Master of Science in Healthcare Quality and Safety (MS-HQS) capstone presentations

Improving the Ultrasound and Clinical Diagnosis of Macrosomia to Reduce the Primary Cesaerean Delivery Rate

Norman Back, MD, FACOG — Tue, 16 Apr 2013 07:33:54 PDT

The primary cesarean delivery rate in the United States has been climbing. One reason to perform a cesarean delivery is an estimated pre-delivery rate greater than 4500 grams. This estimated weight is obtained through either clinical examination or ultrasound. Overestimation of the weight can lead to unnecessary cesarean deliveries. On multiple occasions, obstetricians have performed cesarean deliveries for ultrasound-diagnosed macrosomia only to find the true weight to be far below 4000 grams. This project was designed to determine if a discrepancy exists between the admitting diagnosis of macrosomia and the true delivery weight in a community hospital. The project was further designed to evaluate whether feedback to the physicians and sonographers, would improve future accuracy in estimating fetal weights at delivery. Finally, it was hoped that armed with this knowledge, the department could lower the cesarean delivery rate by reducing the number of primary cesarean deliveries performed for macrosomia. All members of the department were contacted and invited to an initial brainstorming meeting. This was followed by monthly review meetings. Physicians were sent monthly report cards describing their cesarean delivery rates and comparing them to the rest of the department. In order to educate the physicians and sonographers, letters were sent out monthly to each obstetrician and sonographer listing the admitting estimated fetal weight (EFW) and actual delivery weight of all infants delivered with a weight equal to or greater than 4000 grams or an admitting diagnosis of macrosomia. We markedly improved physician compliance in documenting admitting EFW as well as improving physician awareness, of their own and their colleagues’ cesarean delivery rates. Despite the above achievements, we failed to achieve any significant change in the primary cesarean delivery rate. In addition, we incidentally found discrepancies between all four of the hospital’s data collecting systems used in this study.

Presentation: 35 minutes

Using a Health Information Exchange to Improve Medication Reconciliation

Sandra B. Selzer — Thu, 13 Sep 2012 12:08:06 PDT

This project focused on utilizing new healthcare technology to address the problems associated with medication reconciliation during transitions in care. A health information exchange (HIE) was used to document and share medication lists for a subset of patients in the Camden Coalition of Healthcare Providers’ (CCHP) Care Transitions Program. The project utilized the quality improvement science of Plan-Do-Study-Act (PDSA), which involves small tests of change to a process in order to improve outcomes. Data sources included hospital discharge summaries, a medication reconciliation form, and the Camden Health Information Exchange. Eleven (11) patients enrolled in CCHP’s Care Transitions Program were followed over a four-month period beginning with hospital discharge. Two PDSA cycles were conducted to improve the medication reconciliation process, and medication lists and discrepancies were collected at each phase for analysis. The project team documented 135 medications across 8 discharge summaries, 207 medications in the homes of 11 patients, and 184 medications for these 11 patients are currently maintained in the Camden HIE. The variation in medication lists across care transitions depended on factors such as type/severity of illness, literacy level and mental status. Use of the HIE to narrow down the list across healthcare providers resulted in a clean, accurate and timely list of medications for these high-risk patients. Although the study did not get as far as needed to study the effect of using a HIE to share medication data across settings, it provided a good argument for the HIE’s value in documenting and tracking medications across the patient’s continuum of care. The project also highlighted the need for improved discharge documentation by hospitals, as well as better care coordination after hospital discharge.

The Use of Interpreters to Improve the Quality and Safety of Healthcare Through Better Communication in Obstetric Patients: Effect on Primary Cesarean Delivery Rate

Stephen A. Pearlman, MD — Thu, 13 Sep 2012 11:59:16 PDT

Patients with limited English proficiency have poorer healthcare outcomes. An assessment of the cultural and linguistic competency of Christiana Care Health Systems revealed that our language services were not sufficiently robust and this was affecting care. Therefore, the purpose of this quality improvement study was to improve healthcare outcomes, specifically the rate of primary cesarean delivery, through improved language assistance, to patients with limited English proficiency presenting to labor and delivery. The methods employed included use of the TeamSTEPPS program to educate the staff on how to improve safety for patients with limited English proficiency, adding a live Spanish interpreter and augmented telephonic interpreter services. Our results showed that there were 3510 deliveries in the 6 month period before the intervention and 3176 deliveries following the intervention. The overall primary C-section rate did not change between the two epochs (21.94% vs. 21.45% p=0.69). Because the primary language of our patients is not captured by our information technology system we subdivided them according to ethnicity. There were decreases in the primary C-section rates in the Hispanic (17.8% pre vs. 15.6% post intervention, reduction 12.4% from baseline) and Asian populations (21.1% pre vs. 16.7% post intervention, reduction 20.9% from baseline) but these differences did not reach statistical significance. There was a significant reduction in the number of babies born weighing less than 2500 grams after the intervention (9.4 % pre vs. 7.4% post, p=0.004). Our conclusions are that staff education and the introduction of interpreter services in the Labor and Delivery department of a large teaching hospital improves the quality of care delivered

Stubborn, Persistent, Dangerous C.difficile Infections. Is Improvement Possible?

Sara Townsend — Thu, 13 Sep 2012 11:49:36 PDT

C.difficile also known as C.diff or CDI has developed into a dangerous infection for the United States’ health care system. While much work has been done to improve C.diff rates, health care teams have not been successful in reducing C.difficile infections. Many studies have focused on the mode of transmission of C.difficle, yet there still is not consensus on understanding how this infection is spread. Bryn Mawr Hospital, a community hospital in the suburbs of Philadelphia, Pa, has struggled to improve their C.diff rates like their peers throughout the country. While their infection rates for C.diff are lower than the national average, their C.diff rates vary depending on the month, with no standout reason to explain why. The infection prevention team at Bryn Mawr Hospital wondered why they could not maintain their low C.diff rate or reduce that rate to nearly zero, as had been accomplished with other types of infections in their hospital. With this question in mind, the infection prevention project team developed an improvement project to decrease the rate of C.difficle by interfering directly with the transmission of C.difficle spores. The team’s strategy was to first educate healthcare workers who most came in contact with C.diff spores and then to provide multiple opportunities to end the careless spread of these spores. Departments that participated in the intervention included nursing, patient care techs (PCTs), environmental services group (EVS), nutrition and the patients themselves. While the education and plan to improve the cross transmission of C.difficile was well received at Bryn Mawr Hospital in all groups that were educated, there were many barriers to realizing actual improvement in reduced rates of C.difficle in the timeframe of this study. Time, a change in testing strategies for C.difficile and other hospital initiatives stood in the way of a quick understanding if improvement has in fact occurred. However, in time, if the methods are continued, and the different departments work together, improvement may be seen.