Broadway Clinic
2008-2009 PDSA Project
Lipid Screening and
Promoting Healthy Lifestyles
Participants
MAs: Blanca Cordero, Celia Mendez, Felipe Joaquin and Maritza Estrada
RN: Sally Ortiz, Haydee Bayon and Anna Zeleft
CPNP: Renie Eis
Residents: Brooke Davey, Steph Marion, Lisa Nowell, Cyril Sahyoun, Taryn Wiley-Rio,
Corinna Moore, Meg Sullivan, Jen Louis-Jacques, Stu Holzer, Deena Blanchard, Tom
Hooven, Anne Abbott, Emily Rothbaum, Erik Jensen and Gabe Rama
Faculty: Nan Salamon, Mariellen Lane, Pran Saha, Laura Robbins, Heidi Beutler
and John Rausch
AIM Statement
We aim to screen 90% of children age
4-12 years with a BMI ≥ 85% and/or a
positive family history of dyslipidemia
or premature cardiovascular disease
(CVD) with a random fasting lipid panel
AND provide counseling regarding
healthy lifestyles choices using the
5-2-1-0 recommendations.
Lipid Screening Protocol: random lipid
panel will be ordered for children with risk
factors (overweight or obesity, positive
family history) at ages 4 years and 11 years
when they are in the clinic for blood work
or vaccines.
-for those patients with positive screen:
intensive nutritional and exercise
counseling using 5-2-1-0 message and retest
with fasting panel in 3 months
-if fasting panel still elevated, refer to Dr.
Starc
Pending Return Orders
Pending Lipid Return Orders
Pending PPD Return Orders
#
ordered
#
completed
%
Review
1
8
4
50
Review
2
9
3
33
July-Nov.
2008
#
ordered
# placed
# read
42
17 (40%)
15 (88%)
• Checked rate of return for pending orders placed for both
PPDs and fasting lipid panels
• Results supported decision to choose RANDOM lipid panel as
screening test for project
Cycle 1
(Deena Blanchard, Taryn Wiley-Rio and Stephanie Marion)
• Both didactic and systems changes
done during cycle
• Using provider feedback as well as
input from Dr. Starc, Broadway
practice guidelines generated (who to
screen, positive screen includes values
in 75% or higher)
• System changes done in form of
laminated signs hung in provider
rooms and common areas
Cycle 2
(Corinna Moore and Meg Sullivan)
• Based on data from cycle 1, it was clear that further
systems support was needed
• Original signs were revamped and new signs detailing
abnormal values were hung on EVERY computer
monitor
• No improvement in rates of lipid panels ordered for
patients meeting screening criteria
Cycle 3
(Stu Holzer)
• Adjustment made to definition
of positive screen to improve
adherence to lipid screening
protocol (now only values 95% or
above):
Total Cholesterol >200
LDL-C >130
HDL <37, TG >120(girls),
>110(11yo boys) >85 (4yo boys)
•Corresponding systems changes
made in form of new signs hung
on EVERY computer monitor (old
signs taken down)
For all patients age 4 with at
least one:
For all patients age 11 with
at least one:
1.
2.
1.
2.
BMI> 85% (>17)
+Fm Hx:
- Dyslipidemia
- CVD in women <65 yo
- CVD in men <55 yo
Order a Random Lipid Panel
If High:
1.
2.
3.
4.
TC >200
LDL >130
HDL <37
TG >120(girls), >85(boys)
Repeat Fasting Lipid Panel in 3
months
If still High Refer to Cardiology
BMI> 85% (girls>21, boys>20)
+Fm Hx:
- Dyslipidemia
- CVD in women <65 yo
- CVD in men <55 yo
Order a Random Lipid Panel
If High:
1.
2.
3.
4.
TC >200
LDL >130
HDL <37
TG >120(girls), >110(boys)
Repeat Fasting Lipid Panel in 3
months
If still High Refer to Cardiology
Cycle 4 (incomplete)
• Attempted to institute ‘high risk’ lipid screening order
set as well as family hx prompt
• Orders placed in 2/09, but never completed secondary
to insufficient Eclipsys staffing
• Represents potential recurring barrier to
implementation of EMR related systems changes
Summary of Lipids Data
• Baseline Data (Erik Jensen): 66 with increased BMI, 8/66 (12%) screened (no FamHx
recorded)
4yo patients
11 yo patients
# pts
with incr
BMI
# pts
with
incr
BMI
# pts
with +
FamHx
# pts
screened
%
# pts
with +
FamHx
# pts
screened
%
Cycle 1
3
0
2
66.7
Cycle 1
1
0
0
0
Cycle 2
4
1
0
0
Cycle 2
2
1
1
50
Cycle 3
7
1
0
0
Cycle 3
4
0
4
100
Final
Review
(Anne
Abbott)
16
1
4
25
Final
Review
(Anne
Abbott)
5
0
0
0
Total
20
3
6
30
Total
12
1
5
42
5-2-1-0 Lifestyle Modification
Guidelines
• Developed in 2006 in New Hampshire after extensive
chart reviews of primary care practices
• NH Childhood Obesity Panel used this data as impetus to
develop practical guidelines to help prevent childhood
obesity
• Expert panels in these states decided and evidence
supports that these messages are the most important to be
giving families/pediatric patients
• 5 fruits and vegetables a day, 2 hours or less screen time, 1
hours exercise daily, NO soda/sugar-sweetened drinks
5-2-1-0
Supporting Literature
•
•
•
•
•
•
•
•
•
•
Dietary Guidelines for Americans 2005. United States Department of Agriculture and United States
Department of Health and Human Services.
Physical Activity for Children: A Statement of Guidelines for Children Ages 5-12, 2nd Edition. Council for
Physical Education for Children (COPEC) of the National Association for Sport and Physical Education, 2004.
Patrick, K. et al. Diet, physical activity, and sedentary behaviors as risk factors for overweight in
adolescence. Arch Pediatr Adolesc Med V 158, p. 385-390, 2004.
Gable, S. et. al. Television and frequency of family meals are predictive of overweight onset and
persistence in a national sample of school-aged children. Journal of the American Dietetic Association. V
107,1, p. 53-61, 2007.
Dennison et. al. Television viewing and television in bedroom associated with overweight risk among lowincome preschool children. Pediatrics V 109, p. 1028-1035, 2002.
Crespo, et al. Television watching, energy intake, and obesity in US children. Results from the third
national health and nutrition examination survey, 1988-1994. Arch Pediatr Adolesc Med V 155, p. 360363. 2001.
Giammattei, J. et. al. Television watching and soft drink consumption: Associations with obesity in 11 to
13 year old schoolchildren. Arch Pediatr Adolesc Med V157, p. 882-886. 2003.
Faith, MS et al. Fruit juice intake predicts increased adiposity gain in children from low income families:
Weight status-by-environment interaction. Pediatrics V118(5) p. 2066-2075, 2006.
Wang, YC, et. al. Estimating the energy gap among US children: A counterfactual approach. Pediatrics
V118(6) p. e1721-e1733, 2006.
Malik VS et. al. Intake of sugar-sweetened beverages and weight gain: A systematic review. Am J Clin Nutr
V 84:274–88, 2006.
5-2-1-0 Surveys
(Stu Holzer, Emily Rothbaum and Tom Hooven)
Cycle 1
Cycle 2
• Surveys (Spanish and English)
were given to all families with
children 2-12 yrs presenting for
WCC
• 70% of potential families received
survey and overall liked it
• Surveys were trialed over 1
afternoon and parents found it
comprehensible
• Literacy was noted to be at
11/12th grade level (based on
SMOG and Fry literacy scoring
systems)
• Surveys were modified with input
from the HEAL program (Emelin
Martinez), Sally Ortiz (Broadway
RN) and MAs Blanca and Celia
• Surveys currently at 4/5th grade
level with further evaluations
pending
Patient Name
Place sticker here
Does your child eat 5 or more servings of fruits and vegetables on most
days?
5
Does your child eat breakfast every day?
Does your child eat dinner at the table with the family at least 2 times per
week?
2
Does your child watch TV, videos or play computer games less than 2
hours per day?
Does your child have a TV in the bedroom?
1
Does your child participate in some type of physical activity in or outside
of school for at least 1 hour every day?
0
Does your child drink juice, soda or punch?
Does your child drink mostly skim milk or 1% and not 2% or regular milk?
Does anybody in your family have high cholesterol?
Yes
No
Patient Name
Place sticker here
¿Come su niño/a 5 o mas raciones de frutas y vegetales casi todos los días?
5
¿Come su niño/a desayuno cada día?
¿Cena su niño/a en el comedor con la familia por lo menos 2 veces a la
semana?
2
¿Mira su niño/a television, videos, o juegos en la computadora menos de 2
horas al día?
¿Tiene su niño/a una television en el dormitorio?
1
¿Participa su niño/a en una actividad física en la escuela o fuera de la
escuela por lo menos una hora al día?
¿Toma su niño/a jugo o refrescos regularmente?
0
¿Toma su niño/a leche baja en grasa y casi nunca de 2% o leche entera
(tapa roja)?
¿Hay alguien in su familia que tiene colesterol alto?
Sí
No
FOR ALL PATIENTS:
5
At least five fruits and vegetables a day.
2
Spend two hours or less a day in front of a TV, computers, video games.
1
One hour of physical activity or exercise every day.
0
No soda, sports or fruit drinks that are high in sugar. Drink water and
three to four cups of low fat milk per day.
Para todos los pacientes :
5
Coma cinco frutas y vegetales al día
2
Pase dos horas o menos al día delante de la televisión, la computadora,
o los juegos de video.
1 Haga una hora al día de actividades físicas o ejercicios.
0 No tome bebidas alta en azúcar, como refrescos gaseosos, bebidas
deportivas, y jugos de frutas. Tome agua o tres a cuatro tazas de leche baja
en grasa
Baseline 5-2-1-0 Data
-70% of all families with children 2-12 years at clinic for well child visits
received survey
-76% eat breakfast every day
-Parents report that 61% watch only 0-2 hours of TV daily, but 66%
have TVs in their bedrooms
-Only 6% eat 5 or more fruits and vegetables a day
-Fruit juice difficult to assess, as initial survey had number of ounces,
many answered 1, 2 or 3 and likely answering servings/day, not number
of ounces/day
-33% of families indicated having a family history of elevated cholesterol
(37/111 surveys handed out)
Conclusions
• Overall, we did not meet our goal of screening at least 90% of 4
and 11 yo with random lipid panels. Additionally, assessing and
documenting high risk family history remained poor
• Possible reasons:
1) inadequate systems support/reminders for providers
(not remembering protocol, no where on follow up
templates to document family hx)
2) ??insufficient provider consensus??
• Pending future system changes: adding high risk order set to
Eclipsys and adding a family hx section to all amb pediatrics
follow up templates