M. Ahmed, MD
- Critically ill patients that present to the emergency room often require time sensitive resuscitative measures, which often necessitates placement of a central venous catheter.
- Efficient placement of a central venous catheter is often limited by the time it takes to gather the number of supplies needed for the task.
- It is already known that central venous catheter procedure carts and kits decrease the incidence of central line associated bloodstream infections (CLABSIs)1 as well as reduce the incidence of procedural mistakes during central line insertion2
- However, there is a paucity of data in regards to the impact of central line procedure carts on the efficiency of central line insertion.
- The objective of this study was to assess whether a pre-stocked central line cart would reduce the time it takes to place the catheter in critically ill patients in the emergency room.
The ‘med history note’: A standardized method of reducing medication history errors among internal medicine residents in a teaching hospital
Odunayo Banjoko, MD; Babatunde Ogunnaike, MD; Genene Amoia-Pigliacelli, PharmD; and Doron Schneider, MD
According to the institute of medicine’s preventing medication errors report, the average hospitalized patient is subject to at least one medication error per day. Errors have been known to occur during admission, transfer and discharge of patients. An accurate medication history on admission is crucial and can go a long way in preventing medication reconciliation errors. Of note, more than 40% of medication errors occur from inadequate reconciliation, during admission, transfer and discharge of patients. Of these, 20% result in harm.
Laura Cifrese, MD; Sonia Gill, MD; Megan Margiotta, MD; Muhammad Athar, MD; Rodney Bell, MD; Sara Hefton, MD; Fred Rincon, MD, MSc, MBE; Syed Shah, MD, MBA; Jacqueline Urtecho, MD; Matthew Vibbert, MD; David Wyler, MD; and Amandeep Dolla, MD
- Duty hour restrictions, cross coverage, and the growing number of mid-level practitioners has led to an increased number of handoffs across medical specialties
- These handoffs are well-known points of communication breakdown which can lead to patient safety issues
- Factors contributing to an effective handoff include standardization of communication, appropriate training and supervision, ample time, a quiet environment, and a supportive culture
- We hypothesize that attending supervision of handoffs is feasible and can improve practitioner perception of transitions of care
Elizabeth Collins, MD and Kristine Swartz, MD
- A multi-faceted, volunteer-led, hospital-based program1has been shown to: •Reduce the incidence of delirium •Decrease hospital length of stay •Reduce hospital costs.
- Implementation of such a program requires upfront investment.
- A smaller, volunteer-based visitation program for older adults may provide support for the allocation of more hospital resources in delirium prevention and establishment of a formal Hospital Elder Life Program1in this institution.
- This research aims to investigate: •If the implementation of a visitation program is feasible at this hospital •Volunteer experience with the program.
B. L. Deiling, DO; E. Kilmartin, MD; and T. L. Kennedy, MD
During any surgical procedure, clear and standardized communication among surgeons, anesthesiologists and operating room nursing staff is a necessity for all aspects of patient safety. During TURP procedures, the perioperative staff must alert team members of the signs and predictors for the potential of TURP syndrome or NSS overload. The goal of our quality improvement project is to increase communication and diagnostic actions based on irrigation fluid amounts among surgeons, anesthesiologists, and the operating room nurses in order to decrease complications in TURP patients at Jefferson over the next six months.
Erika Dillard, MD, PhD; Yusef Mosley, MD; Joshua Marks, MD; Christina Jacovides, MD; Geoffrey Ouma, MD; and James Harrop, MD
Currently no protocol exists for thromboprophylaxis (TPx) and screening in SCI patients at TJUH. As such, often patients are either not started on TPx or are started on an inappropriate regimen depending on admitting team preference. In addition, patients often receive an admission DUS then weekly thereafter as a screening mechanism for DVT even if asymptomatic.
Our goal is to determine the effectiveness of our current method for initiating pharmacological TPx as well as efficacy and cost of our current screening method compared to national guidelines by addressing these questions:
- What is the occurrence of VTE in SCI patients at TJUH?
- What screening tools are utilized (clinical exam, DUS)?
- How often is recommended LMWH initiated? Does this vary with care team?
- Is TPx initiated within 72h and, if not, why (ie, anticipated surgery, bleeding risk, intracranial hemorrhage)?
- How often are SCI patients screened? How often are clinically insignificant DVTs diagnosed?
- What are the costs associated with the current screening method at TJUH?
Adequate patient education - The key to improving patient experience while being under contact precautions?
Edosio Eloho, MD; Mary Naglak, PhD; Doron Schneider, MD; Hadiatou Barry, MD; Babatunde Ogunnaike, MD; Puneet Dhillon, MD; and Neethu Gopisetti, MD
To improve patient satisfaction with the quality of education provided about CP by at least 30% by the end of 7 months. Through the provision of a standardized patient education sheet to hospitalized patients placed on CP within their first 24 hours being placed under contact isolation.
Order from Order Sets: Analysis of Ordering Patterns and Patient Outcomes Before and After Order Set Changes on the Inpatient Psychiatry Units at TJUH
David Halpern, MD
To decrease the total number of times one-time orders were added for patients for Vistaril, Remeron, Melatonin, Colace, Senna, and MiraLAX. Increase number of times urine PCP and urine oxycodone added to the urine drug screen.
To decrease overall length of stay and improve treatment outcomes
Ellina Hattar, MD; Kelly Hufford, DPT; Marie Wilson, RN; and James Harrop
Physical therapy is imperative in achieving early mobilization, thereby reducing morbidity of immobility such as venous thrombolic events, improving postoperative pain, and facilitating appropriate disposition among patients who have recently undergone spine surgery. At TJUH, patients undergoing elective spine surgery are planned to engage in physical therapy (PT) twice a day. There are however several impediments that may limit the ability of patients to adequately participate in PT.
Nikolaus Hjelm, MD; Gregory Epps, MD; Ryan Rimmer, MD; Lauren Bogdan, MD; and Erin Reilly, MD
After every surgery, surgeons send their patients home with discharge instructions. The information is intended to educate the patients about their postoperative care and how to safely care for themselves upon returning home. Each surgeon reviews and approves the discharge instructions before they are given to their patients. This information is once again reviewed by the patient’s nurse before the patient leaves the hospital.
Within a large hospital, there are often several surgeons within each specialty that perform the same surgeries. The department of Otolaryngology at Thomas Jefferson University Hospital is no exception. Within otolaryngology there are several subspecialties. At Jefferson’s University campus hospital, these subspecialties consist of rhinology, otology, head and neck, plastics, and laryngology. Currently there are three rhinologists, two otologists, six head and neck surgeons, three plastic surgeons, and three laryngologists.
Within the department, there has been a movement towards standardizing discharge instructions for every subspecialty. The belief is that if every surgeon that performs the same operation comes to an agreement with postoperative care, there will be less confusion among the nurses and residents who are often the first-line medical staff responsible for answering patient questions. Among the subspecialties within our department and institution, some have already standardized their discharge instructions while some have not.
As residents, we answer home call questions from patients from 5pm to 8am every weekday and at all times over the weekends. It was our goal to determine if patients who received standardized postoperative discharge instructions had less postoperative questions over these time periods than those patients who had not. This would allow us to reflect on our care of patients in the postoperative setting and see if patients were more educated about their care if they received standardized postoperative instructions.
Riti Kanesa-thasan, MD; Liya Gendler, MD; Megan Margiotta, MD; Kristin Lohr, MD; Grant Turner, MD; Rebecca C. Jaffe, MD; Christopher G. Roth, MD; and Suzanne Long, MD
- The Joint Commission has linked communication failure as a root cause for a majority of sentinel events.
- The “I-PASS” system is a hand-off mnemonic that has been shown to decrease medical errors, prevent adverse events, and improve communication.
- Multiple Jefferson residency programs have adopted I-PASS training over the last year to standardize sign-outs between treatment teams and departments.
- Radiology residents also participate in hand-offs with other departments, especially in cases of adverse patient reactions that occur within radiology (ie: allergic reaction, seizure, contrast extravasation). In addition, radiology residents also participate in hand offs between daytime and overnight teams, including sign out of pertinent protocols, studies, and clinician communications.
- The aim of this study was to assess the adaptability of I-PASS training to the needs of a diagnostic radiology residency program.
Erica Li, MD; Rebecca Simon, MD; Michael Weissberger, MD; Angela Silverman, MD, MPG; Bryan Botti, MD; Laura Emerson, MD; Zoe Agoos, MD; Rachel Ehrman-Dupre, MD; Jennifer Moyer, MD; Andrew Rabovsky, MD; and Geoffrey Mills, MD, PhD
- Increase percentage of JFMA patients with follow-up appointment scheduled after discharge to 100% by March 2018
- Increase percentage of JFMA patients who show up to their follow up appointments after discharge to 80% by March 2018
Megan Margiotta, MD; Danielle Wilhour, MD; Elan Miller, MD; Robin D'Ambrosio, BSN, SCRN; Maria Carissa Pineda, MD; Fred Rincon, MD; Rodney Bell, MD; and Diana Tzeng, MD
- Teach incoming neurology residents how to respond efficiently and appropriately to stroke alerts
- Improve the confidence level of residents during stroke alerts
The effects of office-based interventions to increase patient enrollment in an online electronic medical record portal
Lionel McIntosh, MD; Allison Rague, MD; Claire Thesing, MD; Amy Lachewitz, MD; Gillian Love, MD; Daniel Sizemore, MD; Zachary Klock, MD; Aimee McMullin, MD; Zeynep Uzumcu, MD; and Patrick McManus, MD
We aimed to increase the number of JFMA patients signed up with MyChart by 50% over a 5 month time frame by educating providers and staff on ways to implement patient portal sign up into the office visit as well raising awareness of the portal for both providers and patients
Nikolaos Mouchtouris, MD; Catriona Harrop, MD; Edward Kloniecke, MD; Victoria English, CRNP; David Wyler, MD; Kamini Patel, RN, MBA; Ashwini Sharan, MD; and James Harrop, MD
Our goal is to develop evidence-based guidelines that:
- streamline the order/timing of interventions in patients who develop PUR after spine surgery
- identify those at high-risk of long-term urinary retention that require further workup
- minimize the rate of PUR –goal is to reduce to 3.5% in FY 2019
- and determine the cost savings from our intervention when applied to all surgeries
A Provider-Based Survey on Quality of Care and Identification of Quality Gaps in Inpatient Palliative Care
Adam Pennarola, MD, MPH; Matthew Murphy, MD; Elizabeth Collins, MD; Beth Wagner, MSN, CRNP, ACHPN; and John Liantonio, MD
Inpatient Palliative Care Teams (IPCTs) are often called upon to provide multidisciplinary care across hospital settings at Jefferson. However, there is currently no mechanism in place wherein providers consulting the IPCT can provide feedback to specialty palliative care clinicians. Such input from providers could be used to elucidate those services provided by the team which are most appreciated and those which require further development in order to be truly effective. Furthermore, such input may also serve to identify completely new areas for inpatient palliative care needs.
Aparna Polavarapu, MD; Rachit Patil, MD; and Maromi Nei, MD
To determine if there is a reduction in time to EEG reporting after institution of the Pediatric Epilepsy fellowship track.
Richard F. Schmidt, MD; Michael J. Lang, MD; Robin Dharia, MD; Fred Rincon, MD; Thomas Zdanowski, RN, MSN; Robin D'Ambrosio, RN, MSN; Stavropoula Tjoumakaris, MD; M. Reid Gooch, MD; Pascal Jabbour, MD; and Nabeel Herial, MD
- Critically evaluate the existing stroke activation and ET protocols for compliance with new 2018 metrics and guidelines.
- Review DTP times under the existing protocol to assess for potential inefficiencies or gaps in care delivery, specifically addressing differences between processes at JHN compared to ED/Gibbon.
- Make changes to the existing stroke alert protocol to better reflect current guidelines, streamline care, and ultimately improve process metrics (DTP times).
- Establish a system for recursive continuous analysis of AIS patients to identify protocol gaps, inefficiencies and areas for further intervention.
Improving Medical and Endovascular Management for Acute Ischemic Stroke Through Multidisciplinary Education and Simulation
Richard F. Schmidt, MD; Megan Margiotta, MD; Elan Miller, MD; Robin D'Ambrosio, BSN, SCRN; Robin Dharia, MD; Maria Aini, MD; Diana Tzeng, MD; Fred Rincon, MD; Pascal Jabbour, MD; and Nabeel Herial, MD
- Reduce door to treatment times (both DTN and DTP) to meet and exceed existing guidelines metrics.
- Educate residents about acute stroke management, including national guidelines and new institutional protocols to improve efficiency during stroke alerts.
Carly Sedlock, MD; Tatiana Bekker, MD; Tara Sunder, MD; Mario Caldararo, MD; Divya Chalikonda, MD; and Newton Mei, MD
We aimed to increase Jefferson Hospital Ambulatory Practice (JHAP) electronic medical record documentation of advanced care planning discussion of 209 identified “high risk” patients via independently labeled ACP notes by 5% (from 1.4% to 6.4%) over a six-month period (October 1, 2017- April 1, 2018).9 We elected to focus this pilot project on high risk patients due to time constraints of the study period and we felt that these high risk patients would likely derive the most benefit from ACP planning in the outpatient setting.
Aekata Shah, DO and Jennifer Seymour, DO
The purpose of our study was to demonstrate how various quality improvement initiatives activated in selected Jefferson Northeast family medicine teaching offices have enabled effective HCV screening. Given the cost effectiveness of screening and early treatment versus treatment of the disease in the later stages of progression,8 we hope to encourage other primary care offices to implement quality initiatives to encourage appropriate HCV screening. This is especially important for the baby boomer generation, as well as for high risk individuals with a history for and/or current IV drug abuse or other high risk behaviors.
Rashesh Shah, MD; Hanna Sofie Ellingsen, MD; Molly Halloran, MD; Reetu Mukherji, MD; Juergen Kloo, MD; and Yair Lev, MD
- Our aim was to design and implement cardiac monitoring education for medical residents in order to help residents feel more comfortable navigating and assessing telemetry.
- Our objective was to create and pilot a telemetry education video among Internal Medicine residents (from March to May 2018) resulting in a 75% increase in ability to demonstrate essential telemetry skills as determined by a pre and post video assessment.
Brianna Shinn, MD; Brandon Menachem, MD; Robert Park, MD; Sarah Houtmann, MD; Zachary Lee, MD; Thomas Holden, MD; Tomoyuki Hongo, MD; Vincent Yeung, MD; Goni Katz-Greenberg, MD; and Peter Burke, DO, MBA
In this study we conducted an analysis of 22 inpatients with an eGFR<20 that revealed there was a greater prevalence of patients without permanent AV access for HD initiation when compared to national data. These findings demonstrated the need for improved transitions of care and timely creation of AV access for this patient>population, thus we sought to improve this. This is the first inpatient initiative that our group is aware with the aim of improving timely AV access and transitions of care for an inpatient population (Figure 1).
Bad Out of the Box: A Report on Pre-operative Failure Rates of Reusable Flexible Ureteroscopes at a Single Institution
Whitney R. Smith, Brian P. Calio, Scott G. Hubosky, Kelly A. Healy, and Demetrius H. Bagley
Purpose: Single-use flexible ureteroscopes offer the advantage of being consistently functional and perfect for immediate clinical use right “out of the box.” Cost is the barrier to widespread acceptance of these instruments. Economic models have been put forth which compare the expense of acquiring and maintaining reusable flexible ureteroscopes to that of using single-use flexible ureteroscopes.However, one poorly defined variable in these models is the frequency of encountering an unsuitable reusable flexible ureteroscope at the beginning of a case. We sought to define this in a consecutive series of patients undergoing flexible ureteroscopy.
Patients and Methods: Prospective analysis of all consecutive cases requiring flexible ureteroscopy over three months was undertaken. A combination of fiberoptic and digital flexible ureteroscopes comprised the available inventory. Per protocol, these instruments were grossly cleaned in the endourology suite after use, and sent to central processing for final cleaning, sterilization (STERRAD) and packaging. Repairs were managed by a third party repair service when needed. Ureteroscopes were defined as acceptable if they provided reasonable visualization, deflection, an open working channel that would accept passage of instruments and no evidence of gross contamination or overt damage/deformity.
Results: Of 228 consecutive cases, a total of 261 reusable flexible ureteroscopes were unwrapped and 93 (90%) cases were initiated with the first instrument opened. In 11 (9.0%) cases, the initial ureteroscope opened was unacceptable for use and required opening an additional ureteroscope(s). In 7 cases, at least 2 instruments were opened. Also, 3,4, and 5 instruments needed to be opened in 1 case each. One case had to be rescheduled after 4 consecutive instruments were opened and all were unsuitable. Of 17 unfit instruments, 19 problems were noted and included broken deflection (4), dried cleaning solution on the instrument tip (4), inability to pass a laser fiber through the working channel (5), digital camera dislodged from distal bending rubber (2), crushed proximal shaft (1), digital image failure (1), lens trouble causing optical failure (1) and a missing sterilization cap (1). Considering all 119 instruments opened, 17 (14%) were unsuitable for immediate use.
Conclusions: In up to 12.6% of cases, the initially opened reusable flexible ureteroscope is not fit for initiation of the procedure. This rate may vary among institutions depending on repair, processing, and nursing practices but represents one area where single use devices can fill an essential and immediate role.
Awareness During an Intensive Care Unit Procedure: A Root Cause Analysis and Creation of the D5 Handoff Tool
Elise Strickler, DO and Bryan Lutman, DO
The objectives of this study are to:
- perform root cause analysis of the systemic causes of an incident of awareness that occurred during bedside EGD and
- create a handoff tool that is easily remembered that conveys the essential information about ICU intubations.
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