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2 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

3 Should Resected Femoral Heads Routinely be Sent to Pathology Following Femoral Neck Fractures?Department: Orthopaedic Surgery CRMC Collaborating Department(s): Department of Pathology, Finance Department Presenter Name(s): Geoffrey Rohlfing, DO, Maximino Brambila, MD, Jason Davis, MD.

4 TITLE/PROBLEM STATEMENTThe purpose of this study is to determine the incidence of positive findings, specifically neoplasia, in FH specimens sent for PATH after arthroplasty for femoral neck fracture, and to determine the cost effectiveness of this practice. In the process we will discover the percentage of FH specimens that were sent for PATH and elucidate the patient characteristics and demographics of those whose FH were sent to pathology versus those not. We hypothesize that many femoral head specimens, resected from hip fracture surgery, undergo pathologic examination that would otherwise not be indicated based on the patient’s history, physical exam, or radiographic findings. We also hypothesize the overwhelming majority of these examinations are negative resulting in little to no alteration of care, but with an increase cost.

5 SOLUTION New innovation or technology used: noneBenefits Standards being adopted: Only sending femoral heads to pathology when medically indicated, not on every case. Benefits: Cost savings for the patient, hospital, and insurance company. Improved efficiency in hip fracture care. Standards specifically being ignored (if applicable): none Drawbacks & benefits

6 IMPLEMENTATION State assumptions about resources allocated to this project People: Resident, faculty, research coordinator, Summer Biomedical Intern, CRMC Finance Department, Pathology Department Equipment: Computers Locations: CRMC Support & outside services: None

7 Concordant Discrepant DiscordantResults Exclusions: 745 Elective THA 1,595 Hip Fractures 850 HA/THA 384 Femoral Heads not Sent to Pathology 466 Femoral Head Specimens Examined Concordant Discrepant Discordant 464 (99.6%) 0 (0.0%) 2 (0.4%)

8 RESULTS Sent to Pathology # of Patients (%) Age in Years (sd)Gender (%) Yes 466 (54.8) 78.2* (11.8) Male-150 (51.0) Female-316 (56.8) No 384 (45.2) 74.5 (13.7) Male-144 (49.0) Female-240 (43.2) *indicates significant difference at p<0.000

9 RESULTS Patients with Femoral Head Specimen Positive for Neoplastic Process Patient Gender Age Mechanism of Injury Cancer History Antecedent Hip Pain Pathology Treatment 1 Female 49 Tripped None Yes Multiple Myeloma Proximal Femoral Replacement 2 68 GLF CLL/SLL Hemiarthroplasty 3 Male Walking Lung Cancer with metastasis Adenocarcinoma of Lung 4 73 CLL No CLL = Chronic Lymphocytic Leukemia SLL = Small Lymphocytic Lymphoma GLF = Ground Level Fall

10 CURRENT STATUS High-level overview of progress against scheduleOn-track in what areas: Data collection is completed and manuscript preparation is underway Behind in what areas: none Ahead in what areas: none Unexpected delays or issues: None

11 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

12 Extra Corporeal Membrane Oxygentation: Why A Dedicated Team Improves OutcomesDepartment: Internal Medicine CRMC Collaborating Department(s): Pulmonary/Critical care Presenter Name(s): Deepti Mundkur; Chirag Rajyaguru; Faye Pais; Karamjit Dhaliwal-Binning; Mohammed Fayed; Timothy Evans

13 Increased Mortality With EcmoECMO as a procedure independently increases mortality rate. A 50% mortality rate has been reported by the ECLS registry. This is especially important in critically ill patients in whom this procedure is frequently employed. The mortality in patients undergoing ECMO at CRMC was suspected to be higher than the national.

14 Importance of an ECMO teamSuccessful outcomes in patients undergoing ECMO is largely dependent on the collaborative support from an inter-disciplinary team. Identifying appropriate patients who would benefit from ECMO should be decided by this team

15 Standards being adoptedPhysicians trained in ECMO (who can provide 24-hour coverage) Critical care specialists Thoracic or trauma surgeons ECMO coordinator who can be – ICU nurse, registered RT with strong ICU background On staff biomedical engineer for technical support Palliative care specialist ECMO transport team: to transport patients while on ECMO

16 Standards being ignoredPatients continue to receive ECMO without the consultation of the ECMO team There are only 2 ECMO trained physicians and 1 ECMO trained fellow at CRMC to meet the demands of this high acuity, high volume, tertiary care, level I trauma center, covering the 6.5 million people of central California

17 IMPLEMENTATION State assumptions (false) about resources allocated to this project People – Sufficient critical care physicians and ICU support staff required to provide 24/7 patient care Equipment – Adequate number of ECMO machines are available Location – Readily available ICU beds for emergent patients Support & outside services – A biomedical engineer on call for mechanical support

18 RESULTS

19 RESULTS

20 CURRENT STATUS Ongoing efforts:Continued collection of data for patients undergoing ECMO with and without the consultation of the ECMO team. Setbacks: Data acquisition on specific patient parameters like ventilator data, procedure related complications and long term outcomes including post-ECMO quality of life Analysis of secondary outcomes including predictors of poor outcomes in patients undergoing ECMO, ventilator-free days, length of hospital stay and long term survival Dedicated team personnel and sufficient equipment Ensuring all ECMO candidates go through a dedicated ECMO team

21 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

22 Current outcomes of blunt open pelvic fractures: how modern advances in trauma care may decrease overall mortality Department: General/Trauma Surgery CRMC Collaborating Department(s): Orthopaedic Surgery, Interventional Radiology Presenter Name(s): Sammy S. Siada, DO, James W. Davis, MD, Krista L. Kaups, MD, MSc, Rachel C. Dirks, PhD, Kimberly A. Grannis, MD

23 introduction Open pelvic fracture, caused by a blunt mechanism, is an uncommon injury with a high mortality rate In 2008, the Western Trauma Association (WTA) published an evidence-based algorithm for managing pelvic fractures in unstable patients The use of massive transfusion protocols (MTP) has become widespread, as has the availability of pelvic angiography The aim of this study is to evaluate the outcome of open pelvic fractures in association with related advancements in trauma care

24 METHODS A retrospective review was performed of all patients who sustained blunt open pelvic fractures from January 2010 to April 2016 The WTA algorithm, including MTP (1:1:1 ratio) and pelvic angiography were uniformly used during this time Data collected included age, injury severity score (ISS), transfusion requirements, use of pelvic angiography, length of stay (LOS), and disposition Patients with penetrating injuries and closed fractures were excluded Data were compared to a similarly designed study from 2005 Dichotomous variables were compared using Chi square tests with significance attributed to a p value < 0.05.

25 results During the study period, there were 1505 patients with pelvic fractures, 87 (6%) were open. Of these, 25 were due to blunt mechanisms and made up the study population. Use of angiography was higher (44% vs 16%; p=0.011) and mortality was lower (16% vs 45%; p=0.014) than in the study Fourteen patients (56%) were hemodynamically unstable, and 12 had MTP initiated. Most deaths (75%) occurred from exsanguination in the first 24 hours. No patients underwent pre-peritoneal packing.

26 BASELINE PATIENT CHARACTERISTICSStudy (n) ISS GCS Age Males LOS 2005 (44) 30 12 39 68% 22 2016 (25) 29 11 42 21 p - value 0.87 0.67 - 0.98

27 CHANGES IN CARE FOR OPEN PELVIC FRACTURESStudy (n) Patients transfused Pelvic embolization Fecal diversion Mortality 2005 (44) 32 (73%) 7 (16%) 4 (9%) 20(45%) 2016 (25) 17 (68%) 11 (44%) 3 (12%) 4 (16%) p - value 0.68 0.011 0.70 0.014

28 conclusions The care for patients sustaining open pelvic fractures by blunt mechanism has evolved in recent years Changes include the use of an evidence-based algorithm, treatment of coagulopathy including massive transfusion protocols, and increased use of angioembolization The overall mortality for open pelvic fractures has decreased with these advances.

29 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

30 Title of Study: Pulmonary embolism response teamDepartment: Pulmonary Disease and Critical Care Medicine CRMC Collaborating Department(s): Cardiology, Cardiothoracic Surgery, Critical Care, Emergency Medicine, Hospitalist Medicine, Interventional Radiology, Pulmonary Disease Presenter Name(s): Kirat Gill MD, Ednann Naz MD, Timothy Evans MD PHD

31 TITLE/PROBLEM STATEMENTPulmonary embolism (PE) is the third most common acute cardiovascular event after myocardial infarction and stroke with over half a million cases annually in the United States. The estimated annual incidence of PE is 23 to 69 cases per 100,000 persons resulting in 676,000 inpatient hospital days and an annual cost of 7 to 10 billion dollars per year in the US. The reported mortality is up to 30% resulting in more than 100,000 deaths per year. Currently, the major treatment modalities for acute PEs involve systemic anticoagulation, systemic thrombolysis, catheter-directed interventions, and/or surgery.

32 TITLE/PROBLEM STATEMENT (cONTINUED)Although the treatment of low-risk PE is generally straight- forward and requires relatively little collaboration, treatment of intermediate and high-risk PE is more complex. The treatment of PE has historically been inconsistent. In addition, there is a paucity of data supporting specific therapeutic strategies. Add to this the ever expanding and increasingly complex nature of modern treatment modalities and the importance of expertise in the diagnosis, risk stratification, choice and implementation of treatment becomes increasingly critical.

33 SOLUTION The Pulmonary Embolism Response Team (PERT) model allows for multidisciplinary input to optimize clinical decision making, risk stratification and efficient resource utilization. Our PERT team would be composed of specialists in Cardiology, Cardiothoracic Surgery, Emergency Medicine, Interventional Radiology, Hospitalists, and Pulmonary Disease and Critical Care Medicine. An activation system would be created wherein an on – call PERT fellow responds to an activation and immediately convenes a conference among the specialists after ascertaining the appropriate data. Team members would then review the case and accompanying radiographic and laboratory data. A consensus decision would be made in regards to treatment and the appropriate team would be mobilized. Additionally, a PERT conference could help decide when a patient may benefit for transfer for an invasive therapy not available at the sending facility.

34 IMPLEMENTATION State assumptions about resources allocated to this project People: Involvement of aforementioned specialties for treatment, education of hospital housestaff and clinicians Equipment: Activation system, alerts within EMR and software necessary for conference call Locations: Hospital-wide Support & outside services:

35 RESULTS Data from the Massachusetts General Hospital (MGH) PERT team showed that in 30 months, there were 394 unique PERT activations, 314 (80%) for confirmed PE. PERT activations increased by 16% every 6 months. Most confirmed PEs were submassive (n = 143, 46%) or massive (n = 80, 26%). The PERT treated a relatively large proportion of patients with PE and systemic or catheter- directed thrombolysis (n = 35, 11%), though the most common treatment was anticoagulation alone (n = 215, 69%). Hemorrhagic complications were rare overall, especially among patients treated with catheter-directed thrombolysis. The all-cause 30-day mortality of PERT patients with confirmed PE was 12%. Chest Aug;150(2): doi: /j.chest Epub 2016 Mar 19.

36 CURRENT STATUS On-track: -Discussed with specialties involved-Presented at Quality Committee Meeting Forth-coming: -Implementation of software and alerts within EMR -Promulgation of concept within the hospital -Expansion of concept to surrounding hospitals

37 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

38 Strengthening Medical Homes for Children With Down Syndrome in the San Joaquin ValleyDepartment: Pediatrics Community collaborators: CVRC, EPU, DSACC, VCH Presenter Name(s): Rachel Manalo, DO, Denise Der, MD, Bonnie Singh, MD, Michael Smith, Joseph Shen, MD, Serena Yang, MD

39 PROBLEM STATEMENT Approximately 100 babies with Down syndrome (DS) are born each year in the San Joaquin Valley Children with DS are at high risk for developing chronic physical, developmental, and behavioral problems requiring long-term management Per survey results from 2015, only 7% of children with DS in San Joaquin Valley received all the recommended services specified by the AAP (American Academy of Pediatrics)

40 SOLUTION Focus groups Benefits of the focus group formatDesigned to investigate barriers to health care access facing children with Down syndrome in the San Joaquin Valley. Met with groups of parents of children with Down syndrome and their primary care providers Benefits of the focus group format Open and guided discussion to explore parental and provider perceptions of social support, expectations, and barriers to health care access for Down syndrome patients Helped to identify problems areas and brainstorm ways to improve care for Down Syndrome patients

41 IMPLEMENTATION/METHODSA list of questions was developed based on a literature review of attitudes and behaviors of parents and providers who care for children with Down syndrome Groups of 3 to 8 participants (caregivers and health care providers) were recruited via various local community partners to participate in focus groups Locations: EPU, CVRC, CHC, VCH Support & outside services: funded by American Academy of Pediatrics Resident Community Access to Child Health (CATCH) grant

42 RESULTS: demographics

43 RESULTS: Parent Focus GRoupsPrimary care physician strengths “Our son is 3 years old and we did not have a pre-delivery diagnosis. Our pediatrician said we need to sit down and I have something to tell you. She has been a champion for us.” “She talks to my son directly and shows respect for him.” Ideas to improve care “A one-stop shop clinic to make sure if there is anything my pediatrician is missing. OT, Speech, PT and all specialties under one roof to talk to each other.”  “There needs to be a clinic for children and adults with Down syndrome.” “I was 14 weeks pregnant and home alone getting ready for work. The geneticist called me at home and told me that the baby was 99.9% positive for Down syndrome.” Support Group Participation “Unless a parent contacts DSACC, there is no way for them to contact you.” “I truly believe that contact with other parents is the most important thing so they don’t feel isolated. And to get medical information.”

44 RESULTS: Provider Focus GRoupsAccess to Subspecialists “Referring is easy…Sometimes it is an issue with access. It may take 3 months to get into GI.” “Many kids with Down syndrome tend to have problems with their behavior… and need psychiatric intervention and that is extraordinarily difficult in terms of access” “For behavioral therapy, I’m embarrassed to say I have no idea [where they go]” Barriers for families to keep appointments “Financial ability to afford transportation” “Their behavior sometimes can be a [physical] barrier” “Other obligations that come up. Other children” Dissatisfaction with care “Limitation of what you can do in one visit. ” “One feedback we get is ‘I wish we could see all the subspecialties at once’ instead of coming out here on three different occasions in a week for appointments.” “They tried to have a California Children’s Services (CCS) Down syndrome clinic but they need more of a variety of things.”

45 Next steps Improving access to various subspecialties, most importantly behavioral and mental health programs Seamless transitioning of care to adult providers Improving the delivery of the diagnosis of DS to families (working with OBGYN and Genetics colleagues) Research on creating one-stop shops for DS patients

46 Thank you

47 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

48 Day versus night laparoscopic cholecystectomy: a comparison of outcomes and costDepartment: Surgery CRMC Collaborating Department(s): Trauma Program, emergency department Presenter Name(s): SS Siada, SM Schaetzel, HD Hoang, AK Chen, FG Wilder, RC Dirks, KL Kaups, JW Davis

49 Is it safe to operate at night?Early laparoscopic cholecystectomy (LC) for acute cholecystitis has been advocated to reduce morbidity, hospital length of stay (LOS), and risk of complications Acute care surgery (ACS) model has been developed to improve outcomes, maximize resources, and reduce cost Several studies have shown that performing LC at night has an increased rate of complications and conversion to open cholecystectomy

50 HYPOTHESIS Compared with day LC, patients undergoing night LC haveDecreased hospital LOS Decreased cost of hospitalization No difference in complication rate No difference in conversion to open rates

51 METHODS Retrospective review was performedTertiary-level safety-net hospital (650 beds) 10/ /2015 Acute cholecystitis from ED Exclusion criteria: Elective/incidental cholecystectomy Planned open cholecystectomy Gallstone pancreatitis Choledocholithiasis Admission to medicine

52 METHODS Day LC = 7am – 5pm Night LC = 5pm – 7amPatient variables included: Age BMI SIRS ASA class Pre-operative hypotension Severity of gallbladder disease Complications within 30 days

53 METHODS Primary outcomes of interest: Overall hospital length of stayConversion to open cholecystectomy Rate of complications Cost of hospitalization

54 Acute cholecystitis n = 1553 Excluded patients n = 687Study population n = 866 During the study period, 1553 patients with a pre-operative diagnosis of acute cholecystitis, who underwent laparoscopic cholecystectomy, were analyzed; 866 met inclusion criteria. Of the patients in the study cohort, 647 (75%) had LC during the day and the remaining 25%had LC at night. Day LC n = 647 Night LC n = 219

55 Baseline CharacteristicsGroup (n) Day (647) Night (219) P value Age 41 ± 16 42 ± 16 0.87 BMI 32 ± 7 0.42 Female gender 464 (72%) 157 (72%) 0.99 SIRS 83 (13%) 26 (12%) 0.71 ASA 3/4 (30%) (37%) 0.04 Baseline demographics and the number of patients with SIRS were similar between the day and night groups (Table 1); however, patients undergoing night LC were more likely to be ASA class 3 or 4 (37% vs 30%, p = 0.04).

56 Severity of Disease Day (647) Night (219) p-valueDay (647) Night (219) p-value Symptomatic cholelithiasis 16 (2%) 4 (2%)  0.50 Acute cholecystitis 408 (63%) 131 (60%)  0.43 Chronic cholecystitis 138 (21%) 52 (24%)  0.47 Gangrenous/necrotizing cholecystitis 79 (12%) 29 (13%)  0.70 Gallbladder perforation/abscess 6 (1%) 3 (1%) 0.70 There was no statistical difference in the incidence of each category of between the day and night groups (Table 3). The most common pathology identified intra-operatively was acute cholecystitis, which was found in 62% of patients. Gangrenous cholecystitis was found in 12%

57 Outcomes Group (n) Day (647) Night (219) p-value Cholangiography140 (22%) 35 (16%) 0.07 Length of case 1:42 ± 0:51 1:42 ± 0:43 0.38 Conversion 57 (9%) 9 (4%) 0.02 Length of stay 2.8 days 2.4 days 0.002 LOS - SIRS 2.6 days 2.1 days 0.001 There were no differences in the use of intra-operative cholangiography or the length of operation (Table 2) between the day and night groups. Interestingly, conversion to open rate was significantly higher in the day LC group compared with the night LC group (9% vs 4%) even though there was no difference in the prevalence of SIRS or incidence of gangrenous cholecystitis between the day and night groups. Additionally, length of stay was shorter in the night group (2.4 vs 2.8 days, p = 0.002). When patients with SIRS were excluded, patients who underwent night LC had a greater reduction in length of stay (2.1 vs 2.6 days, p = 0.001).

58 OUTCOMES Group (n) Day (647) Night (219) p-value Cost $4479 $4230 0.15Cost -SIRS $4304 $3894 0.09 Complications 53 (8%) 14 (6%) 0.41 Mortality 2 1.0 Cost of hospitalization was slightly less in the night group but did not achieve statistical significance. When patients with SIRS were excluded, patients who underwent night LC had a greater reduction in the cost of hospitalization ($3894 vs $4304, p = 0.09). The overall complication rate was 8%, with statistically similar rates between day and night groups (Table 2). Major intra-operative complications were infrequent in both groups, and CBD injury occurred twice (0.2%), both of which occurred during day-time procedures. The most common complication was cystic duct stump leak requiring ERCP and stent placement, occurring in 1.2% of all LC patients. This was followed by re-admission for pain control and retained CBD stones, both of which occurred in 0.9% of all LC patients. Two deaths occurred, yielding a mortality rate of 0.2%. Both deaths occurred in patients who had daytime LC. One of the deaths occurred after major post-operative omental hemorrhage requiring re-operation and subsequent myocardial infarction. The other death occurred as a sequela of an unrecognized gastric injury and resultant sepsis.

59 conclusions Performing LC at night is safeNo increase in complication rate Higher conversion to open rate in daytime LC Night LC have shorter of length of stay No difference in cost

60 Surveillance of Bacterial Contamination of Elevator-Based Endoscopes after Reprocessing with Steris 1E Chemical Sterilization: A Single-Center Study Department: UCSF Fresno Division of Gastroenterology and Hepatology CRMC Collaborating Department(s): CRMC Endoscopy Unit Presenter Name(s): Adnan Ameer, MD, Umesha Boregowda, MD, Mark Osburn, RN, Lisa Avalos, RN, Ana Araujo, RN, Jayanta Choudhury, MD, Rabindra Kundu, MD

61 Surveillance of Bacterial Contamination of Elevator-Based EndoscopesOptimal surveillance of reprocessed elevator-based endoscopes (EBE) has not been established, in light of recent reports identifying CRE (carbepenam-resistant Enterobacterericeae) transmission associated with persistently contaminated EBE. Liquid chemical sterilization with standard high-level disinfection of EBE has not been evaluated. oblem/topic

62 Reprocessing with Steris 1E Chemical SterilizationComparing the bacterial decontamination of EBE by standard method and using Steris 1E (35% peracetic acid) chemical sterilization (S1ECS) after standard method.

63 IMPLEMENTATION Single-center study was conducted at Community Regional Medical Center, Fresno, CA between February and May 2015. Bacterial cultures were obtained from 17 elevator-based endoscopes (12 ERCP and 5 EUS scopes). Initially cultures were obtained after reprocessing with standard method as per industry product guidelines. Second set of bacterial cultures obtained after reprocessing with standard method and S1ECS. Data collection and analysis was done using SPSS software version 22. Determining 48 hours bacterial culture results as pass or fail for negative and positive bacterial cultures. Identification of characteristic “low concern” and “high concern” bacteria, including CRE.

64 RESULTS Total of 309 cultures were obtained; 105 cultures after reprocessing with standard method and 204 cultures after reprocessing with standard method and S1ECS. Standard method failed to decontaminate in 33% cases and S1ECS failed in 5.4% cases. It was also observed that decontamination with standard method failed to decontaminate EUS scopes (47%) more frequently than ERCP scopes (26%); no such difference was observed with S1ECS (5%).

65 RESULTS Endoscope Cultures: Pass/Fail Cultures Obtained:No CRE identified during this investigation

66 CURRENT STATUS S1ECS is more efficient in decontamination of elevator- based endoscopes (EBE) compared to standard high-level disinfection. Our study is limited by the number of EBE cultured. Current progress: on-going surveillance of reprocessed elevator-based endoscopes (EBE) using Steris 1E chemical sterilization Bacterial cultures obtained from ERCP and EUS scopes Q monthly (expected number of cultures > 1500 Plan for data analysis summer 2017

67 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

68 Timing is everything: Outcomes in traumatic subdural hematomas based on time to ORDepartment: Surgery CRMC Collaborating Department: Trauma Presenter Name: Rachel J. Caiafa, MD

69 TITLE/PROBLEM STATEMENTPer the American College of Surgeons Committee on Trauma guidelines: Patients with traumatic subdural hematomas who require operative decompression should go to the OR within 4 hours of arrival Does not consider neurologic exam Does not consider acuity of subdural on CT

70 SOLUTION Patients with mixed (both acute and chronic components) or chronic subdural hematomas can go to the OR less emergently If no neurologic symptoms or signs Benefits Improved resource utilization with the OR, anesthesia, and neurosurgical teams No difference in discharge disposition, mortality, or hospital or ICU length of stay

71 IMPLEMENTATION Current guidelines state that operative decompression should occur within 4 hours of arrival Departments affected: Emergency department Operating room PACU Trauma ICU Trauma/neurosurgical floors Requires 24/7 availability of: Neurosurgeons Anesthesiologist/CRNAs Operating room and PACU staff

72 Acute SDH Mixed SDH Chronic SDHRESULTS Acute SDH Mixed SDH Chronic SDH OR≤4 OR>4 N 154 135 19 58 20 98 Age 51 50 68* 71* 66* GCS 7 10*° 10* 14*° 12* 14* ISS 27 26*° 22* 19* 21* ICU LOS 10 12 6 4*° 6* 3* Hospital LOS 15 19*° 9* Home or Rehab 27% 42%*° 53%* 64%* 70%* 62%* Mortality 44% 21%*° 37% 3%*° 5%* 4%* *p<0.05 compared to Acute SDH≤ °p<0.05 compared to OR≤4 Acute SDH Mixed SDH Chronic SDH OR≤4 OR>4 n 154 135 19 58 20 98 Age 51 50 68* 71* 66* GCS 7 10*­° 10* 14*° 12* 14* ISS 27 26*­° 22* 19* 21* ICU LOS 10 12 6 4*° 6* 3* Hospital LOS 15 19*° 9* Home or Rehab 41 (27%) 56 (42%)*° 10 (53%)* 37 (64%)* 14 (70%)* 61 (62%)* Mortality 67 (44%) 28 (21%)*° 7 (37%) 2 (3%)*° 1 (5%)* 4 (4%)* * p<0.05 compared to Acute SDH≤ ° p<0.05 compared to craniotomy≤4

73 RESULTS Patients who present with mixed or chronic subdural hematomasHigher Glasgow Coma Scores Lower Injury Severity Scores Discharged more frequently to rehab or home Lower mortality If patients with mixed or chronic subdural hematomas present without neurologic symptoms, they do not need to go to the OR emergently overnight or on weekends Improved resource utilization Decreases the likelihood of over-burdening limited OR resources during on-call hours

74 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by April 7th, 2017

75 The Dreaded Discharge Summary; A Daunting Task Simplified to improve patient safetyDepartment: Internal Medicine VA-CCHCS Collaborating Department(s): - Quality and Patient Safety, Systems Redesign Presenter Name(s): Matthew White, DO (Resident) Regina Godbout, MD (Chief of Medicine, VACCHCS) Wessel Meyer, MD (Chief of Staff, VACCHCS)

76 A problem with many layersRules and Regulations Per Veterans Affairs Central California Health Care System bylaws: discharge summaries must be completed within 48 hours of a patient’s discharge The Problem Our program’s compliance with this regulation was far below goal, with an average of less than 50% of discharge summaries being completed on time Our Goal At least 80% of all discharges accompanied by high-quality discharge summaries within 48-hours from the time of discharge Cause and Effect What is causing our problem? Initial Thoughts: We hypothesized that poor time management complicated by the numerous responsibilities placed on a senior resident are the key barriers to achieving our goal Key Players: Senior Residents: responsible for writing the discharge summary Interns: responsible for daily documentation and discharging the patient It has been well established that good communication during transitions of care has improved patient safety. Timely and high-quality discharge summaries are paramount to a successful transition of care from the inpatient setting to outpatient services. In fact, hospital readmission rates may be decreased when patients are evaluated in follow-up appointments by ambulatory care providers who have received the discharge summary.

77 An effective SOLUTION Step 1: Identify the resident-perceived barriers: Resident-focused survey Step II: Reduce the burden and address the barriers: Clinical Navigators: Nurse Practitioners Liaison between social work, physical therapy, and internal medicine to prepare for a safe and efficient discharge from the day of admission. Modification of the daily progress note to include information expected in a high quality discharge summary Hospital Course: A daily update of significant events and changes in management Intern’s responsibility to update, will help the senior resident quickly summarize a patient’s hospital course upon discharge. Anticipated Discharge: To help with early discharge planning and preparation Anticipated date of discharge, barriers to discharge, follow up upon discharge, and medication changes upon discharge Step III: Monitor progress and refine: Collect weekly data regarding percentage of discharge summaries completed on time Promote the 5 Lean Principles through real-time resident feedback to achieve sustainable, resident-centered behavioral change Standards adopted: VACCHCS bylaws that require discharge summaries to be completed within 48 hours of discharge. 5 Lean principles: Value Stream Flow Pull Perfection Value

78 IMPLEMENTATION: A multidisciplinary approachInterdepartmental collaboration VA Fresno/UCSF Fresno Internal Medicine Resident-driven change Clinical Navigators: Nurse Practitioners Three additional positions, one dedicated to each ward team Systems Redesign Modification of progress note templates Quality and Patient Safety Monitoring % discharge summaries completed on time per week

79 RESULTS: What the Residents thinkResident Survey: Q1: What is the biggest barrier preventing you from completing discharge summaries on time? A combination: overworked, burdened by chart review, Q2: In general, on which of the following days is it the most difficult to complete discharge summaries on time? Post-call day after 28-hour shift Q3: What would help you write the discharge summary on time? Multiple free response suggestions Q4: If the hospital course along with medication changes and outpatient follow up plan were updated prior to discharge, would this reduce the burden of writing the discharge summary on time? Yes: 58% Maybe 33% No 8% Q5: Would you be willing to update the information in Q4? Yes 8% Maybe 66% No 25% 12 total participants Q3: Free responses Hospital course section If interns formatted their notes with information needed to make DC summary Dedicated uninterrupted protected time for DC summaries Without having to answer pages or calls unless they are urgent Minimizing distractions/unnecessary pages Reducing the cap of patients per senior resident Not requiring DC summaries for patients LOS <48 hrs

80 RESULTS: What the Residents thinkQ6: How important is it to you to complete discharge summaries on time? Very important 8% Somewhat 66% Not at all 25% Q7: Have you encountered a situation where the discharge summary was not completed by the time you evaluated your patient in clinic for a discharge follow up? Yes 75% No 25% Q8: Do you believe that patient care and safety suffers when discharge summaries are not completed in a timely fashion? Q9: Do you believe your discharge summaries provide other physicians with the necessary information required to provide the safest care for patients during the discharge follow-up period? Yes 75% Maybe 25% No 0% Q10: The Society of Hospital Medicine has proposed a discharge summary check list to ensure key elements are included in each summary. Would you use such a checklist to improve the quality of your discharge summaries? Yes 58% Maybe 42% No 0%

81 Results: actions speak louder than wordsPre-Intervention: Initially thought bylaws required DC summaries within 24 hours We learned the true bylaws allow 48 hours to complete the summaries; we now have a better understanding of the bylaws

82 Results: actions speak louder than wordsPost-Intervention: Improvement seen as a result of increased monitoring of DC summary completion, weekly feedback, and increased sense of team approach to achieve goal Clinical Navigators: 02/21/17 (week 5-6) Progress Note Template Modifications: 03/29/17 (week 12)

83 CURRENT STATUS High-level overview of progress against scheduleOn-track: Integration of Clinical Navigators Upward trend in % completed discharge summaries within 48 hours Behind: Enforcing changes to daily documentation Unexpected delays or issues Delay in implementing modified progress note Next steps: - Continue to track data, expect upward trend to sustain once changes to daily documentation become habitual and clinical navigators are seamlessly incorporated

84 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

85 Radiation Dose Reporting ImprovementDepartment: UCSF Orthopaedic Surgery CRMC Collaborating Department(s): Radiology Presenter Name(s): Daniel Brown, MD; Lisa Husak, MPH CCRP

86 Radiation Dose Reporting IMprovementDuring Orthopaedic Surgery, especially trauma surgery, the patient, surgeon, and OR staff are exposed to radiation from Fluoroscopy. The amount of radiation exposure depends on several factors such as: patient body habitus; fracture location, type, and complexity; surgeon skill and technique; and technologist skill. Some factors are modifiable, some are not. Improvement in modifiable factors to reduce radiation exposure cannot be made unless there is first accurate reporting of the amount of radiation exposure in each case. Currently, the reporting of radiation exposure, by submitting the Dose Report into PACS with the final images, is less than 50%.

87 SOLUTION Current standard set by the ASRT (American Society of Radiologic Technologists) is for the Dose Report to be submitted, but this is not happening at CRMC consistently By ignoring reporting, we are unaware of the amount of radiation we and the patients are exposed to in a specific case, and unable to reduce it With submission into PACS of final fluoroscopic images, the dose report will also be included Each surgeon will be able to see the amount of radiation used in each case No new technology is required No new costs, no extra effort When submitting final images, technologists simply need to check the box to include the Dose Report

88 IMPLEMENTATION Problem first noticed June It has not changed since then. Implementation will include: Radiation Technologists Fluoroscopes CRMC ORs, both 2C and TCCB Radiation Technologist Supervisors

89 RESULTS We retrospectively examined all Orthopaedic Surgery cases from June and July 2016 to see if they 1.) used Fluoroscopy, and 2.) if they did use Fluoroscopy, did they submit the Dose Report. We then examined February to see if the rate had changed. Current Dose Report utilization/submission rate is 45%. This is essentially unchanged from June and July (P=0.66)

90 RESULTS: Prior to Implementation

91 CURRENT STATUS Intervention occurred in March 2017In March 2017, we spoke with the supervisor and select technologists. Still to be completed: follow up Fliers in boxes Fliers on Fluoroscopes May also consider: Additional sign in OR April 2017 At the end of the month we will collect data again to see if the reporting rate has changed

92 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

93 Pitfalls of a Non-Algorithm Based Pleural Effusion Workup in a Large Community Teaching Hospital:Department: Pulmonary and Critical Care CRMC Collaborating Department(s): Internal Medicine, Pulmonary, Laboratory Presenter Name(s): Kenneth Juenger, MD PCCM

94 Pleural fluid analysisPleural fluid pH measurements are used in the management of exudative pleural effusions and to guide treatment in parapneumonic effusions and empyemas. Inconsistency in sampling and frequency of ordering pleural fluid pH and pleural fluid analysis (PFA) can lead to inaccurate and incomplete workup of patients with a pleural effusion. This can lead to incorrect treatment and/or additional workup which can be costly and unnecessary to the patient.

95 Objective This study will look retrospectively at the ordering and testing of PFA samples to determine the frequency of sampling, timing of processing results, and evaluate the completeness of PFA to assess for variability in practice based on department. Once assessed and analyzed, quality improvement measures can be implemented to improve upon current practices and better patient management.

96 Methods: Data from 101 consecutive patients who had a thoracentesis performed at a community teaching hospital between April 2016 and September 2016 were reviewed retrospectively using EMR. The data included provider ordering pleural fluid analysis (PFA), thoracentesis operator, timing of pH and glucose results, type of PFA ordered and sample container used for transportation. As a bench mark for quality, we used one hour as the optimal time for pleural fluid pH measurement and 2 hours for all other chemistry testing. Continuous data was analyzed using Student's t-test and proportional data was compared using Chi-square test.

97 Results: A total of 101 patients were reviewed who underwent thoracentesis. 47 patients (46.5%) had pleural fluid pH drawn. 11/47 of these patients (23.4%) had pH resulted within 1 hour. Mean time of pH delay: 112 minutes for Pulmonary Department 210 minutes for Interventional Radiology Department. 28/74 patients (37.8%) who had glucose drawn resulted within 2 hours. Mean time of glucose delay: 157 minutes for Pulmonary Department 199 minutes for Interventional Radiology Department.

98 Results: Proper workup was ordered in 40/101 (39.6%) patients;15/26 (57.7%) by Pulmonary department 16/44 (36.4%) by Hospitalists 7/18 (38.9%) by Internal Medicine Department 2/13 (15.4%) by others. Thoracentesis was performed by Interventional Radiology in 66/101 (65.3%), 13/101 (12.9%) Internal Medicine Department, and 22/101 (21.8%) Pulmonary Department. Pleural fluid was sent to lab in 6 different sample containers.

99 Figure I: the mean time delay in measurement for pH and glucose.

100 RESULTS: complete workup?

101 CURRENT STATUS Data collection complete on 150 more patients.Currently being analyzed to assess for further comparison. Will then be able to discuss methods to improve current techniques, protocols, sampling, and measurement of PFA. Quality improvement methods will then be implemented to improve upon the above and better patient care and potentially outcomes as well as reduce the cost to the healthcare system because of incomplete and/or inaccurate data.

102 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

103 Depression Screening in Diabetic PatientsDepartment of Family and Community Medicine Clinica Sierra Vista Kulraj Dhah, DO; Laura Pierce, DO; Juan Carlos Ruvalcaba, MD

104 PROBLEM STATEMENT Diabetic patients are at an increased risk for depression 1 in 4 patients with type 2 diabetes mellitus has clinically significant depression Depression in diabetic patients is associated with: Worse medication adherence Poor glycemic control Increased mortality Increased costs

105 SOLUTION Dot Phrase for 2-item Depression ScreenSimple, cost-effective Adopted American Diabetes Association Clinical Practice Recommendation 3: Comprehensive Medical Evaluation and Assessment of Comorbidities Annual assessment of depression

106 IMPLEMENTATION Design: Pre-post Intervention:Random sample of 20 patient charts before and after the intervention Intervention: Clinic director met with IT to facilitate dot phrase creation Two PGY2 residents instructed to use dot phrase Location: Clinica Sierra Vista Dates: October 13, 2016 to January 31, 2017

107 RESULTS: Diabetic Patients Screened for Depression

108 CURRENT STATUS Overview of progressDuring the trial period, we found that the screening questions helped identify previously undiagnosed depression in patients with diabetes. This co-morbidity may play a significant role in compliance with medications, control of blood glucose and overall risk of complications. Based on our results, our clinic plans to continue with the annual screening questions for our Diabetic patients. We are working to improve our efforts to screen all of our Diabetic patients.

109 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

110 Increasing Pneumococcal Vaccination Rates in Patients with DiabetesChanged spelling in title Department of Family and Community Medicine ACC Family Health Center Mohsin Jawed, MD; Navpreet Gill, MD; Ila Naeni, DO

111 TITLE/PROBLEM STATEMENTPeople with diabetes are at an increased risk for pneumococcal infections, including bacteremia that has a mortality rate as high as 50% Evidence supports vaccination against Streptococcus pneumoniae in all diabetics given their immunologic response to the vaccine Vaccination leads to decreased hospitalizations, health care costs, and has morbidity and mortality benefits

112 SOLUTION Use electronic medical record (EMR) to allow providers to:Track data over time Identify patients due for preventative visits and screenings Quickly identify diabetic patients without proper vaccinations

113 IMPLEMENTATION Goal was to increase immunization rates among patients with diabetes at ACC Family Health Center, October through February 2017 Baseline and follow up data were obtained from the Epic EMR registries Utilization of “.imm” smart phrase under all our diabetic assessment/plans

114 RESULTS

115 RESULTS

116 RESULTS

117 CURRENT STATUS Overall vaccination rate increased 10%39% of eligible patients were vaccinated High baseline vaccination rate Improvements can be made within the registries to differentiate PCV13 from PCV23 vaccinations. This would ensure proper vaccination status among the different ages in the diabetic population

118 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

119 Increasing inpatient palliative care consultsHospice & Palliative Medicine Shane Lieberman, MD & John Thompson, DO

120 Effective education for providersReferring physicians often have preconceived notions of what the palliative care team does Studies demonstrate that inpatient palliative care consults lead to increased patient satisfaction, decreased hospital length of stay and cost savings to the hospital and the medical system

121 SOLUTION Provide education to the internal medicine hospitalist group regarding the role and benefits of palliative care Number of consults will increase Patient benefits will be achieved (i.e. increased satisfaction, decreased length of stay, and better pain and symptom management)

122 IMPLEMENTATION Hospice & Palliative Medicine FellowsInformal educational conversation with hospitalist 2-minute scripted conversation about when & why to consult palliative services Answer any questions from hospitalist CRMC January 2017

123 RESULTs TBD TBD

124 Results Baseline Follow-up Intervention No intervention Group size 2133 15 39 Number of consults 55 76 Median (Min - Max) 2 (0 – 8) 1 (0 – 15) No consults 6 (29%) 13 (39%)

125 CURRENT STATUS 39% of providers have been educatedPending results – increase education for providers Pending results – change method of education vs. message Unexpected delays or issues Number of providers reached Difficult to directly measure patient-centered outcomes Results available April 15, 2017

126 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

127 quantitative Blood loss vs. estimated blood lossDepartment: ObGyn Presenter Name(s): Lynsa Nguyen, MD; Dr. Subhashini Ladella, MD

128 quantitative Blood loss vs. estimated blood loss: How do they compare?Obstetric hemorrhage is identified by The California Department of Public Health Maternal Child and Adolescent Health Division as the leading cause of maternal mortality in California in (2). The World Health Organization estimates that the US maternal mortality ratio (MMR) increased 136%, from 12 deaths per 100,000 live births in 1990 to 28 deaths per 100,000 live births in 2013 (3). Other estimates of the US MMR are more conservative, but also show an increase in contrast to decreasing MMRs in the majority of developed and developing nations (3). It has been well established that visual estimated blood loss is inaccurate. More commonly, visual EBL most commonly results in underestimation by at least % (1). Studies have consistently found that large volumes are typically underestimated and small volumes overestimated. No correlation has been found between accuracy of EBL with specialty, age or years of experience. Studies have shown the inaccuracies of EBL; therefore relying on EBL to determine the need to initiate postpartum hemorrhage protocols may be inappropriate. There is potential for interrupting the progression of hemorrhage to severe morbidity and mortality if accurate blood loss can be determined.

129 quantitative Blood loss vs. estimated blood loss: How do they compare?Currently, at CRMC, both EBL and QBL are recorded. Postpartum hemorrhage is defined by a blood loss of 500cc in a vaginal delivery and 1000cc in a cesarean section. Here at CRMC, supportive treatment with volume resuscitation is not necessarily initialized with postpartum hemorrhage. It is based on the clinician’s judgement based on blood loss and the patient’s status. Typically an EBL is more readily accessible when quick action is needed. There has been a discrepancy observed between reported visual EBL and QBL. Therefore, the goal of the study is to determine the comparative accuracy of EBL and QBL measurements. Is it worth going through the extra work and costs to provide a quantitative blood loss?

130 SOLUTION The specific aims of this study include:Showing a significant increase in the accuracy of quantifying blood loss by using QBL over visual EBL. If shown to be more accurate, physicians and staff on labor and delivery would no longer need to provide an EBL and instead could transition to only assessing QBL. Effecting a significant decrease in maternal morbidity and mortality associated with obstetric hemorrhage in childbirth with the initiation of assessing QBL. The concern with the use of EBL is failure to recognize excessive blood loss and such failure would delay effective intervention.

131 IMPLEMENTATION State assumptions about resources allocated to this project People: Clinicians and RNs have already collected appropriate information per routine on Labor and Delivery. Support & outside services: Previously collected information through retrospective chart review (via EPIC) of patients that have delivered on the Labor and Delivery unit at CRMC from February to present is being conducted. Investigators are pulling the following data: pre-delivery hemoglobin, post-delivery hemoglobin, estimated blood loss, quantitative blood loss, complications, age, BMI, parity, and ethnicity. Investigators are looking at the pre-delivery and post-delivery hemoglobin levels and comparing the drop in hemoglobin to the blood loss given by QBL and EBL. Morbidity and mortality rates from obstetric hemorrhage during the time of QBL collection is also being reviewed. Equipment: Plastic drapes for collection of blood and scale Locations: CRMC Labor and Delivery

132 RESULTS Delivery data from February 2016 to May 2016 have been reviewed. The goal for now is to collect data From February 2016 to June 2016 for analysis. Data being reviewed: date and time of delivery, mode of delivery, gravida and parity, patient’s weight, initial hemoglobin (prior to delivery), repeat hemoglobin (after delivery), date and time of repeat hemoglobin, EBL, QBL The initial hemoglobin and repeat hemoglobin are used to calculate the blood loss from delivery. This is compared to the QBL and EBL.

133 CURRENT STATUS High-level overview of progress against scheduleOn-track in what areas: Data collection instrument and pregnancy episode list have been secured. Behind in what areas: : Chart reviews. Unexpected delays or issues – Members of the research team have not been able to access QBL values due to their limited EPIC access. This has slowed down the progress of chart review completion.

134 References 1. The Association of Women’s Health, Obstetric and Neonatal Nurses. “Quantification of Blood Loss: AWHONN Practice Brief Number 1.” Nursing for Women’s Health 19.1 (2015): Web. V 2. California Department of Public Health. The California Pregnancy- Associated Mortality Review. Reports from 2002 and 2003 Maternal Death Reviews. California Department of Public Health, Maternal Child and Adolescent Health Division. Sacramento 3. World Health Organization. Trends in maternal mortality: 1990 to Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division

135 Quality Improvement & Innovation Symposium 2017 Submission FormSecond Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Form All Submissions Must be Submitted By Program Director or Representative by March 31st, 2017

136 Syphilis during pregnancy: one- versus three- dose benzathine penicillin G regimen, and subsequent diagnosis of congenital syphilis Department: OBGYN Presenter Name(s): Andrea Seid, DO; Anubhav Agrawal, MD

137 Syphilis during pregnancy: Uncertainty about the optimal treatment regimenCongenital syphilis in the Central Valley, California is increasing. Here in Fresno County, the total number of syphilis cases in adults is the highest in the state, and has dramatically increased from <20 cases 2010 to approaching 120 cases in 2014, and now >150 cases in 2015 (Rutledge, 2014). Syphilis during pregnancy can result in vertical transmission and is deleterious to the fetus. The rate of congenital syphilis in Fresno County more than triples that of the state of California rate. (Rutledge, 2014). Currently guidelines for the treatment of maternal syphilis vary on the timing and duration of disease. Women with early syphilis (primary, secondary or early latent) should be treated with a single dose of 2.4 million units of benzathine penicillin G. Late latent syphilis (>1 year without treatment/nonreactive within past year) is 2.4 million units weekly x 3 weeks for a total of 7.2 million units (Centers for Disease Control and Prevention, 2016) (Berman, 2004). However, while penicillin has proven effective in treating syphilis in pregnancy and in preventing congenital syphilis, uncertainty remains about the optimal treatment regimen (dose, duration and preparation) (GJA, 2004).

138 Syphilis during pregnancy: Uncertainty about the optimal treatment regimenThe CDC indicates that some evidence suggests that additional therapy is beneficial for pregnant women. Congenital syphilis can be prevented if the mother is diagnosed and treated appropriately and without delay, and the baby is evaluated and treated per CDC STD guidelines (Kidd, 2016). In this study, our goal is to determine if a 3-dose regimen of PCN, specifically for early latent syphilis is an acceptable alternative during prenatal/antepartum care in high-risk areas.

139 SOLUTION The specific aims of this study include:Determination of the number of newborns with congenital syphilis at CRMC and correlate with maternal penicillin treatment received. Evaluation of maternal syphilis after 1- and 3-dose regimens of penicillin. The purpose of these aims are to evaluate that regardless of diagnosis timing, congenital syphilis of the newborn is less if a three-dose regimen of penicillin is used rather than a single-dose regimen.

140 IMPLEMENTATION Medical Charts of CRMC patients identified as being pregnant and with syphilis between January 2010-December 2016 will be reviewed for penicillin regimen received (1- or 3-dose) and incidence of congenital syphilis. State assumptions about resources allocated to this project Data will be collected from the CRMC hospital electronic record system, EPIC, using ICD9 and ICD10 codes for syphilis complicated pregnancy, congenital syphilis, maternal syphilis. Health Information Management (HIM) will be assisting in the data collection for this study. To secure dates of treatment not available in EPIC, we will call the Fresno Department of Public Health and contact Dr. Lichtenstein’s office where most CRMC patients are treated for syphilis. From each patient and neonate we will be reviewing known history of syphilis, gestational age at diagnosis, gestational age at treatment, number of treatments, maternal RPR titer levels, placental pathology, treatment for congenital syphilis given, and evidence of congenital syphilis identified by neonatology/pediatrics.

141 RESULTS Preliminary data shows that for all patients treated adequately (>1 mo prior to delivery) with unknown duration (3 doses PCN), there was no congenital syphilis in neonates Of the neonates who had ≤2 doses PCN with congenital syphilis, three had 1-2 doses just prior to delivery, and two had >3 weeks prior to delivery with 1-2 doses. Of the neonates who did not have congenital syphilis, and got ≤2 doses PCN, all three were treated inadequately (did not complete recommended doses >1mo prior to delivery)

142 5 3 10 RESULTS Preliminary data from n=18* ≤2 doses PCN ≥3 doses PCN +3 10 + Congenital Syphilis - *Data collection is currently on-going. From HIM review, expected n>200

143 CURRENT STATUS High-level overview of progress against scheduleOn-track in what areas: IRB approval and Patient list for review have been secured. Behind in data collection Data analysis has taken a significant amount of time, expected to be complete within the next couple of months ≤2 doses PCN

144 REFERENCES Berman, S. (2004). Maternal syphilis: Pathophysiology and treatment. Bulletin of the World Health Organization , 82, CDC. (2016, 09 19). Sexually Transmitted Diseases. Retrieved 10 23, 2016, from Syphilis: CDC*. (2016, 06 27) Sexually Transmitted Diseases Treatment Guidelines. Retrieved , 2016, from Syphilis in pregnancy: Centers for Disease Control and Prevention. (2016, 07 27) Sexually Transmitted Diseases Treatment Guidelines. Retrieved 10 23, 2016, from Syphilis: GJA, W. (2004). Antibiotics for syphilis diagnosed during pregnancy (Cochrane Review). (Chichester, Ed.) The Cochrane Library (4). Kidd, S. (2016, 07 18). Medscape. Retrieved 10 23, 2016, from Congenital Syphilis Is on the Rise? Reviewing Prevention Steps: Rutledge, J. (2014). The 2014 Fresno County Department of Public Health Annual Report. Fresno: Fresno County Department of Public Health.