in 2012 (1). The USPSTF's Grade A recommendation for CRC screening says that average risk,
non-symptomatic patients should begin screening at age 50 and continue until age 75 (2). Accepted screening
modalities include either fecal occult blood testing (FOBT), fecal immunochemical test (FIT), flexible
sigmoidoscopy, or colonoscopy (2). Our screening rate of eligible patients at CommuniCare, Davis was 30% at the
initiation of this project. Our goal was to increase the screening rate for CRC in eligible patients from the rate of
30% at time of initiation of the project, to 58%. Our short-term goal was to determine the method of outreach that
most increased compliance with CRC screening through FIT testing in men and women age 50-75 years old who
are patients at CommuniCare Davis, and have not had a colonoscopy in the past 10 years or fecal immunochemical
test or fecal occult blood test in the past 1 year. We selected FIT testing because it is a relatively simple,
non-invasive test for occult blood in stool yet highly effective. Methods: Response: Our primary intervention was increasing directed outreach to patients eligible for and in need of CRC
screening. We identified three methods of outreach to patients in need of CRC screening: (1) 10 cold calls to
patients who need FIT test according to our registry to encourage the patient to come in to complete the screening
(2) Identify 10 patients during our “huddle” at beginning of the day who need FIT test and discuss/offer FIT test
during their appointment (3) Mail 10 FIT tests to patients identified as needing FIT testing for them to return by
mail. We recorded the number of FIT tests completed/returned for each method as a way to predict the most
effective mode of outreach to guide future efforts. Results: Response: Thus far, the greatest response has been with speaking to patients when they are already coming in for
an appointment. Our data collection is still underway and we are planning subsequent PDSA cycles with larger
cohorts after this first round is completed. Discussion: Response: Data collection still underway. Will be completed in the next month. Submitted Tracking Number: 247 Abstract Title: Response: Indwelling Urinary Catheter Removal in Relationship to Post-Operative Urinary Retention: Timing is
Everything Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Tina DiPierro tjdipierro@ucdavis.edu RN, MSN, NE-BC Nurse Manager Mentor Additional Participants
Name Degrees Title Role
Charlie Dharmasukrit RN, MS, CMSRN Clinical Nurse Learner Introduction: Response: Aggressive measures to prevent CAUTI (catheter-associated urinary tract infections) encouraged the
Orthopedic Surgeons to order very early removal of the indwelling catheters placed during surgery, often at 0600
on post-operative day (POD) 1. It appeared to nursing staff on the orthopedic unit that this was leading to an
increase in the occurrence of postoperative urinary retention requiring one or more intermittent catheterizations and
often the necessity to discharge patients home with an indwelling catheter in place for follow-up with a Urologist
post discharge. Nurses worked with physicians to develop a protocol for removal of the indwelling catheter on
post-operative day 2 between 0000 and 0400. This protocol was implemented March 2012. The researchers
obtained Institutional Review Board approval to perform a retrospective chart-review study to determine if the
number of intermittent catheter and/or indwelling catheter re- insertions significantly decreased as a result of the
new protocol. Methods: Response: The protocol called for nursing staff to remove the Foley catheter between 0000 and 0400 in the
morning of POD 2 and was applied to patients on the orthopedic joint, spine, and trauma services. A total of n=243
patient charts were retrospectively reviewed. This sample included n=105 total knee and hip replacement patients
pre-implementation of protocol who were admitted November 2011 through February 2012, in addition to n=137
total knee and hip replacement patients post-implementation of protocol who were admitted November 2012
through February 2013. Results: Response: Statistical Analysis was conducted using the statistical software environment R, version 3.2.0.
Adjusting for age and surgery type, women who had their Foley catheter removed prior to POD 2 0000- 0400 had
odds of intermittent catheterization 3.9 times higher than women who had their Foley catheter removed during the
protocol-specified time window (p=0.022). Adjusting for time of Foley catheter removal, gender, and surgery type,
older patients had significantly higher odds of intermittent catheterization, with an estimated 5% increase in odds
for each additional year of age (p=0.032) and had significantly higher odds of indwelling catheter reinsertion, with
an estimated 16% increase in odds for each additional year of age (p Discussion: Discussion: Response: The data did not show any significant difference between implementation of the protocol and the
incidence of post-operative urinary retention as measured by the number of intermittent catheters and indwelling
catheter reinsertion. However, removal of the indwelling catheter within the time-frame as dictated by the protocol
did show a significant reduction in all catheter reinsertions within the female population. This study did not account
for history of post-operative urinary retention, underlying medical conditions, and medications administered that
are known precursors to urinary retention (i.e. narcotics). Post-operative urinary retention may result in patient
discomfort, increased length of stay, and increased incidence of all catheterizations. The usage of a protocol to
remove indwelling catheters in the early hours of POD 2 has the potential to reduce the incidence of postoperative
urinary retention. Submitted Tracking Number: 324 Abstract Title: Response: Meaningful Office Visit for Outpatient Oncology: Ensuring Patient- Centered Care Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Joy Morgan joymorgan@ucdavis.edu R.N., O.C.N. MS Student Learner Additional Participants
Name Degrees Title Role
Melissa Soderlund R.N., O.C.N. MS Student Learner Introduction: Response: Introduction: A recent Institute of Medicine report outlined a conceptual framework with key domains
essential for a high-quality cancer care delivery system. Goals of the recommendations ensure coordinated,
comprehensive patient-centered care and patient engagement through shared decision-making. Chemotherapy
ordering is a complex process that requires a structured error-avoidance plan. In an outpatient community cancer
center, oncology nurses voiced frustration with increasing volume of post-clinic visit care coordination due to lab
results not being available at the time of the clinic visit. The nursing team was dissatisfied with the time spent
reconciling lab results with chemotherapy orders and obtaining order revisions based on preset parameters.
Additionally, patients were denied an opportunity to discuss the lab results and their plan of care during the office
visit, which increased the amount of nurse post-visit care coordination. The aim of this project is to improve the
current clinic visit process by utilizing a multidisciplinary team to ensure patient-centered care. Goal: Decrease the
number of chemotherapy orders written prior to MD review of lab results to 25% by March 2016. Methods: Response: Methods: A multidisciplinary team developed a detailed process map to identify challenges, causes, and
possible solutions to improve the process. A retrospective chemotherapy order and pharmacy order revision audit
was completed. Patients were surveyed as to preference of lab draw prior to- or same day of clinic visit and then
an audit was conducted along after implementing the process change. Results: Response: Results: The process map revealed the complexity of the patient visit in relation to whether or not the
lab result was available at the appointment and when chemotherapy orders were written. However, physicians
believed patients would prefer not to make an additional visit for a lab test. The chemotherapy order/lab audit
revealed that chemotherapy orders were written (n=45) 62% of the time without the lab result available for patient
and physician review. Pharmacy audit: (n=68) 60% of order clarifications related to lab result timing. Patient
survey: 95% (n=86) preferred to have labs test prior to appointment so the results could be discussed. Based on
these findings, a process change was implemented successfully for one physician; subsequently the change was
adopted for all physician visits. Discussion: Discussion: Response: Discussion: This project suggests patients want to participate in their care and treatment planning during
clinic visits, consistent with patient-centered care. By initiating pre-clinic visit lab testing, chemotherapy orders
written before lab review decreased from 62% to 24%. Physician review of lab results prior to writing
chemotherapy orders reduced the number of order clarifications and decreased the amount of post-clinic visit care
coordination. Future goals should consider the date and time of the lab compared to the date and time of the office
visit as well as patient satisfaction with inclusion in treatment decisions. Submitted Tracking Number: 249 Abstract Title: Response: Medical necessity of routine admission of children to the Intensive Care Unit with mild traumatic brain
injury Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Jared Ament jared.ament@ucdmc.ucdavis.edu MD, MPH Resident Learner Additional Participants
Name Degrees Title Role
Joseph Galante MD Trauma Surgery Faculty Mentor Krista Keachie MD Resident Learner Daniel Nishijima MD Emergency Medicine Faculty Mentor Patrick Tertulien BS Student Learner Marike Zwienenberg MD Neurosurgery Faculty Mentor Introduction: Response: Approximately 475,000 children are treated for traumatic brain injury (TBI) in the USA each year; most
are classified as mild TBI (Glasgow Coma Scale [GCS] score 13-15). Patients with a “positive” head CT, defined
as either intracranial hemorrhage or skull fracture, irrespective of severity, are often transferred to tertiary care
centers for Intensive Care Unit (ICU) monitoring. This practice creates significant burden on the healthcare system.
The purpose of this investigation was to derive a clinical decision rule (CDR) that maximizes safety and resource
allocation. Methods: Response: We retrospectively reviewed mild TBI patients ≤16 years old presenting to a Level 1 trauma center
from 2008-2013. Data were abstracted from institutional TBI and trauma registries. Independent covariates
included, age, GCS score, pupillary response, CT characteristics, and injury severity score. A composite outcome
measure, ICU-level-care, was defined as cardiopulmonary instability, transfusion, length of stay >2 days,
intubation, placement of intracranial pressure monitor or other invasive monitoring, and/or need for surgical
intervention. Stepwise logistic regression defined significant predictors for model inclusion with p Results: Response: A total of 290 patients with mild TBI were included in the analysis; 63 (21.7%) had ICU-level-care.
The CDR consisted of 5 final predictor variables: admission GCS2, non-isolated head injury, and midline shift
>5mm on CT. The decision rule identified 53 of 63 patients requiring ICU-level care (sensitivity 84.1%; 95% CI
75.1%-93.2%) and 102 of 227 patients who did not require ICU-level care (specificity 44.9%; 95% CI
38.5%-51.4%). Discussion: Response: We derived a clinical tool that defines a subset of pediatric patients with mild TBI at low risk for
ICU-level-care. Although prospective evaluation is needed, the potential for improved resource allocation is
significant. An additional goal is to conduct a cost-utility analysis comparing the clinical decision rule with current
practices. Submitted Tracking Number: 300 Abstract Title: Response: Minimizing Wrong Site, Wrong Patient, Wrong Procedure Incidences By Improving Pre- Procedure
Documentation Compliance Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Benjamin Keller bakeller@ucdavis.edu MD Surgical Research Fellow Mentor Additional Participants
Name Degrees Title Role
James Becker MD Surgical Research Fellow Learner Diana Farmer MD Professor & Chair; Pediatric Surgery Mentor Laura Goodman MD Surgical Research Fellow Learner Kathe McDonald GME Representative Mentor Lori Teach GME Representative Mentor Introduction: Response: Wrong site, wrong patient, and wrong procedure events are infrequent but persistent in surgical care,
and can be devastating for the patient and provider. While a significant amount of effort has been placed into
preventing these events from occurring in the operating room, the same level of attention has not been placed on
preventing wrong site, wrong patient and wrong procedure events in the clinic and during bedside procedures. With
the changing landscape in health care and a new focus placed on these "never events" by the National Quality
Forum and the Joint Commission, it is imperative to implement new strategies to prevent these events. The purpose
of this project is to improve pre-procedure documentation compliance and decrease the occurrence of these
“never-events” at UCDMC by improving bedside and clinic workflow. Methods: Response: This project is being implemented in two phases. The first phase ensured that the data reports generated
by Health Information Management (HIM) for pre-procedure documentation compliance were accurate and
meaningful, and that the electronic medical record (EMR) navigator for pre-procedure documentation was intuitive
and easy to use for clinicians. To do this, resident representatives from each clinical department were queried for a
list of their most common bedside and clinic procedures. These lists were then used to build accurate
pre-procedure documentation compliance reports. To improve the EMR procedure navigator, changes were drafted
and executed with the help of HIM. The second and current phase of the project is focused on documentation
compliance education. This phase consists of department-specific education at grand rounds and point of care
reminders in the clinical environment. Results: Response: After developing department-specific lists for common bedside and clinic procedures, the
pre-procedure documentation compliance summary was run by HIM. This initial report showed that correct
performance and documentation of a pre-procedure time-out, was 36% for bedside procedures and 15% for
clinic-based procedures. Some specialties and clinics did not document any pre-procedure time-outs. With poor
compliance confirmed, specialty-specific presentations have been created to educate clinicians about the
compliance issues with pre-procedure documentation, and to educate providers about using the EMR navigator. In
addition, point-of-care reminders, including education sheets to be placed on equipment carts and in UCDMC
custom procedure packs, have been created. Currently this education phase is underway and pre-procedure
documentation compliance reports will be tracked to measure improvement. Discussion: Response: While pre-procedure documentation compliance cannot be directly tied to a reduction in wrong site,
wrong patient, wrong procedure incidences given their rarity, each reminder to the patient care team may prevent
an event from occurring. Our initial work on this project demonstrates that pre-procedure documentation
compliance for bedside and clinic procedures at UCDMC is poor. With the multiple approaches included in phase
two of this project, we hope to improve compliance to over 80% in the next academic year. Submitted Tracking Number: 313 Abstract Title: Response: Out of Rhythm – Is Telemetry Always the Answer? Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Karnjit Johl kkjohl@ucdavis.edu M.D. Associate Internal Medicine Program Director Mentor Additional Participants
Name Degrees Title Role
Chhavi Bajaj M.D. Internal Medicine Resident PGY 3 Learner Hershan Johl M.D. Associate Clinical Professor Mentor Maha Sami M.D. Internal Medicine Resident PGY 2 Learner Jacqueline Stocking R.N., M.B.A. Quality and Safety Mentor Tianyi Wang Learner M.D. Internal Medicine Resident PGY 3 Introduction: Response: Cardiac monitoring is often used for patients admitted to the hospital. The American Board of Internal
Medicine Foundation, through its Choosing Wisely Campaign, and the Society for Hospital Medicine, through its
Choosing Wisely Recommendations, have identified the need for appropriate telemetry use including for those who
have dangerous arrhythmias or who are at risk of sudden cardiac death. Excess telemetry usage without indications
can increase healthcare costs and can result in inappropriate distribution of limited resource. For example, given
the limited availability of telemetry beds, patients who need telemetry often will have to wait in the emergency
room for a prolonged period of time delaying their care and admission to the hospital for appropriate management
and treatment. Methods: Response: We will use a descriptive cross-sectional study design to compare the prevalence of inappropriate
telemetry admission orders before and after a Choosing Wisely quality improvement intervention.. Patients
admitted to telemetry will be identified by an automated electronic health record report. Each medical record will
be analyzed by two physicians and the rationale for the telemetry order categorized into three classes: AHA I
(definite indication), AHA II (potential indication) and AHA III (not indicated) and comparing the prevalence of
each category between groups. In cases of disagreement between the two physicians, a third independent physician
will review the data to arrive to a consensus. The intervention will include education and the addition of a drop
down menu embedded into the internal medicine admission order set which will require selection of an AHA class
that justifies the need for telemetry. Results: Response: Preliminary pre-intervention data revealed that a significant proportion of patients on cardiac telemetry
were categorized as AHA class III indication. Through this intervention, we aim to reduce inappropriate (AHA
class III) telemetry orders by 50%. The post-intervention data collection and analysis is currently in process and
results will be presented at the symposium. Discussion: Discussion: Response: Patients admitted to cardiac telemetry without a clear AHA indication (class III) experience an increased
Emergency Department length of stay and contribute to decreased availability of inpatient beds, both of which
negatively impact throughput. It is important to not only ensure patients receive the appropriate level of care, but
also to practice cost conscious care and appropriate allocation of resources. We hypothesize that placing simple
restrictions on the use of telemetry can have a positive impact on healthcare and improve patient safety and care in
the hospital without compromising other aspects of patient care and provider satisfaction. Submitted Tracking Number: 286 Abstract Title: Response: Patient Centered Recovery Program: A Step Beyond the Street Sheet Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Aimee Moulin akmoulin@ucdavis.edu MD Assistant Professor Mentor Additional Participants
Name Degrees Title Role
Debra Kahn MD Associate Professor Mentor Introduction: Response: Nationally ED visits for substance abuse are increasing.1, In 2011 about 2.5 million ED visits resulted
from medical emergencies involving drug misuse or abuse.1, The UCD Emergency Department is no different.
Last year approximately1,700 patients were seen for primary substance use disorders. Many other ED patients
have a co-occurring substance use disorder that complicates their medical and psychiatric treatment. . Very few of
these patients receive treatment for, their substance use. disorder in the ED. Our aim with the Patient-Centered
Recovery program (which is adapted from a UC San Diego, and funded by the University Office of the President).
is to encourage healthcare providers to screen for substance use disorders, refer to our in-house substance abuse
counselor for a brief intervention, and provide linkages to community substance abuse treatment programs. It is our
hope that this program will increase the likelihood of patients entering specialized treatment for substance abuse,
and decrease the medical, psychiatric, and social complications of substance use disorders. Methods: Response: Our primary target population is patients with co-occurring mental health and substance abuse
disorders, however all patients with primary substance abuse disorders presenting to the UCD Emergency Room
are eligible. Psychiatry Faculty and Residents, Emergency Medicine Faculty and Residents, and ED Social
Workers identify patients with a substance abuse disorder who will likely be discharged from the UC Davis ED.
Our program runs M-F 8a to 5p. Patients are evaluated by the UCD Certified Alcohol and Drug Councilor using
the SBRIT model, (Screening Brief Intervention and Referral to Treatment). For patients with an interest in
treatment every effort is made to connect the patient with local treatment programs, and in some cases these
patients can be transferred directly from the ED to residential substance abuse treatment. Results: Response: Since the beginning of the program we have identified 135 patient with substance use disorders. Many
of our patients had multiple prior ED visits, 19 had 5 or more ED visits in the 6 months prior to our intervention
for substance abuse. One patient had 30 visits to the ED in the 6 months prior, and has not returned in the
intervening 2 ½ months. A vast majority of our patients had a form of government insurance, 78% Medi-Cal, 11%
Medicare, 7% Private Insurance, 1% VA, and 2% were un-insured. Thirty patients or 22% reported that they were
currently homeless. Of the patients seen by the CADC, a majority 60% were interested in treatment and referred to
a recovery program. Discussion: Discussion: Response: Many patients presenting to the UCD ED with substance use disorders are receptive to intervention and
treatment. Patients are interested in treatment referrals. Wehave more patients ready to begin treatment programs
than available programs. We hope to partner with community substance treatment programs to increase treatment
options for our ED patients. We expect to show that patients consulting with our substance abuse specialist and
receiving an SBIRT intervention with personalized referrals will have improved outcomes in terms of recurrent
medical and/or psychiatric emergencies. Submitted Tracking Number: 276 Abstract Title: Response: Patient-level Factors Associated with Quality of Care Delivered to Children Treated in Pediatric
Emergency Departments Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Parul Dayal pdayal@ucdavis.edu MS Graduate student Learner Additional Participants
Name Degrees Title Role
Nathan
Kuppermann MD,
MPH Professor, Emergency Medicine and
Pediatrics Mentor James Marcin MD,
MPH Professor, Department of Pediatrics Mentor Patrick Romano MD,
MPH Professor of General Medicine and
Pediatrics Mentor Introduction: Response: While children comprise 27% of all emergency department (ED) visits in the U.S., many EDs are not
fully prepared or capable of caring for children. As a result, the quality of care (QOC) provided to children in the
ED can vary greatly. It is important to identify factors associated with this QOC to direct interventions towards
improving QOC and addressing disparities. In this study, we examined the association of various patient-level
factors and QOC delivered to children in the ED, and hypothesized that certain factors would be associated with
higher QOC. Methods: Response: We abstracted data from 600 records of pediatric patients ( Results: Response: In univariable analyses, higher average QOC scores were significantly associated with male sex
(30.8±2.0 vs. 30.4±2.3), non-Hispanic white race (31.0±2.1 vs. Hispanic: 30.5± 2,0, Non- Hispanic black:
30.2±2.3), private insurance (31.1±2.1 vs. Public: 30.4±2.1, Uninsured: 29.9±2.5) and triage level (Emergent:
30.8±1.9, Urgent: 30.6±2.2, Non-urgent: 29.8±2.6). Chief complaint categories were significantly associated with
QOC scores. The chief complaint categories of trauma and asthma/wheezing had higher QOC scores (trauma:
31.2±2.3, asthma/wheezing: 30.9±1.8) compared to gastroenteritis (30.5±2.0), abdominal pain (29.6±2.0),
seizures/other neurological issues (30.2±2.3) and upper respiratory symptoms (30.2±2.3). In the multivariable
analysis, chief complaint categories were significantly associated with QOC; specifically fever (aBeta= -0.65, 95%
CI: -1.24, -0.06) and upper respiratory symptoms (aBeta= -0.68, 95% CI: -1.30, -0.07). Female gender was also
associated with lower QOC scores (aBeta= -0.31, 95% CI: -0.62, 0.005, p=0.05). Discussion: Response: Clinical factors were associated with the QOC delivered to pediatric patients receiving care in a diverse
sample of children’s hospital EDs. The differences in QOC were primarily attributable to the child’s chief
complaint category. Further research is needed understand what differences in processes of care ultimately impact
the QOC delivered to children in the ED with certain chief complaints compared to others. Submitted Tracking Number: 288 Abstract Title: Response: PREANESTHETIC FASTING: A SOURCE OF DISATISFACTION AMONG INPATIENT
PEDIATRIC PATIENTS AND THEIR FAMILIES Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Danielle Birmingham dnbirmingham@ucdavis.edu M.D. Pediatric Anesthesia Fellow Learner Additional Participants
Name Degrees Title Role
Niroop Ravula M.D. Assistant Clinical Professor Mentor Asst III Perioperative Services Mentor Linda Valdez Introduction: Response: Preanesthetic fasting guidelines are designed to minimize the risk of pulmonary aspiration for any
patient undergoing anesthesia. The current NPO policy at UC Davis Medical Center indicates a minimum fasting
period of 2 hours for clear liquids, 4 hours for breast milk, 6 hours for infant formula or a light meal, and 8 hours
for nonhuman milk or a regular meal including meat and fatty foods. Despite these guidelines, inpatients are
frequently kept NPO for well beyond 8 hours. Prolonged fasting, particularly in the pediatric population, can have
detrimental consequences including significant dehydration, hemodynamic instability under anesthesia, difficulty
obtaining IV access, poor glycemic control, child irritability and overall patient and family dissatisfaction. This
problem is often frequently encountered among inpatients scheduled for add-on surgeries or procedures. The
purpose of this study was to evaluate the fasting time for pediatric inpatients scheduled for MRI and CT scan and to
identify areas of potential improvement. Methods: Response: We performed a single center retrospective review of all pediatric inpatients age 18 years or younger
who underwent radiographic imaging between March 2015 and October 2015. Data was provided by perioperative
services including: type of procedure, date of procedure, patient age, time at which patient was made NPO and
time at which anesthesia was performed. Only patients who had undergone an MRI or CT scan without
intervention were included. Patients who underwent drain placement, line placement, nuclear medicine procedures
or IR procedures were excluded. The provided time points were used to determine fasting time. Data was further
analyzed based on patient age and procedure. Results: Response: A total of 75 patients met inclusion criteria ranging in age from 10 weeks to 17 years old. 50.7% of
these patients underwent an MRI of the brain. Among all patients, the average fasting period was approximately
10 hours 45 minutes with a minimum time of 2 hours 35 minutes and a maximum time of 20 hours 51 minutes.
Average fasting times did not significantly differ among age groups: 9 hours 47 minutes for ages 0-2, 12 hours 7
minutes for ages 3-5, 11 hours 53 minutes for ages 6-10, 12 hours 8 minutes for ages 11-15, and 10 hours 21
minutes for ages >15. Discussion: Discussion: Response: Prolonged fasting is a frequent occurrence despite institutional and national guidelines. Our data
indicates that at a single tertiary care center the average pediatric inpatient scheduled for an MRI or CT scan with
anesthesia is kept without food for more than 2 hours beyond the recommended 8 hour fasting period and without
clear liquids for more than 8 hours beyond the recommended 2 hour fasting period. Although our results are
limited in scope and do not account for all pediatric patients scheduled for anesthesia, they highlight a significant
problem. One of our primary initiatives to address this issue will be to educate pediatric nursing and house staff on
current NPO guidelines. Additional steps will be taken to better facilitate communication and scheduling between
anesthesia, radiology and the pediatric service. Submitted Tracking Number: 312 Abstract Title: Response: Research, Education, and Community Health in the San Joaquin Valley (REACH SJV): Improving
Medical Education and Healthcare Delivery Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Chelsea Gong clgong@ucdavis.edu Medical Student Learner Additional Participants
Name Degrees Title Role
Tonya Fancher M.D., M.P.H. Project Advisor Mentor Emanuel Jaramillo Medical Student Learner Angel Mendoza Medical Student Learner Project Advisor Mentor Medical Student Learner Frederick Meyers Lilia Sanchez M.D., M.A.C.P Introduction: Response: REACH SJV is a student-driven team-based project in Fresno, CA established to improve quality of
healthcare delivery by understanding the physician deficit in the SJV and bridging gaps in medical education. The
program aims to increase the number of physicians with Valley ties through collaboration with an established
pipeline program and retain UCSF-Fresno trained physicians in the SJV by identifying key motivators of practice
location. Furthermore, we recognize the time constraints of our education limit the necessary community exposure
vital to increasing our cultural awareness. By supplementing our clinical skills with community immersion, we
shift our focus to patient- centered care to improve quality of healthcare delivery. Methods: Response: Our four-week program has four components: mentorship, research, community immersion, and
preceptorships. Utilizing teams, each component was led by two students, with all students participating.
Mentorship provided workshops and individualized support to Fresno State undergraduates, assessed by medical
school application and matriculation rates. Research anonymously surveyed residents to identify motivators that
predicted their place of practice, hypothesizing that personal motivators are more likely to retain residents in the
SJV. Community immersion occurred through platforms of dialogue with local communities: Sikh, Hmong,
Oaxacan, and farmworkers of Corcoran. Preceptorships enhanced clinical skills measured with self-assessment
surveys. Results: Response: Mentorship: Longitudinal assessment needed. 17 undergraduates participated; two applied and received
admission offers. Research: Five personal motivators had statistical significance. Serving specific patient
populations (p=0.01, OR=15.74) and primary care specialization (p=0.02, OR=16.02) were positive predictors for
retaining residents, while teaching opportunities (p=0.01, OR=0.09), environmental impacts on lifestyle (p=0.02,
OR=0.05), and debt over $200,000 (p=0.01, OR=0.07) were negative predictors. Community Immersion:
Qualitatively, we found community immersion increased our awareness of different cultures, such as learning
about the connection between Hmong families and shamanism. Preceptorships: Three areas showed significant
improvement: increased comfort in performing pediatric physical exams, assessing appropriate work-ups, and case
presentations. Discussion: Response: REACH SJV was developed to understand physician shortages and increase quality of medical
education to improve healthcare delivery. Research and mentorship provided avenues to address physician
shortages. Mentorship proved beneficial to underrepresented students. Given their likelihood to return and serve
their intended population, we should focus recruitment efforts on SJV students through mentorship. Having
identified personal motivators as predictors for future practice location, we also hope to influence residency
recruitment towards graduates who wish to serve the SJV. Preceptorships and community immersion addressed the
gaps in our education. Along with improved clinical skills through patient encounters, dialogue with different
communities enhanced our communication across cultural backgrounds. SJV preceptorships provided insight into
population-specific health issues not otherwise understood in preclinical years. REACH SJV is a team-based
approach that enhanced leadership, and as leaders, we can improve quality of medical education and healthcare
delivery by adding cultural humility to our technical skills and helping recruit the future physicians of the SJV.
Future directions include identifying better assessment methods and funding. Submitted Tracking Number: 296 Abstract Title: Response: Shortening Family & Community Medicine Resident Response Times to EMR Inbasket Phone Calls.” Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Brent Hanson bwhanson@ucdavis.edu MD Resident Physician, Project Coordinator. Learner Additional Participants
Name Degrees Title Role
Thomas Balsbaugh MD Director of PCMH Mentor Kay Nelsen MD Program Director Mentor Upal Sarker MD Resident Physician, Project Coordinator. Learner Introduction: Response: The advent of electronic medical records (EMR) has shifted significant portions of patient care to
virtual spaces such as physician inbaskets. This work represents a significant time requirement and source of stress
for Family and Community Medicine (FCM) residents. Our large patient panels and roles as primary care providers
create a large volume of tasks that must be done through EMR. How we approach these tasks affects the efficiency
of our clinic, the quality of patient care, and patient experience. Our current culture and workload prevent residents
from responding to phone calls within an appropriate time frame. Our goal is to address 90% of inbasket phone
calls within 24 hours, with zero responses taking greater than 72 hours. Methods: Response: Project Coordinators worked with EMR technicians to quantify the volume of inbasket tasks and length
of time residents currently take to address them. Individual data over the previous 6 months was gathered and
provided to residents. As part of quality improvement curriculum, FCM residents participated in Values Stream
Improvement (VSI) training during monthly didactic sessions. During these sessions, residents mapped inbasket
processes and identified challenges. Subsequently, each resident categorized the reasons remaining tasks had not
been addressed. We identified the most common challenges, brainstormed solutions, and plotted them on an
impact- feasibility matrix. The solutions with the highest impact and lowest effort were selected for
implementation. Results: Response: EMR reports from July to December 2015 show FCM residents receive over 300 inbasket tasks on
average each month. 65% of phone calls are addressed within 24 hours, with an average response time of 2.1 days.
In addition, 19% of calls are unaddressed at 72 hours. The five most common challenges are: 1) needing to sign a
form in person, 2) needing to call a patient back, 3) task addressed, encounter not yet closed, 4) using the task as a
reminder, 5) needing to review the chart. Solutions include clinic staff using dot phrases for documenting incoming
phone calls and faxes, determining the scope of tasks that can be delegated to clinic staff, and formalizing
expectations for resident response times. Discussion: Discussion: Response: Our clinic has a high volume of inbasket tasks. Our current response times to phone calls are better than
previously expected, however, not at goal. Many of the challenges that lengthen response times are related to the
varied methods different residents use to address tasks. Clarifying and formalizing processes quickly became the
theme of our solutions. Next steps include creating dot phrases to be used by staff, and discussing delegation of
tasks with our Patient Centered Medical Home Committee comprised of faculty, residents and clinic management. Submitted Tracking Number: 259 Abstract Title: Response: Surgical Resident Shift Length Does Not Impact Types of Errors Made Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Jamie Anderson jeanderson@ucdavis.edu MD MPH Surgical Resident Learner Additional Participants
Name Degrees Title Role
Joseph Galante MD Program Director, General Surgery Residency Mentor Laura Goodman MD Surgical Resident Learner Guy Jensen Surgical Resident Learner MD Introduction: Response: In 2010, resident duty hours were restricted in an attempt to improve patient safety and resident
education. An underlying assumption is that longer work hours result in increased complications due to fatigue.
However, the restrictions have also increased hand-offs, and some worry this may unintentionally cause an
increased risk to patient safety. We hypothesize that longer work-hour shifts by first year surgery residents
(“interns”) do not increase incidence of adverse events due to fatigue, nor does it change the types of errors
performed. To test this hypothesis, we performed a retrospective review of all complications reported to our
Morbidity and Mortality (M&M) committee, comparing types of errors made during a year when first-year surgical
residents were restricted to 16-hour shifts to the following year, in which shift length was unrestricted, and
first-year residents regularly worked 24-hour shifts. Methods: Response: All surgical mortality and morbidity (M&M) submissions at a university hospital surgery department
from July 1, 2013-June 30, 2015 were reviewed. During 2013-14, standard 2010 duty hours were in place. In
2014-15, duty hour restrictions at this institution were relaxed with no restrictions on length of shift. Root causes
of adverse events were compared between academic years. 16 root causes were categorized as technical, judgment,
cognitive, or team failure (including miscommunication, fatigue). Results: Response: 383 adverse events, including 54 deaths, were analyzed. There was no difference in errors resulting in
mortality between years (p=0.479). There was fairly equal distribution of errors due to technical (195, 26.1%),
judgment (196, 26.2%), cognitive (229, 30.7%) errors. Team failure accounted for 127 errors (17.0%). The only
sub-category that was marginally statistically significant was communication among the surgery team, in which a
greater percentage of errors were committed in 2014-15 (13.1% vs. 7.1%, p=0.050). Overall, manual technical
errors (44.1%) and delay in diagnosis (40.0%) were the two errors most often committed. Only 14.3% of cases
were urgent or emergent, and only 5.8% of cases were performed at night. There was no difference in proportion
of errors performed urgently/emergently or at night between years. Patients with a complication had an average of
2.5 errors (SD 1.6). Approximately one-third of cases (129, 33.7%) had only one error; these were most commonly
from technical errors (52, 40.3%). Discussion: Discussion: Response: When duty hours were less restrictive, there was a slight increase in the proportion of errors due to poor
communication, but no other differences in types of errors made. The surgical morbidity and mortality conference
should place greater emphasis on identifying root causes of errors to identify areas of improvement. Policies
determining duty hours should also be guided by optimizing resident education. Submitted Tracking Number: 272 Abstract Title: Response: Taking Huddle to the Next Level to Improve Continuity and Outcomes Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Esther Vazquez eqvazquez@ucdavis.edu RN, BSN CNIII Learner Additional Participants
Name Degrees Title Role
Debra Burgess RN, BSN, HCA Quality Nurse Mentor Karley Kinsey RN, BSN CNIII Learner Introduction: Response: Coordination of cancer care is complex, involving multiple sites for entry. Head and neck oncology
patients require multidisciplinary management involving a surgeon, an oncologist, radiation therapy,
psychiatrists/social workers, nursing and nutritional support. Patients treated with combined modality treatment
(CMT) are also at high risk for developing complications leading to the need for urgent hydration and treatment
breaks. Complex treatment plans necessitates optimal communication between Cancer Center staff in the clinics,
Infusion Room and Radiation Oncology to facilitate treatment as care. The purpose of this project is to improve the
continuity of care, clinical outcomes and interdepartmental communication at the Cancer Center for CMT patients
and other high risk cancer patients transitions to outpatient therapy and along the care continuum. Methods: Response: A nurse-led interdepartmental huddle process aimed at improving patient outcomes and communication
between departments was developed. Huddle sessions included nurses/nurse navigator, case manager, social
worker, dietitian, and other clinical staff as needed. CMT and other patients at high risk for developing
complications were the priority. This typically included head and neck, GYN, colorectal cancers and patients
lacking family and/or socioeconomic support systems. Frequently, these patients needed help to coordinate
appointments, and extra support to prevent weight loss, dehydration, anxiety and pain. Once referred for huddle
patients were re-assessed weekly to navigate care and ensure the huddle process was beneficial. This process led to
the development of a “risk-based” acuity tool to objectively evaluate high-risk patients. Results: Response: Metrics for improvement included staff surveys to evaluate the huddle process; need for urgent
hydration during treatment; and number of unplanned therapy breaks. After huddle issues with issues with
interdepartmental communication decreased to 10% leading to higher staff satisfaction. The need for urgent IV
hydration during radiation and CMT decreased to 6%, which is a 56% drop compared to the pre-huddle baseline.
We estimate there was a 10% decrease in complication related treatment breaks. Discussion: Response: The interdepartmental huddle process lead to improved staff communication and the ability to work
together as a team. High risk oncology patients benefitted through more coordinated care improving outcomes and
the patient's healthcare experience. More studies are needed to evaluate specific treatment complications to
continue to improve patient care. Submitted Tracking Number: 305 Abstract Title: Response: Technological Tools in the Fight Against Clostridium Difficile Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Catherine Adamson caadamson@ucdavis.edu RN PCS Quality and Safety RN Learner Additional Participants
Name Degrees Title Role
Sean Fraser RN RN analyst Learner Stacy Hevener RN Manager, PCS Quality and Safety Learner Mary Manaloto RN PCS Quality and Safety RN Learner Grant Director: Stop C. difficile Project Learner Christopher Polage MD Introduction: Response: We needed to bridge RN nurse workflow and EMR tool utilization. To make this QI project a success,
bedside RNs needed to integrate new workflows into their routines. Two of the new tasks that RNs were having
trouble remembering to perform were to complete a C difficile risk assessment upon admission, and to perform a C
diicile surveillance swab test at the time of discharge. We aimed to gather staff input in order to identify the barriers
to completing these tasks, and then create EMR tools, reminders, and alerts to real-time prompt nurses to complete
these tasks. This was a multidisciplinary effort involving nursing, IT, the RN analyst, and the project medical
director. Project Timeline March 12, 2014 - June 24, 2015 Methods: Response: After meeting with frontline staff to identify barriers and elicit suggestions/input, our group created two
tools. The first, in order to remind the nurse to complete the admission risk assessment, was a best practice alert,
implemented August 21, 2014. The second, in order to remind the nurse to perform the swab test just before
discharge, was a two-part EMR reminder that was NOT an alert. This was a "soft stop" as requested by the
supervising Nursing Director so as to not delay the discharge process. Implementation:July 30, 2014. Results: Response: We found that compliance with admission assessment completion rose from 75-85% to a sustained
90-98%. We found that compliance with performing the surveillance test at discharge rose from 45-60% to a
sustained 75-85%. Data are still being collected to ensure sustainability. Discussion: Response: We found that hospital-wide best practice alerts (judiciously applied to avoid alert fatigue)and
nonintrusive EMR reminder systems are effective at prompting appropriate workflow performance, especially as
the staff learn and internalize the new behavior. Daily compliance reports, shared regularly with staff, encourage
and celebrate the desired behavior. Submitted Tracking Number: 319 Abstract Title: Response: The Cost-Effectiveness of a Hospitalist Service for Safely Triaging Admissions from the Emergency
Department” Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Kanal Singh kanal.singh@va.gov M.D. Chief Resident of Quality and Patient Safety Mentor Additional Participants
Name Degrees Title Role
Raja Jagadeesan M.D., M.P.H. Chief of Hospital Medicine Mentor Introduction: Response: The hospitalist field has grown immensely since its foundation over 20 years ago, with an ever
expanding role--a role which is especially interesting given the changes in medical insurance and hospital
reimbursement, such as Medicare’s ACO system. When examining capitated healthcare organizations (such as the
VA), lessons learned will become more applicable in the broader healthcare field, especially as Medicare
incentivizes systems to self-aggregate into ACOs to cut down costs. There have been many studies on the cost
effectiveness of hospitalist groups, often with conflicting conclusions. We sought to conduct a study on the role of
cost effectiveness of triaging by our hospitalist group here at VA Mather (a 45 bed hospital in Northern California,
with an average patient stay of 3.6 days). Our hospitalist group is composed of six full time physicians who work
on a seven on and seven off traditional model. Hospitalist triage ED admissions for appropriateness of
hospitalization, and as reflected in the analysis below, this can lead to cost savings while preserving patient safety. Methods: Response: We analyzed manually reported data over one year period (2015) from 4 out of 6 hospitalists, noting
number of hospitalist consultations by the ER, and subsequent number of discharges per disc discretion of the
hospitalist. We conducted subgroup analysis looking representation to the ER or readmission in 30 days, or
mortality (at 30 or 90 days). Results: Response: We reviewed data from 1,104 hospitalist consultations/evaluations of which 128 patients slated for
admission were discharged from ED (11.6%) after hospitalist consultation. 30 of represented to ours/other ED
within 30 days; 13 were admitted at VA Mather or other hospitals within 30 days. Two out of the 128 patients
passed away within 90 days but both were readmitted within 30 days post discharge. This means 10.4% of patients
are successfully discharged home without readmission at 30 days. Assuming that on average patients discharged
from ED after hospitalist consultation would have normally required a 1.5-2 day total stay, and hospital admissions
to generally cost $3000-$3500 per diem, we estimate that our hospitalist group saved between $517,000 to
$805,000. If we extrapolate this data to the number of patients evaluated in ED for admission by our hospitalist
group over the course of the year (~ 2,200 to 2,500 patients on average) we have an estimated cost savings
between 1,030,500 to 1,820,000. Discussion: Discussion: Response: Hospitalist groups emerged as a subgroup in IM out of the necessity for dedicated inpatient physicians
in an increasingly complicated medical system. Studies have repeatedly shown that dedicated inpatient physicians
can lead to significant cost savings to healthcare organizations, in particular ACOs. Our data support this same
conclusion. Further study into developing effective means of outpatient follow up after ED discharge can also
improve on this current model by improving patient safety. Submitted Tracking Number: 280 Abstract Title: Response: The Feasibility of Developing and Implementing In Situ Simulated Trauma Codes Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Matthew Kiefer mvkiefer@ucdavis.edu MD Simulation Fellow and Clinical Instructor Learner Additional Participants
Name Degrees Title Role
Muna
Aljahany MBBS Simulation Fellow Learner Aaron Bair MD, MS Professor, Medical Director of CHT and
CVC, Associate Dean CME Mentor Joseph
Galante MD, MAS Professor, Chair of Department of Surgery Ian Julie MD, MAS Assistant Professor, Co-Director Simulation
Fellowship Mentor Christine
Williams RN, MS,
CNS Trauma Program Manager Mentor Mentor Introduction: Response: Additional team members: Allison Shuken, RN, MS; Anthony Carden, MD; Bonnie McCracken, MSN,
RN, NP-C, NEA-C; Edgardo Salcedo, MD; Erik Laurin, MD; Jennifer Mattice, RN, MSN; Kellie Brendle, RN,
MS, CNS; Ryan Bales, RN, BSN; William Hammontree, RN, BSN In early 2014, a multidisciplinary team from
the UC Davis Departments of Surgery and Emergency Medicine began a process of simulation-based trainings to
improve the management of traumatically injured patients. Cases were constructed based on actual cases where
errors or delays in care were identified by the quality improvement (QI) process. Methods: Response: Three cases were developed as follows: (i) a victim of motor vehicle collision requiring application of
pelvic binder to prevent deterioration from hemorrhage related to an unstable pelvic fracture; (ii) a construction
worker presenting after fall with open femur fracture requiring application of tourniquet to prevent exsanguination;
(iii) an elderly man “found down” with intra- abdominal bleeding and hypothermia requiring rapid rewarming,
diagnostic ultrasound, and rapid blood transfusion. Twice a month on a rotating basis, these simulated cases were
run in the trauma bay of the emergency department. High-fidelity mannequins were utilized, programed and
supported by CVC staff. On-call residents, nurse practitioners, nurses and technical staff responded in real-time
through the trauma activation system (i.e. 922 critical trauma activation). After the case was run to completion, a
structured debrief was performed by nursing, trauma and emergency medicine educators. The debriefing focused
on team leadership, technical trauma resuscitation skills, and communication. Additionally, a summary of the
educational highlights, along with recorded video, was sent via UCD email to participants to highlight key learning
points. Results: Results: Response: Over the course of 16 months of the intervention most Trauma Program nurse practitioners and surgical
residents in the UC Davis Department of Surgery have participated in one or more of the simulated trauma
scenarios. Staff and space constraints challenged initial implementation, however concerted efforts by an
inter-professional group emphasized to staff the importance of training under such real life conditions. Thus far,
members of the training team have noticed improvements in the use of personal protective equipment, team
leadership, closed-loop communication, and technical skills as performed by trainees and staff over the 16 months
of the intervention. Changes implemented as a result of these trainings have included a demarcation (i.e. red line)
in the trauma bay for crowd control, structured delineation of team member positioning relative to the patient, and
additional nurse training on the use of the Level One blood infuser. Discussion: Response: Our plans are to further evaluate various key time intervals related to care, appropriateness of
documentation in the EMR, use of tranexamic acid and blood products, and resident leadership skills. Our
16-month experience with simulated in situ trauma codes proves the feasibility of designing and implementing an
educational intervention that is closely integrated into the QI process. Integrating Quality Symposium Abstract Evaluation Form Abstract #: 284 Abstract Title: Enhancing the practice of Nursing through Teach-Back communication- Pilot Program Scale:
Poor = 0 Fair = 1 Good = 2 Excellent = 3 N/A Score for this evaluation: __________________ Recommend (circle one):
Rejection Poster (55 to 60 max) Podium (13 max) Criteria:
1. Background/introduction a. Is the project/program innovative or unique? b. Is the rationale logical, sound and supported by the information presented? 2. Methodology a. Are the interventions/methods/practices appropriate? b. Is the data analysis method clearly specified? 3. Results a. Do the results clearly present the outcome of the project/program? 4. Conclusions/Recommendations a. Do the conclusions flow logically from the results? 5. Overall quality of the abstract a. Is the abstract well-written, clear and flows well? 6. Contribution a. Does the project/program contribute new and useful information addressing a timely and significant quality problem? 7. Congruence with Integrating Quality (IQ) goals a. Does the project/program appropriately involve learners? Notes: Submitted Tracking Number: 284 Abstract Title: Response: Enhancing the practice of Nursing through Teach-Back communication- Pilot Program Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Megan Heather megchrz@yahoo.com MSN CN IV Learner Additional Participants
Name Degrees Title Role
Diana Pearson MSN CN IV Mentor Introduction: Response: The program was a quality improvement program designed with the main goal of improving patient
education techniques. It was developed with the knowledge that nurses are providing a high level of care for their
patients, however were being scored low in nursing communications specific to listening, explaining/teaching and
courtesy as evidence by hospitals HCAHPS scores. Frequent readmissions due to inconsistent care and
communication are also a major issue. This impacts the entire health system by overcrowding, misuse of health
resources, and negative patient/ family outcomes. The pilot program began May 2015 and is scheduled to continue
for one year. It has been structured for Davis 14 nurses. Specific Aims: Create a consistent model for patient/family
education. Provide pilot RN’s enhanced communication training. Improve patient outcomes and satisfaction with
care Improve HCAHPS scores Methods: Response: Piloted a health literacy/teach-back model that combines Unity Point Health’s “Always Use
Teach-back” program and The National Patient Safety Foundation’s “Ask Me 3” tool. The program was piloted on
Davis 14 focusing on the following key program pieces: Unit based-3 hr. ‘Teach-back Communication Intensive’
class for RN’s, ongoing RN de-briefing, focused population specific patient education materials and handouts, and
EMR DOT phrase for documentation. Class offered role plays for nurses to practice communication tools with
patients/ families. Nurses were observed pre and post class providing nursing education. There is a nurse
communication leader available to proactively support nurses on the unit. Students were provided a evaluation
form pre and post class that was completed by each student. HCAHPS scores evaluated. Results: Response: Evaluations show that after the communication intensive, nurses feel they have a higher level of
confidence using the teach-back technique, providing education to patients/families with low health literacy levels,
and expressing empathy and compassion compared to before completing class. Nursing communication HCAHPS
on Davis 14 have increased an average of 9.5% since program start. We learned that ongoing follow up is
necessary for the RN’s to create consistency in using the teach-back technique. We discovered that nurses felt they
were doing teach- back prior to the class. They discovered that they had not been using teach-back after all. The
process of how nurses educated their patients/ families changed based on the teach-back technique. Nurses
supported the program and are embracing the teach-back technique on a daily basis. Discussion: Discussion: Response: The Teach-Back Communication Pilot Program is becoming well integrated into Davis 14. The nurses
on D14 continue to improve their communication techniques with providing patient education. The improved
confidence and skill level of the nurses as well as the increased HCAHPS scores show the positive outcomes that
this program has created. In conclusion this pilot project has been extremely successful in improving nursing
communication,and empowered patients to be better prepared to care for themselves after discharge. Ongoing
efforts for this program will include designing and implementing a teach-back communication program that is both
interdisciplinary and system wide. Submitted Tracking Number: 253 Abstract Title: Response: The use of a body diagram to improve quality of care in dermatology: Interim study results Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Jillian Millsop jillian.millsop@gmail.com M.D., M.S. Dermatology Resident Learner Additional Participants
Name Degrees Title Role
Larissa
Larsen M.D. Assistant Professor, Department of
Dermatology Mentor Raja
Sivamani M.D., M.S.,
C.A.T. Assistant Clinical Professor, Department
of Dermatology Mentor Introduction: Response: In dermatology, many conditions require the use of topical medications. Often, patients are prescribed
more than one type of topical medication and must remember the treatment instructions provided at their clinic
visit. The conventional method in clinical practice is to educate the patient verbally during the clinic visit and/or
provide written instructions for applying the topical medications. In clinical practice, however, we have found that
it can be difficult for patients to recall these instructions which may lead to poor outcomes, poor compliance, and
decreased patient satisfaction. One method to improve quality of care to patients is to provide a visual tool such as
a body diagram for patients to recall instructions for medication use. In our study, we aim to evaluate the impact of
the body diagram for topical medication use on the quality of care received by the patient. We assess the comfort
level of patients in applying topical medications to the appropriate body part and for the instructed amount of time
and the ability to recall instructions in applying topical medications in patients receiving the body diagram
compared to patients who do not receive the body diagram. We present the interim results of our study. Methods: Response: We plan to recruit 42 adult subjects from the UC Davis Dermatology clinic. Subjects are randomized to
a group that will either receive a body diagram at their clinic visit or that will not receive a body diagram. Each
subject will complete an initial survey at the time of their clinic visit and a post survey 1 month later. Both the
initial survey and the 1 month post survey include 8 questions assessing the patient’s perceived quality of care
during the visit and comfort level of applying the prescribed topical medications to the appropriate body part, for
the instructed amount of time, and perceived ability they can recall instructions for topical medication use. Results: Response: Twenty-one subjects have been recruited thus far. The quality of care perceived by patients who
received the body diagram and those who did not receive the body diagram was similar and both groups responded
positively to questions regarding quality of care, with the exception of one subject who did not receive the body
diagram and reported negative responses. For comfort level in applying topical medications for the appropriate
amount of time and ability to recall the amount of time to apply medications, minor differences were found:
subjects who had not received a body diagram did not all respond positively to these questions in contrast to
subjects who had received a body diagram. Subjects responded less positively about their quality of care, comfort
level for applying topical medications, and perceived ability to recall instructions in the 1 month post survey as
compared to the initial survey. Discussion: Response: Thus far, the results demonstrate that we may need to enhance our ability to improve perceived
long-term quality of care to our dermatology patients. The use of a body diagram may be the first step to
improving care. Submitted Tracking Number: 283 Abstract Title: Response: Ventilator Associated Pneumonia (VAP) in the PICU: Reducing Rates through a Five Part Prevention
Bundle Main Contact:
First Name: Last Name: Email Address: Degrees: Title: Main contact's role: Cheryl McBeth clmcbeth@ucdavis.edu RN,BSN,MS, CCRN UC Davis Children's Hospital Nurse Educator Mentor Additional Participants
Name Degrees Title Role
Eunice Butler RN,MSN Clinical Nurse Learner Amy Powne PICU/PCICU Nurse Educator Mentor RN,MSN,CNS,CCRN Introduction: Response: Ventilator Associated Pneumonia (VAP) is a leading cause of hospital acquired infections which
potentiates increased morbidity and mortality rates in the pediatric patient population. In 2010 the PICU VAP rates
hovered at four times the benchmark rate (1.8) of the National Healthcare Safety Network (NHSN). Due to the
staggering rate (7.86) an interdisciplinary team dedicated to preventing VAP was developed to address barriers of
VAP prevention care and create an evidenced-based bundle. The overarching goal of this committee was to
improve the quality of care provided to ventilated patients and reduce the incidence of VAP in the PICU. Methods: Response: Utilizing the Lean SIX Sigma and DMAIC methodology, the committee developed clearly defined
goals: improve the quality of care delivered and lower the VAP rate to below the NHSN benchmark. Through an
evidenced based approach, a VAP prevention bundle was developed and implemented. Multidisciplinary education
was conducted over a five-month period through one-on-one teaching, in-services, posters, and bedside signs.
Compliance of bundle elements was monitored by bedside audits completed by the VAP team. Results: Response: While the 2011 VAP rate remained above the NHSN benchmark, the number of VAPs in the PICU
continued to steadily decline from 15 to 7. In June 2012, less than two years post bundle implementation the VAP
rate fell below the NHSN benchmark (1.2) to1.16. Five years after implementing the PICU VAP Prevention
Bundle, the rate continues to be low, with a 2015 rate of 0.41 showing a consistent improvement of outcomes. As
our educational goals were met, we began to see a change in the culture of workflow with regard to VAP and
overall unit and patient safety. Discussion: Response: Despite moving to a new unit in November 2011 (increasing bed capacity by 30%) and the addition of
more than 60 bedside nurses in the last three years, the PICU VAP rate remains below the NHSN benchmark
demonstrating a sustained culture change. The committee continues to re-assess the progress and educational needs
to maintain these low VAP rates. Importantly, the committee continues to educate staff with the latest
research-based evidence and strives to build on the momentum of a unit culture steeped in an environment of
safety.