Background: -Breastmilk recommended for infant health. (AAP, 2012 - - PowerPoint PPT Presentation

Aim: Through office-based interventions, we aim to improve the

breastfeeding continuation rates of infants at 6 months of age by 10% by June 2020 in a publicly-insured primary care pediatric population.

Background:

• Breastmilk recommended for infant
• health. (AAP, 2012 & USDHHS, 2010)
• Breastfeeding rate: CPM<South

Carolina<US. (CDC, 2018)

• Racial disparity in breastfeeding rates
• nationally. (Louis-Jacques et al, 2017)
• Adoption of ABM Clinical Protocol

#14 can raise breastfeeding rates in primary care clinics. (Dumphy et al, 2016)

Breastfeeding questions prompt Nurse education Wording change for ethnic applicability Spanish interpretation card Prompt for help with breastfeeding on return to work

Methods

• Chart review of infant WCCs for infant race, nutrition source, lactation

consult, breastfeeding plan, and breast pump ownership.

• Subjective survey on level of support moms feel.

Not all nurses were asking during rooming.

Many mothers fed breastmilk & formula, but only reported one method.

Nurses not fluent in Spanish unsure how to ask. BF rate dropoff @ 1-2 months. Return to work?

PDSA cycles Barriers discovered

Results and Conclusions

• No increase in breastfeeding rate at

age 6 months, despite interventions.

• 87% of survey responders satisfied

with breastfeeding support at CPM.

• Racial disparities in breastfeeding

rates exist at CPM.

• Improvement in culturally

competent care.

• Better data collection methods

are now in place.

Next Steps:

• “Back-to-Work” informational

pamphlet: pumping, storing milk; workplace rights.

• Future PDSA cycles: further

adoption of steps suggested in Clinical Protocol #14, to make CPM a Breastfeeding-Friendly Physician’s Office.

Meeting the Healthy People 2020 breastfeeding goal at CPM will be a long process, and require joint effort of medical, nursing, and support staff.

Contact information: Becky.Roland@PrismaHealth.org

Revisiting Return to Learn

Trey Suhrstedt, MD Mentors: Franklin Sease, MD and Vicki Nelson, MD

Improving the Effectiveness of a Concussion Management Protocol in Greenville County Schools

Aim/Background

• Aim: Enhance the health and education of Greenville county students who

have suffered from a concussion by determining the impact of the Return to Learn Protocol (the Protocol), identifying barriers to its implementation, and providing education and guidance to improve its effectiveness

• Concussions can interfere with students’ ability to participate in school
• The number of concussions is rising
• Following a structured, standardized protocol can improve concussion

symptoms

• Return to learn is a relatively new concept
• The Protocol standardizes how students return to school following a

concussion, allowing time for adequate rest and appropriate accommodations

Methods

Participant selection:

• The main target of this project is Greenville County teachers

Study design:

• An initial survey will be sent to teachers. Afterwards, the will

receive a recorded educational presentation and follow-up survey

Results

Conclusion/Next steps

• Need more data
• Potential for a large impact with further education and guidance
• Some ambiguity in results so far
• PSDA cycle currently in process due to initial low response rate

Contact Information

• Trey.Suhrstedt@prismahealth.org
• 864-867-8080

“No Clots for Kids”-House Staff Education for VTE Prophylaxis Protocol

Eric Polley, MD, Elizabeth Tyson, MD, Mark Krom, DO

Aim/Background

• VTE incidence in pediatric patients has increased over the last two

decades by a factor of 10, soaring from 5.3 per 10,000 to 58 per 10,000

• The reason for this increase is multifactorial (indwelling catheter,

prolonged immobility, auto inflammatory syndromes, etc.)

• AIM: Qualitatively improve the knowledge and comfort of pediatric

residents in the Prisma Health Pediatrics residency with using pharmacologic prophylaxis for VTE prevention in at-risk children

Methodology

• VTE prophylaxis protocol was developed

which will be used to screen patients while in the hospital to determine their risk of developing VTE

• I created an educational video to teach VTE

incidence, causes, and order set utilization

• Pre- and Post-module surveys to assess

efficacy of module

Analysis and Results

• 20 residents, 5 completed
• 10 question survey once

completed

• Scaling questions (scale of 1-5)
• On the right, 2 selected

questions from the post-module questionnaire are featured: familiarity with VTE screening and likelihood of ordering prophylaxis

• Q2: On a scale of 1-5, how familiar are you with Prisma

Health’s new protocol which will be implemented to reduce the incidence of VTE?

2.5 5 7.5 10 12.5 Pre Module Post Module

• Q9: How likely are you to order anticoagulation

for appropriate pediatric patients now that you have completed this module? (Scale of 1-5)

1 2 2 3 4 Post Module

Conclusions and Next Steps

• Study was low power (n=5)
• Residents who completed module

had better understanding of VTE risk

• 80% of residents (4/5) will now
• rder VTE prophylaxis

appropriately

• Recommend integration into
• nboarding for future residents
• The Next Steps of this

project is to fully integrate the module into resident

• nboarding material
• A long term patient data-

centered retrospective analysis of VTE incidence since implementing educational module

Contact Information

• Eric Polley, MD-Resident PGY IV, Internal Medicine/Pediatrics
• Prisma Health Upstate
• 701 Grove Road, Greenville, SC 29605
• (864) 608-6322

Transition of Autism and Intellectual Disability to Adult Medicine

Zachary Wood, Meds Peds PGY-4 Justin Holladay, Meds Peds PGY-4 Nancy Powers, Developmental Behavioral Pediatrics

AIM/BACKGROUND

• The purpose of this quality improvement project is to

improve the transition of adolescents and young adults with autism and intellectual disability from pediatric to adult providers.

• Significant pressure is getting placed on health systems

for accommodations of patients with autism and intellectual disabilities.

• Currently at Prisma Health Upstate there is no

dedicated program in place for adult patients with autism and intellectual disability.

PRIVILEGED AND CONFIDENTIAL This document is not subject to discovery pursuant to South Carolina statutes. 20

METHODS

• Patient selection: Patient analysis included a chart review of

adolescents and young adults aged 14 and up who currently receive care at the Developmental Behavioral Pediatrics Clinic in Greenville, SC and received care at the clinic from 03/01/2019 to 03/01/2020. Patients were included via an Epic request for charts with a diagnosis of autism spectrum disorder, intellectual disability and/or both.

• Study design: Data was collected by manual chart review

measuring the current number of patients who have transition discussed in their visits, as well as the average age of transition discussion initiation and presence of successful transition to adult

• provider. This was done with the goal after our intervention to evaluate

the change in both total number as well as time-to-transition initiation at the Developmental Behavioral Pediatrics Clinic.

• Data Analysis: A sample size of 250 patients were investigated to

identify presence of transition of care discussion. We compiled data regarding the age at initial transition discussion and whether a successful transition to adult provider had taken place. No statistical analysis performed.

PRIVILEGED AND CONFIDENTIAL This document is not subject to discovery pursuant to South Carolina statutes. 21

PRIVILEGED AND CONFIDENTIAL This document is not subject to discovery pursuant to South Carolina statutes. 22

CONCLUSIONS

• Average transition talk is well behind recommended

age of 14

• Almost half of all 18+ patients do not have

dedicated adult providers

NEXT STEPS

• Assist Prisma Health developmental/behavioral

pediatric professionals with implementing the first phase of building a transition model for youth with ID/DD.

• Create an EMR tool to include transition of care

discussion into visits starting at age 14.

• Create an “age of majority” resources for teachers to

use during the IEP process to discuss transition and decision-making authority in a more comprehensive way that points families toward resources that promote independence.

• Create a webinar that coincides with the “Stop, Look

and Listen” tool to offer additional guidance, resources, and modification ideas to teachers.

• Create an adapted “Stop, Look and Listen” tool for

medical professionals to use when planning for patient transition from pediatric to adult medical

• care. Provide training to staff at Prisma Health

Greenville on both this tool and other resources that may help them promote independence.

PRIVILEGED AND CONFIDENTIAL This document is not subject to discovery pursuant to South Carolina statutes. 23

CONTACT INFORMATION

PRIVILEGED AND CONFIDENTIAL This document is not subject to discovery pursuant to South Carolina statutes. 24

Justin Holladay, MD

Justin.Holladay@prismahealth.org

Zachary Wood, MD

Zachary.Wood@prismahealth.org

“Brr It’s Cold in Here: An Approach to the Hypothermic Infant”

• Jennifer Raffaele MD, Grace Williams MD
• Elizabeth Tyson MD, Mark Krom DO, James Sierakowski DO

Aim/Background

• The purpose of this quality improvement project is to

develop and implement an algorithm to standardize the management of hypothermic infants presenting to a tertiary children’s hospital by May 2020.

• Infants present for hypothermia to our hospital without a set

protocol in how to manage them.

• There is limited data in the literature on hypothermic

infants, and no recommended standard practice recommendations

• Data does suggest that in the first 2 weeks of life,

hypothermia can be a normal finding

Methods

• 1. We created a rewarming protocol to be used in the

ED and inpatient services

• 2. We created an algorithm for evaluation and

management of hypothermic infants.

• 3. We performed a chart review looking at infants

admitted from 2017-2019 with hypothermia (ICD 10 codes P80.9, P81.9, T68).

Results

Blue: No diagnosis Red: SBI/Viral Meningitis Orange: Other

Next Steps

• Now that we have both an algorithm and preliminary data we should do PDSA cycles with our

algorithm and perform post PDSA chart reviews to determine its use and worth.

• Consider re-adjusting WBC risk factor normative ranges based on age
• CBC abnormal: not specific or sensitive
• Consider including percent weight loss as a risk factor
• Percent weight loss between patients with a dx and those without was statistically

significantly different

• Continue to educate residents and ER staff on the algorithm.
• Move messaging about the algorithm to the community, starting with our resident-run clinic
• Perform chart review of Prisma Health- Midlands Children’s hospital hypothermic infants to

increase sample size

Thank you!

• Jennifer Raffaele
• Jennifer.Raffaele@prismahealth.org
• Grace Williams
• Grace.Williams@prismahealth.org

Locked and Unloaded:

Gun Safety Education and Provision of Free Gun Locks to Pediatric Clinic Families

Jessica Groot, MD and Brittiany Gray, MD Faculty Mentors: Blakely Amati, MD and Meredith Eiken, MD

Background/Aim statement

By July 2020, we plan to have a sustainable, time efficient, standardized approach to providing and documenting education to families regarding firearm injury prevention such that over 50% of well child visits of children ages 3-18 have documentation of this, through facilitating ongoing provider education, piloting patient and family centered questioning, and revising existing WCC templates.

Methods

• This project will continue on the foundation established by “Lock ‘em up!”, a quality improvement project from 2018-2019

which successfully partnered CPM with local law enforcement to provide a sustainable source of gun locks

• Eligible participants include any parent or guardian of the 22,000 children served at the Center for Pediatric Medicine

Written vs verbal screening Preferred question phrasing Education to > 75% of providers Increasing accessibility of gun locks to providers accessibility Embedding standardized screening questions in WCC templates

Results

PDSA Cycle 3 - Provider Education Post Assessment Surveys Felt more comfortable counseling families 63% Felt it was more important to screen for firearms 75% Would alter their practice by increase firearm safety screening 94%

Are the guns in your home locked and stored safely?

Pilot study 1: Verbal vs Written Screening. Pilot study 2: Preferred question phrasing

Verbal Screening

Does your child live or visit any homes where there are unlocked guns?

Written Form

Provider education Gun locks relocated Screening question on template

73% 27% 81% 19% n=27 n=16

Conclusion & Next Steps

• The number of children in Upstate

SC with access to unlocked firearms was decreased

• Average parental comfort level 9/10

when discussing gun safety

• 80% documentation of gun safety

screening and education at well child checks

• 120 gun locks were provided to

patients at CPM

Add screening question to ADHD and behavioral health clinic templates Sustainable provider education through BeSMART Survey providers regarding comfort of new screening method

Contact Information

Jessica Groot, MD jessica.groot@prismahealth.org Brittiany Gray, MD brittiany.gray@prismahealth.org

Levaquin Prophylaxis in Pediatric Leukemia: Confirming Prior QI Results in a Local Population

Shane Sundlie, MD and Alex Yu, MD Aniket Saha, MD and Joshua Brownlee, MD

Aim/Background

• Background
• Chemotherapy protocols result in severe neutropenia and increased

risk of overwhelming infection, especially during induction, consolidation, and delayed intensification

• There have been several large multi-institutional studies that have

investigated the utility of Levaquin as bacterial prophylaxis during these phases of therapy

• Results were favorable: decreased rates of bacteremia, antibiotic

use, C. difficile infection, febrile neutropenia

• Aim
• Confirm these findings in our local patient population

Methods

• Population: The Department of Pediatric Hematology/Oncology at Prisma

Health Upstate – AML and ALL patients N = 52

• Levaquin prophylaxis N = 26 (November 2018 – Present)
• Control N = 26(Patients diagnosed January 2016 – November 2018).
• Key areas investigated through chart review:
• clinically documented infections
• microbiologically documented infections
• total hospital days
• total treatment antibiotic days
• Exclusions:
• allergy to fluoroquinolones, received part of treatment at another

institution, or started Levaquin prophylaxis in the middle of treatment.

Results

Levaquin Group Non-Levaquin Group P-value CDI 0 (0, 3) 1 (1, 2) 0.348 MDI 1 (0.25, 2) 2 (1, 4) 0.05* Total Antibiotic Days 13 (3, 52.5) 22 (8.2, 79.2) 0.28 Total Hospital Days 23 (14.5, 107.5) 33.5 (21, 66.8) 0.54 Table 1: Comparison of Medians (Q1, Q3) between treatment and non-treatment group with use of Wilcoxon rank-sum statistical test.

CDI (clinically documented infection); MDI (microbiologically documented infection)

Levaquin Group Non-Levaquin Group P-value C Diff + 7.7% 26% 0.1 Table 2: percent of patients that were C. diff positive at least once during treatment phases with use of Fisher’s exact statistical test

Conclusion/Next Steps

• Conclusions:
• Bacterial prophylaxis with Levaquin does appear to confer some

advantage compared to non-treatment

• Larger population of patients is needed at our institution to likely

see the same advantages as the larger multi-institutional studies

• Next Steps:
• Our Pediatric Hematology/Oncology group will continue to use

Levaquin as bacterial prophylaxis

• We can continue to gather data to increase the power of our study

References

• Alexander S, Fisher B, Gaur A, et al. Effect of Levofloxacin

prophylaxis on bacteremia in children with acute leukemia or undergoing hematopoietic stem cell transplantation. JAMA 2018:320(10):995-1004

• Gafter-Gvili A, Fraser A, Paul M, et al. Antibiotic prophylaxis for

bacterial infections in afebrile neutropenic patients following

• chemotherapy. Cochran Database Syst Rev 2012. 1:CD004386
• Wolf J, Tang Li, Flynn P, et al. Levofloxacin prophylaxis during

induction therapy for pediatric acute lymphoblastic leukemia. Clinical Infectious Diseases 2017:65(11):1790-8

Shane Sundlie, MD Shane.Sundlie@prismahealth.org Alex Yu, MD Alex.Yu@prismahealth.org

Capturing HPV Vaccination Opportunities

• Dr. Quinn Hunt, Internal Medicine and Pediatrics PGY-4
• Dr. Sarah Hinton and Dr. Blakely Amati

Aim Statement & Background

• Aim: increase captured opportunities (CO) for HPV vaccination by

15% in patients aged 11-15 at the resident clinic, Center for Pediatric Medicine.

• Baseline Capture Rate: 48%
• Reason for not receiving vaccination: 30% chronic medical

management (obesity, ADHD, asthma, etc.) and 48% present for sick visit.

Methodology

• Intervention:
• Adapt work flow to utilize “Care Gaps” or “Health

Maintenance” for vaccine review at all adolescent visits

• Weekly reminders of work flow as well as prior weeks CO

percentage Reviewed data in 1 work week periods (Monday through Saturday). Captured opportunity rate recorded for each period.

• Data Collection: weekly review of CO collected via manual

chart review

Analysis & Results

10 20 30 40 50 60 70 80 90 100

HPV Captured Opportunities

Captured Opportunities (%) Total Patients

Baseline Intervention

• Baseline CO%: 48%
• Intervention CO%: 71%

Conclusions

• Captured Opportunity percent increased by about 23%

during intervention period (about 48% to 71%).

• In the high-risk adolescent population, capitalizing on all

patient interactions is paramount.

• By adapting work flow to review vaccine status on all

adolescent visits, we found a promising increase in captured

• pportunities.

Contact Information

• Work Number: (864) 915-4075
• Email: quinn.hunt@prismahealth.org

Burn through the Culture List:

Improving Efficiency of Inpatient EMR processes Aubrey Fleming, MD; Carley Howard Draddy, MD

AIM

• Reduce resident EHR burden

by improving organization and standardizing use of inpatient lab follow up system by June 2020.

Multiple studies showing between

40-50% of work time spent on EHR tasks

Variable numbers (35-60%)

physicians express symptoms of burnout

Those that express these

symptoms, 70-80% report relation to EHR

Significance

Methods

• Apply new epic patient list

column; “specialty comments”

• Allows easier recording

and access to labs needing follow up after discharge

• Resident surveys given

electronically to get qualitative measure of number of clicks and time burden pre-change and post-change Above pre-change list; Below post-changes

Pre-Change

• 85% Survey Responders

felt burdened by the task

• f running the culture list

(about 50% endorse moderate or > burden)

• Approximately 50%

reported clicking through more than 4 windows in

• rder to follow up on

each patient

• Common concern

reported was difficulty knowing which labs required follow up

Post-Change

Limited by responses – 40/53

pre-survey; 26/53 post-survey

Approximately 80% responders

now click through less than 4 windows

100% report decreased burden of

Inpatient culture list EHR process

100% reported that the change

addressed the common concern noted on pre-survey

Results

Conclusions

• Subjective improvement in burden of using inpatient lab follow-up

system

• Decrease in the number of clicks/windows used to follow up on

each patient

Next Steps

Goal to continue to work on efficiency of this process Consider starting a long-term follow-up prospective study attempting to follow rate of

missed labs and effects of any changes to the process

Contact Information

Aubrey Fleming, MD Resident of Pediatrics, Prisma Health Upstate Email: Aubrey.fleming2@prismahealth.org