Lung Cancer Screening Program via Primary Care Clinics

Lung Cancer Screening (LCS) reduces lung cancer mortality by 20 to 24% however in the US only 5.7% of eligiblepatients participate. Increasing screening of individuals at risk for lung cancer is an unmet need. We started a LCSprogram using primary care physicians (PCP) visits where the intake nurse asked age appropriate patients abouttheir smoking status. If patients met criteria, the physician was alerted to perform shared decision making, offersmoking cessation and order a low dose screening CT scan (LDCT). The results were managed by a physician'sassistant dedicated to the LCS program. This quality improvement study analyzed all patients enrolled from June2019 to July 2021. The LCS program rolled out slowly beginning with 6 PCPs in June to November 2019, 26 PCPsfrom November 2019 to February 2020 and all 56 PCPs from February 2020 to July 2021. COVID-19 stopped LDCTsfrom March 2020 to August 2020. Use of a LCS program run through PCP clinics screened 1,247 (21.3%) eligibleveterans, a 3.7 fold increase over the national average. Of the 2,069 (35.3%) eligible patients initially identified by thecomputer based reminder, 1,824 (88.2%) accepted LCS, 1,383 (66.8%) completed the initial LDCT and 136 (9.8%)were ultimately found to be ineligible after completion of the LDCT. The 136 ineligible patients received 173 LDCTs ofwhich 91% were Lung-RADS 1 or 2 and 0.6% were Lung-RADS 4A. Within the appropriately screened patients, 12(1%) lung cancers and 1 papillary thyroid cancer were found and 26.5% of scans showed evidence of Chronic Obstructive Pulmonary Disease and 11.9% showed coronary artery disease. Use of PCP clinics increased enrollment 3.7 fold over national averages.

A Quality Improvement Initiative on sustaining Kangaroo Mother Care Practices During COVID Pandemic

Introduction: COVID-19 pandemic has affected the KMC practices in our SNCU. Lack of clear guidelines and training about continuing KMC in COVID-19 times has further lead to decrease in KMC practices. Method(s): This is a prospective single centered quality improvement study conducted in the inborn unit of a tertiary care hospital. Intervention phase was done in August and September 2020. Preterm mother-infant dyads who were admitted in the inborn Level 2 Neonatal care unit with birth weight less than 2000 grams were enrolled in this study. A QI team comprising of resident doctors, nurses and supporting staff and a lactation counsellor was formed. The potential barriers for prolonged KMC were evaluated using fish bone analysis. A variety of measures were introduced and subsequently tested by seven plan-do-study-act (PDSA) cycles. Data on percentage of initiation of KMC was measured by bedside nurses on daily basis and the data was plotted on run chart every week during implementation phase. Result(s): 116 eligible mother-infant dyads were studied during implementation period (50 days). We achieved our goal by step-wise implementation of changes through multiple PDSA cycles. The percentage of initiation of KMC among eligible preterm infants has increased from baseline of 43.4% to 83.3% and duration of KMC from 1.5 mean hours to 4.5 hours over a period of eight weeks. Conclusion(s): Ongoing quality improvement measures increased the percentage of initiation and duration of KMC among eligible preterm infants without addition of extra man power.Copyright © 2022 by author(s). This is an Open Access article distributed under Creative Commons Attribution License (CC BY NC ).

Implementation of a Home Blood Pressure Monitoring Program for Management of Hypertensive Disorders of Pregnancy, a Quality Improvement Study, in British Columbia, Canada

Background & Purpose: Home blood pressure monitoring (HBPM) in pregnant women is common, but uncertainty exists on utilization of home blood pressure (BP) readings for management of hypertensive disorders of pregnancy (HDP). We conducted a qualitative improvement study to understand how physicians utilize HBPM for pregnant patients and patient acceptability. Method(s): Pregnant patients with risk factors for HDP were recruited. Participants were provided with a validated home BP monitor (Microlife Watch BP) and monitored their BP two times in the morning/evening and manually entered data into a paper diary. Obstetrical Medicine physicians completed written survey after each clinic visit to understand how they used HBPM. Surveys were sent to all participants to assess acceptability of HBPM. Result(s): In total, 103 women were recruited for the study, of which, 43% were enrolled antepartum (mean age 34+/-5 years;mean gestation 171+/-61 days) and 57% postpartum (mean age 35+/-6 years;mean days postpartum 6+/-4 days). Median compliance with home BP readings was 0.94 (IQR 0.57, 1.00). Obstetrical Medicine physicians relied on the range of HBPM readings (70%) to make clinical decisions for management of HDP. Antepartum, 13% of clinic visits resulted in an increase of antihypertensive medications, and 82% required no change in medication. Post-partum, 44% of visits required a decrease anti-hypertensive medication. 98% of participants found HBPM easy to do, and 51% were able to strictly adhere to their measurement schedule. Barriers to HBPM included newborn care (57%), forgetting to check (39%), and lack of time in the mornings (35%). Conclusion(s): HBPM to manage HDP is acceptable to patients and can be safely used to manage HDP ante-partum and post-partum. In light of the COVID-19 pandemic and increasing demand for virtual healthcare visits, further studies are need to assess the effectiveness of HBPM on management of HDP.

IMPACT OF TWICE-DAILY MULTIDISCIPLINARY ROUNDING IN DECREASING TIME TO EXTUBATION FROM MECHANICAL VENTILATION IN THE ICU

SESSION TITLE: Late Breaking Posters in Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Discontinuing mechanical ventilation is a difficult process and takes time. Some patients succeed while others fail and remain on full ventilator support for a longer period. Extubation failure can result in many complications for the patient and a prolonged stay in the ICU. It's a common practice to have an SAT and SBT protocol in the majority of ICUs. Spontaneous awakening trial (SAT) is a nurse-driven protocol for discontinuation of sedation hypnotic drug to facilitate recovery to her baseline level of consciousness/responsiveness and assessment of intrinsic respiratory drive in the critical care setting. In general SAT protocol is followed and most ICUs are in the morning hours. If the patient needs the initial safety screening for SAT the sedative infusion is interrupted with a goal to awaken the patient or SAS 3-4. If the patient is showing signs of SAT failure with either tachypnea or desaturation or cardiac dysrhythmia or unacceptable ventilator asynchrony that the patient is resumed sedation/analgesia at 50% of the previous dose and bolus as needed dose of sedation is also utilized to achieve stability. A spontaneous breathing trial (SBT) is a protocol for systematic weaning of a patient from a mechanical ventilator in preparation for extubation. Before SBT protocol again safety screening is done and if the patient meets the criteria for SBT protocol, the patient is placed on spontaneous breathing mode that his CPAP of 5 to 8 cm of water for 30 to 120 minutes at the same FiO2. Various tools are utilized to analyze the success of the SBT trials including the RSBI index. Each institution has its own assessment of the average length of ventilator stay and the average length of ICU stay. The majority of hospital does SAT/SBT trials once a day for evaluation and successful liberation from ventilator. This project was done with the assumption that if compliance of SAT/SBT huddle is improved and if it is done twice in a day rather than only once the outcome in terms of length of ventilator stay, length of ICU stay, and rate of successful extubation improves METHODS: This is a prospective quality improvement study done at Einstein Medical Center Philadelphia. This is a 16-bed MICU unit and we implemented twice daily hurdle from August 2021 to April 2022. ( Study Period) This project was happening during the COVID pandemic during which the average length of ICU stay and the average length of ventilator stay was already high due to the natural course of COVID ARDS. The SAT/SBT Huddle involved interaction between our respiratory therapist, ICU fellow, and the nurse involved in the patient care. It had a checklist of SAT SBT protocol which needed a signature (electronic or manual) to consider it completed. This was done twice a day from the period of August 2021 to April 2022 (STUDY PERIOD). This study period was compared to the control period (August 2020 to April 2021). The reason for selecting this control period was to remove outlier and increased length of stay due to the COVID pandemic itself with the assumption that the COVID pandemic was present throughout the study and control period. RESULTS: In the control period- ie August 2020 to April 2021 the average ventilator length of stay is 6.85 days. In the study period from August 2021 to April 2022, the average length of a ventilator was 6.21. There is a clear decrease in ventilator length of stay with the intervention and no other change in the sample size. It should be noted that the COVID pandemic with the third surge was happening in both the control and study period. This is approximately a 10% decrease in length of stay. This is a Pilot study and with better compliance with a huddle, the length of stay will decrease further is our assumption. Here the huddle compliance ranged from 60-65% and out estimate is for better power we need at least 70% or more compliance with huddle CONCLUSIONS: Conclusion- This q ality improvement project aims to improve communication amongst healthcare providers with the ultimate goal of patient safety and decreased length of ventilator stay for every patient in MICU. Clearly, the minimal intervention of documenting each huddle and doing it twice a day had a decrease in ventilator length of stay. The greatest challenge for this compliance project is to have documentation of having a twice-daily hurdle. During this period to improve her compliance we have done various methods that included paper signatures electronic signatures and also QR code signatures. Of this, the maximum Complan success rate was achieved with a QR code signature for the huddle members. CLINICAL IMPLICATIONS: Limitation to the study–due to the COVID pandemic the average length of ventilator stay has increased in all hospitals which are affected by the COVID pandemic. Though the reflection of decreased length of ventilator stay is small this gives a glimpse of how her daily communication between a respiratory therapist, nursing staff, and the physician taking care of the patient makes a difference in the patient's overall length of stay and mortality. DISCLOSURES: No relevant relationships by Raminder Cheema No relevant relationships by Megan Dondarski No relevant relationships by Yasmeen Hassan No relevant relationships by Mahwish Hussain No relevant relationships by Myriam Poindijour No relevant relationships by Arnaldo Rodriguez No relevant relationships by Kumar Sarvottam No relevant relationships by Bhavna Sharma No relevant relationships by Teresa Vizak

Method of Instruction Delivery Does Not Affect Quality of Bowel Preparation for Pediatric Colonoscopy

Introduction: Pediatric colonoscopy is a routine procedure used to diagnose and treat gastrointestinal conditions. Effective delivery of bowel preparation (BP) instructions is important to achieve optimal cleanout results and can occur in a variety of methods including in-person, written pamphlet, or video. Inadequate preparation has been shown to increase the duration of colonoscopy, potentially increasing the procedural risk and the inability to complete the procedure, which leads to the need for repeat procedures associated with increased costs, risks, and psychological hardships. Thus, several studies have looked at optimal medication regimens for adequate BP and different delivery methods of BP instructions for adult colonoscopies, finding that more BP education results in greater patient comprehension, thereby improving BP scores. Objective(s): However, there is limited information on which delivery method of BP instruction yields optimal cleanouts, specifically for pediatric patients undergoing colonoscopy. The aim of this quality improvement study was to determine if the quality of BP is affected by the method of instruction delivery. Method(s): Our centre's delivery method of BP instructions had historically been in-person by a physician or nurse case manager (NCM), but in 2019 we developed an online video for families to watch instead. From 2019 to 2021, patients aged 0-18 years and their families received either in-person or video instructions (both along with a written pamphlet to take home) on BP prior to colonoscopy. In 2020, due to the COVID-19 pandemic, patients began receiving instructions over the phone, recorded as 'in-person' along with a mailed-out pamphlet. In March 2020, due to staff shortages, some families were only receiving the written pamphlet, so this third modality of instructions were also included in the study. We excluded inpatient BPs, flexible sigmoidoscopies and repeat colonoscopies. Outpatient BP consisted of pico-salax with dosing based on the patient's weight, the day before the procedure. The Ottawa Bowel Preparation Quality Scale was used to score the BP, with a cut-off score <7 as adequate cleanout at the time of colonoscopy. Patient age, indication for scope, method of delivery and time to procedure were captured. Video and pamphlet only groups were combined into one alternative instruction group due to small numbers for statistical analysis. Primary outcome was the differences in BP scores between the in-person and alternative instruction groups. Result(s): Of the 136 patients (mean age 11.51y (SD 4.53)), 81 (60%) received in-person BP instructions (46 from a physician (62.2%) and 28 from a NCM (37.8%) n=74), 25 (18%) received video instructions, and 30 (22%) received pamphlet only. The median time from BP instruction to the scope procedure was 30 days (IQR 14, 49;range 1-116 days), but only captured prior to onset of COVID pandemic. BP adequacy was achieved in 81.2% of patients (Table 1). There were no significant differences in BP adequacy (76.8% vs. 83.6%, p=0.333) or mean (SD) total BP score between in-person and other (video/pamphlet) methods (5.33 (3.0) vs. 5.33 (2.89), p=0.997), respectively. Age was not a significant predictor for BP scores (p>0.094), but indication for scope did predict total BP score, albeit irrespective of delivery method. Patients who underwent colonoscopy for an indication of IBD had higher total BP scores than those without (M=6.81, SD=2.66 vs. M=5.06, 2.93, p=0.005) and patients who had polyp had lower BP scores than those without (M=2.58, SD=2.07 vs (M=5.59, SD=2.89, p=0.001). Conclusion(s): In conclusion, method of BP instruction delivery for pediatric patients undergoing colonoscopy does not impact quality of BP. Further studies are required to explore the role of parental factors such as education, socioeconomic status, or primary language on BP quality as well as the role of waiting times for endoscopy on the retention of information.

A Quality Improvement Pathway to Promote Health Equity by Increasing Compliance with Diagnostic Testing Following Telemedicine Visits in an Underserved Population

Objective: The primary aim of this quality improvement project focuses on improving compliance with diagnostic testing by 20% over a 6 month period. Background(s): Following the COVID-19 pandemic, there was a rapid upscaling in the use of telehealth. Telehealth is now being used to provide follow up visits in our pediatric gastroenterology fellows clinic, which is comprised of an underserved patient population. Limited access to care has been shown to disproportionately affect underserved populations. Prior to the use of telemedicine, diagnostic testing including blood work was completed or scheduled at the time of visit to promote compliance. With expansion of telemedicine, compliance with diagnostic testing in this patient population became a concern due to limited access and health literacy. Without timely completion of testing and results, there is potential for missed and delayed diagnoses, impeding the ability to treat effectively. Method(s): Prior to initiating intervention, preliminary data was collected including blood work, imaging, and stool studies completed at 2 weeks and by next visit. In PDSA 1, a standardized phrase was created to limit variability amongst providers. Our intervention involved sending Epic patient portal reminder messages within 24 hours of each appointment. In PDSA 2, a second reminder was added 2 weeks post visit. The quality improvement study began August of 2021 and is ongoing. Result(s): Background data was collected for compliance of diagnostic testing at 2 weeks for blood work (33%), imaging (17%), and stool samples (0%). We also collected data on diagnostic testing completed by next visit for blood work (50%), imaging (50%), and stool samples (0%). Post intervention data was then collected over a 6 month period. Our data showed improvement to 50% compliance for completed blood work and 20% compliance for submitted stool samples 2 weeks out from visit. Data showed 100% compliance with blood work and 60% compliance with submitted stool studies prior to next visit, surpassing our goal of 20% improvement in compliance over a 4 month period. Our team also looked at completion of imaging orders, and scheduling of upper endoscopy and colonoscopy procedures prior to next visit. However the numbers were insufficient to draw any meaningful conclusions at this time. Conclusion(s): Our data supports the use of electronic medical record portal messaging systems as a valuable tool for promoting compliance with diagnostic testing in an underserved population following telemedicine visits. This is an opportunity to improve access to care and health equity. Data collection is ongoing for PDSA 2.

LIKELIHOOD OF ENDOSCOPY CANCELLATION BASED ON VANCOMYCINRESISTANT ENTEROCOCCI (VRE) COLONIZATION STATUS AND INFECTION CONTROL PRACTICES

Background: “Terminal cleaning” is a practice of rigorous cleaning of endoscopy suite following endoscopies for patients colonized with vancomycin-resistant enterocci (VRE) with the intention of reducing VRE transmission. Such practice entails double-wiping all surfaces including the floor with disinfectants before a non-VRE patient can use the endoscopy room. While intuitive, such time-consuming practice is not supported by evidence and may have unintended negative impact on patient access to timely endoscopic evaluation. Aims: To determine whether terminal cleaning of endoscopy suite for VRE-colonized patients has any negative impact on inpatient access to timely endoscopic evaluation. Methods: As part of a quality improvement study, inpatient endoscopy data was gathered over a 3-month period between February 2021 and April 2021 at a tertiary centre. EUS, ERCP, and travel cases outside of the endoscopy suite were excluded. The cancellation rates were compared between VRE-colonized patients and non-VRE patients using the Fisher's exact test. P value of <0.05 was considered statistically significant. Results: A total of 262 inpatient endoscopic procedures were scheduled and included in the study. Sixty-six (25.2%) of inpatient procedures were cancelled during this period (Table 1). A total of 24 procedures were scheduled for VRE patients, 9 of which were cancelled because of insufficient operating time and two due to concurrent carbapenamase-producing organism carriage and poor bowel preparation. In the non-VRE group, 55 (23.3%) procedures were cancelled for various reasons (Table 1). In subgroup analysis where cancellations related to COVID-19 (n=14) were omitted, VRE patients had a significantly higher rate of procedure cancellations compared to non-VRE patients (42.3% vs. 18.5%;p<0.01). Conclusions: The overall endoscopy cancellation rate for VRE-colonized patients was higher than those who were non-VRE-colonized. We propose that this is likely secondary to the delays from unnecessary terminal cleans imposed for VRE-colonized patients and await for postintervention data. (Table Presented).

A high-touch outreach model to re-engage patients in mammogram screening

Background: Disparities in cancer screening have been well documented during the Covid-19 pandemic. However, there are limited patient-reported data describing the prevalence and drivers of patient hesitancy towards cancer screening and willingness to resume screening. As health systems continue to experience pandemic-related capacity strain, there is an urgent need for innovative models of re-engaging patients in preventive screening. To address this issue, we developed a medical student-led, high-touch outreach model to re-engage primary care patients at Brookside Community Health Center in cancer screening. Methods: We iteratively optimized semi-structured call scripts and surveys in English and Spanish to contact patients overdue for mammography screening. Student callers included medical and pre-medical students with native Spanish fluency. Using the call script, students identified patient-reported barriers and facilitated mammogram scheduling for consenting patients. For consenting patients, student callers placed a telephone encounter with a pended screening mammogram order in the electronic medical record. PCP confirmation of the order triggered outreach by the radiology department for mammogram scheduling. Patients also received reminder calls from students the week of their appointment. Primary outcomes include screening consent rates, mammogram scheduling and completion rates, and screening results. Patient survey responses were securely recorded using the REDCap survey platform. Results: 198 patients were eligible for the intervention. 60% are primarily Spanish-speaking and 81% are insured by Medicaid. 145 patients (73%) have successfully been contacted, of which 129 (89%) consented for mammogram screening. 74 (57%) of the consenting patients have scheduled their mammogram and 38 (29%) have completed their mammogram. 36% of consenting Spanish-speaking patients with active mammogram orders did not have a mammogram scheduled, compared to 9% of consenting English-speaking. To date, 6 patients had abnormal mammograms requiring subsequent diagnostic imaging, and 1 patient was diagnosed with ductal carcinoma in situ requiring oncologic care. Qualitative analysis of patient surveys found that primary barriers to screening included factors associated with the Covid-19 pandemic (32.9% of contacted patients), lack of awareness of overdue status (25.9%) and patient unavailability (e.g. outside of country) (20%). Conclusions: In this single-center quality improvement study, we found that patients had a high willingness to engage in cancer screening during the pandemic and that trainees can play a vital role in re-engaging patients in preventative care. The disparity between Spanish and English-speaking patients' ability to schedule a mammogram after the consent process suggests that patients with limited English proficiency face additional challenges in accessing screenings.

TELEMED: MEDICAL STUDENT TRAINING IN THE AGE OF TELEMEDICINE

SETTING AND PARTICIPANTS: A quality improvement study was performed through the Weill Cornell Community Clinic's (WCCC) newly formed telemedicine clinic, by administering an online survey designed to evaluate student clinicians' (SCs) comfort and attitudes toward their ability to conduct a virtual care visit. The survey was administered to SCs after the conclusion of a virtual encounter using a confidential online form. Data pertaining to eliciting the medical history, physical exam, and treatment and counseling strategies were collected and analyzed using descriptive statistics. DESCRIPTION: Medical student-run free health clinics represent a unique paradigm in medicine that both provide healthcare services to disadvantaged or uninsured individuals, while also allowing SCs early opportunities to interact with an interdisciplinary care team. Several studies have been published describing the function of student-run free health clinics in various community settings, including the realms of preventative health, acute care, and the management of chronic disease. However, there is a paucity of information related to the provision of healthcare via telemedicine. In the context of the COVID-19 pandemic, WCCC, a medical student-run health clinic in New York City transitioned to a primarily telemedicine-based model. In this study, we sought to describe the experience of SCs in this clinic and assess the strengths and weaknesses of this platform. EVALUATION: A total of 33 SCs were surveyed. On average, SCs spent 38 minutes with patients during each virtual encounter. Compared to in-person encounters, SCs reported spending the same amount of time gathering the patient's history of present illness and past medical history during telemedicine visits. SCs reported spending less time on the physical exam, including measurement of vital signs. A total of 66.7% (n=22) of SCs attempted parts of the physical exam, but only 55% (n=11) of respondents believed the findings they elicited were reliable. SCs cited technological barriers (55%, n=16), environmental factors (17%, n=5) and patient specific factors (17%, n=5) as limiting the physical exam. Online clinical resources were used by 52% (n=15) of SCs, with the majority stating the use of these tools improved diagnostics and the development of a treatment plan. DISCUSSION / REFLECTION / LESSONS LEARNED: In this single student-run free health clinic experience, SCs reported difficulty performing an accurate virtual physical exam but stated access to online clinical resources in real- time is beneficial. Telemedicine is a rapidly evolving platform with tremendous potential to improve healthcare access. Additionally, telemedicine is a valuable complement to in-person clinics, and it is important for SCs to be exposed to the application of telemedicine, as well as its limitations, in serving uninsured patient populations. Future studies can use SCs experiences with telemedicine to improve medical training.

RE-ENGAGING PATIENTS IN BREAST CANCER SCREENING THROUGH A SCALABLE, HIGH-TOUCH CARE MODEL

STATEMENT OF PROBLEM/QUESTION: The COVID-19 pandemic has caused marked declines in cancer screenings and exacerbated preexisting disparities in cancer screening among vulnerable patient populations. DESCRIPTION OF PROGRAM/INTERVENTION: Despite the availability of robust quantitative data reporting disparities in cancer screening during the COVID-19 pandemic, there is a dearth of patient-reported data available describing prevalence and drivers of patient hesitancy towards cancer screening and patient willingness to resume cancer screening. Additionally, as health systems continue to experience pandemic-related bandwidth strain, there is an urgent need to develop innovative models of re-engaging patients in preventive screening that can successfully be implemented in the current healthcare environment. To address this issue, we developed a medical student-led, high- touch outreach model to re-engage primary care patients of the Brookside Community Health Center (BCHC) in cancer screening. We iteratively optimized semi-structured call scripts and surveys in English and Spanish to contact patients overdue for mammography screening. Student callers consisted of medical students and premedical students with native Spanish fluency. Call script language allows students to identify patient-reported barriers and facilitates re-scheduling of mammograms for consenting patients. For consenting patients, student callers input a telephone encounter with a pended screening mammogram order in the electronic medical record;the note is then routed to the patient's PCP for signing. Patients additionally receive reminder calls from students the week of their mammography appointment. MEASURES OF SUCCESS: Primary outcomes include screening consent rates, rates of mammogram scheduling and completion, and screening results. Patient response to survey prompts and student call summaries were securely recorded and analyzed utilizing the REDCap survey platform. FINDINGS TO DATE: 198 patients eligible for the intervention have been identified, of which 60% are primarily Spanish-speaking and 81% are enrolled in MassHealth (MA Medicaid). 145 patients (73%) have successfully been contacted, of which 129 (89%) consented for mammogram screening. 74 (57%) of the consenting patients have scheduled their mammogram, and 38 (29%) have completed their mammogram. Of note, 6 patients had abnormal mammograms requiring subsequent diagnostic imaging, and one patient was diagnosed with ductal carcinoma in situ requiring establishment of oncologic care. A preliminary qualitative analysis of patient surveys has found that primary barriers to screening included factors associated with the COVID-19 pandemic, lack of awareness of overdue status, and patient unavailiability (e.g. temporarily out of the country), and miscommunication between patients and the clinic. KEY LESSONS FOR DISSEMINATION: In this single-center quality improvement study, we found willingness to engage in cancer screening during the pandemic remains high and trainees can play a vital role in mitigating screening disparities during the pandemic.

EXAMINING THE RELATIONSHIP BETWEEN HEALTH LITERACY AND TECHNOLOGY ACCESS AND USAGE IN ADULT INPATIENTS DIAGNOSED WITH TYPE 2 DIABETES MELLITUS

BACKGROUND: Considering the increased reliance on health technology during the COVID-19 Pandemic, Electronic Health (eHealth) interventions have become important for DM self-management (e.g., glucose monitoring). We have previously shown low HL to be a barrier to technology usage in the general inpatient adult population. However, the role of lowHL specifically for DM self-management requires further evaluation. METHODS: This is a sub-analysis of the Hospitalist Study, an observational, ongoing, quality improvement study of adults (age ≥18 years) enrolled from June 2019-March 2021. Patients were eligible for our sub-study if they were English speaking, had a DM diagnosis, and completed the brief health literacy screen. Participants completed questionnaires assessing technology access/use and online capabilities. Descriptive statistics, bivariate chi-squared, and multivariate logistic regression analyses (adjusted for age, race, education, and gender) were performed using STATA version 15.1 (StataCorp). RESULTS: Among 110 participants, the mean age was 61±15 years, most identified as Black (76%) and/or female (51%) and had at least some college education (58%). There were no significant differences in device ownership between low (n=15) and adequate (n=95) HL groups (93% vs. 94%, p=0.96). Those with low vs. adequate HL were less-likely to have previously used the internet (47% vs. 83%, p=0.006) and less-likely to independently use several internet features: use search engine (33% vs. 76% p<0.001), open online attachment (33% vs. 68%, p =0.005), upload images/files to a website (20% vs 54%, p=0.005), print webpages/online information (27% vs. 49%, p=0.04), use a video (47% vs. 72%, p=0.02), and/or use an interactive video (27% vs. 52%, p=0.01). In the multivariate analysis, participants with low HL remained significantly associated with decreased ability to independently perform online tasks (all measures p<0.05). CONCLUSIONS: Our data suggest that low HL may be a barrier to internet access and usage among patients with DM, but not for technology ownership. Future studies are necessary to ensure that at-risk populations can effectively utilize novel eHealth technologies particularly in the rapidly changing landscape of technology use in the clinical setting.

THE IMPACT OF DIGITAL NAVIGATION PATHWAYS ON NO-SHOW RATES FOR PATIENTS UNDERGOING COLONOSCOPY: A QUALITY IMPROVEMENT STUDY

Background: High no-show rates for colonoscopy have been previously associated with poor clinical outcomes, decreased operational efficiency, and diminished utilization of resources. Studies have suggested that addressing barriers like poor health literacy, logistical challenges, and psycho-emotional issues could reduce no-show rates for colonoscopies. Recently, digital navigation tools designed to eliminate such barriers are an emerging trend with promising results leading to better outcomes for patients undergoing colonoscopy. Objective: The goal of this study was to examine the feasibility of an automated, text message-based digital navigation program and determine the impact on no-show rates for patients undergoing colonoscopies. Methods: Rx.Health developed a Digital Navigation Pathway (DNP) that consisted of bowel-prep instructions, appointment reminders, driving instructions, microlearning videos, and educational messaging. Providers at the Gastroenterology (GI) clinic of NYC Health + Hospitals/Lincoln Medical Center prescribed this pathway through RxUniverse, a digital medicine unification platform, to the patients' smartphones. The sample included patients scheduled for colonoscopy between October 2019 to March 2020 (pre-intervention) and October 2020 to March 2021 (post-intervention). Through a year over year analysis, the mean no-show rates and the number of scheduled colonoscopies at the GI clinic were compared between the pre-intervention and post-intervention groups. Furthermore, as a part of the pre/post program implementation analysis, the colonoscopy utilization patterns at the GI clinic were compared. Results: There were 567 colonoscopies scheduled during the pre-intervention period and 381 scheduled colonoscopies in the post-intervention period. The average no-show rate in the pre-intervention group was 27.81 percent compared to 4.46 percent (p<0.00001)* in the post-intervention group, which translated into an 83.9 percent reduction in no-show rates at the GI clinic. Furthermore, this resulted in 23.7 colonoscopies saved per 100 scheduled colonoscopies in the post-intervention group. Conclusion: Patients that were enrolled in the digital navigation program were more likely to show up to their scheduled colonoscopy appointment compared to patients in the preintervention group. Given the pre-/post implementation study design and COVID-19 pandemic that occurred during the intervention period, future cluster randomized controlled trials should be conducted to examine if there is an association between digital navigation programs and no-show rates for patients undergoing colonoscopies. (Figure Presented) Figure 1. Colonoscopy Bowel Preparation Digital Navigation Pathway (Figure Presented) Figure 2. The Effect of DNPs on No-Show Rates during the Pre- and Post-intervention Period (p < 0.00001) *

UTILIZING AN ADVANCED LIVER DISEASE DASHBOARD TO IDENTIFY PATIENTS WITH CIRRHOSIS OVERDUE FOR ESOPHAGEAL VARICES SCREENING: A SINGLE INSTITUTION QUALITY IMPROVEMENT STUDY

Background and Aims: Decompensation events, such as portal hypertensive bleeding, are associated with increased morbidity and mortality among persons living with cirrhosis. Current practice guidelines recommend surveillance for esophageal varices in the setting of clinically significant portal hypertension. The Advanced Liver Disease Dashboard (ALDD) is a national online database developed and maintained by the Department of Veterans Affairs (VA) to facilitate tracking of hepatocellular cancer and esophageal variceal surveillance exams. This online database has potential to optimize workflow through appropriate triage of patients to direct endoscopy or hepatology clinic. The COVID-19 epidemic served as an impetus to utilize a population-based approach to variceal surveillance given delays in access to EGD procedures and limited face-to-face patient encounters. We report the results of our experience at a single VA tertiary care center. Methods: This is a retrospective chart review quality improvement initiative conducted from May 2020 to May 2021 at the San Diego VA Medical Center of patients identified via the ALDD as overdue for esophageal variceal screening. Patients were selected for review by cohort (variceal surveillance/management), platelet filter (none), and category (no EGD (>3Y)). After identifying the study population, patients were managed in three expectant ways: Group 1. Direct EGD referral for esophageal varices screening, Group 2. Direct hepatology clinic referral for further evaluation of diagnosis/ procedure discussion, Group 3. Omit from screening due to age, comorbidities, and/or confirmation of hepatology care at an outside institution. Results: A total of 153 patients were identified during the study period. 11 patients were excluded due to not carrying a cirrhosis diagnosis. 27 patients (19.0%) were directly referred for EGD for esophageal varices screening, 61 patients (43.0%) were directly referred to hepatology clinic for further evaluation of advanced liver disease status and/or discussion of EGD, and 54 patients (38.0%) were omitted from further screening due to age, comorbidities, and/or receiving care with an outside hepatologist. Of the 61 patients referred to hepatology clinic, 12/61 (19.7%) needed to confirm cirrhosis diagnosis. Conclusions: Using an online database of advanced liver disease patients allows for identification of patients overdue for appropriate cirrhosis screening measures and specialist-directed triage to optimize workflow. In the future, the ALDD can be used to improve patient adherence to EGD, increased implementation of pharmacological prophylaxis with non-selective beta blockers in select cases and utilize ALDD review on a recurring basis to minimize missed opportunities for preventive care. (Figure Presented)

IMPACT OF A FELLOW CREATED PRE-VISIT PATIENT QUESTIONNAIRE FOR GASTROENTEROLOGY FELLOWS’ CLINIC

Background Time constraints during ambulatory visits in subspecialty clinics can lead to abbreviated histories and dissatisfaction among fellow trainees. Outpatient gastroenterology (GI) clinic visits can cover a wide range of digestive complaints, thus pre-visit questionnaires (PVQs) are sometimes used to gather information before the start of the visit. The aim of this quality improvement (QI) study was to determine if initiation of a PVQ in our fellows' clinic can increase trainee satisfaction and improve data capture for fellows. Methods The GI fellows at our urban, tertiary care, academic medical center were surveyed to assess their satisfaction with information available pre-visit as well as their habits in obtaining dietary assessment and counseling, query of drug and alcohol use, and screening for mood disorders. The feedback was used to develop a PVQ for patients to complete while waiting to start the visit. The PVQ (Figure 1) was deployed in GI Fellows' clinic between September and November 2021;fellows were resurveyed after 8 weeks. Patient PVQs with one section completed and fellow pre- and post-surveys were included in the analysis using a Fisher exact test and χ2 to determine QI success. Results All 12 fellows completed the preassessment, and 11 completed the post-assessment (one fellow was on leave) as summarized in Table 1. The number of fellows who were unsatisfied with available information before clinic decreased from 7 (58%) to 2 (18%) after the PVQ (p=0.09). Initially, all 12 fellows (100%) never or rarely screened for food insecurity and none knew where to direct food insecure patients, compared to 5 (45%) and 9 (82%) respectively after the intervention (p= 0.005 and p=<0.001). Utilizing food recall increased (58% to 81%). Assessment of mood disorders increased (42% to 91%;p=0.03), and assessment of tobacco, marijuana and alcohol also increased (50%, 42%, and 58% respectively to 91%, 73%, and 100%). A total of 239 patients were seen in fellows' clinic and 144 (60%) PVQs were reviewed. The average patient age was 52 years old and 41% identified as male. 89% filled out the English PVQ. Using the Hunger vital sign for food insecurity, 17 persons (12%) screened positive and could be referred for social services. 76% completed part of the 24-hour food recall section. Alcohol, tobacco, and marijuana use were noted among 32%, 30% and 17% of respondents, respectively. 78% of respondents were vaccinated for COVID-19. PHQ2 and GAD2 scores were on average 1.3 and 1.5, respectively. Conclusions A fellow created PVQ can increase fellow satisfaction as well as create actionable opportunities to improve patient care, specifically around food insecurity. As a fellow driven entity, the PVQ can be refined with fellow feedback. We plan to continue using the PVQ in fellows' clinic and offer it for faculty clinic as well. (Figure Presented)Figure 1: Two-sided pre-visit questionnaire with sides in English and in Spanish (Table Presented)

QUALITY IMPROVEMENT STUDIES ARE FEASIBLE IN AUSTERE PERIODS OF RESOURCE ALLOCATION SUCH AS THE COVID-19 PANDEMIC: IMPLEMENTATION OF A NOVEL AGGRESSIVE POSTOPERATIVE AMBULATION PROTOCOL

Purpose/Background: Quality improvement (QI) and enhanced recovery after surgery (ERAS) protocols are effective in reducing length of stay and complications after colorectal surgery. The COVID-19 pandemic's strain on hospital personnel and resources called into question the feasibility of implementation of QI studies. Hypothesis/Aim: We aimed to successfully implement of a novel, structured postoperative ambulation protocol in colorectal surgery patients and determine its effect on patient outcomes in a time of strained personnel. Methods/Interventions: This prospective non-randomized study included all patient who underwent elective inpatient abdominal colorectal procedures at a single quaternary care center. All patients were already undergoing a standard ERAS protocol at baseline. A structured, aggressive postoperative ambulation protocol was developed. An erasable poster (Figure) was placed in patient rooms which allowed the nursing staff and patient to track progress towards specific ambulation goals. The protocol measured specific metrics such as out-of-bed to chair and the number and extent of daily ambulation relative to postoperative day. The protocol was initiated on post-operative day 0, and increased in duration and distance daily. Nursing staff was educated on the protocol prior to initiation and a standard process was created to outline the documentation requirements. The primary outcome measured was hospital length of stay. Secondary outcomes were return of bowel function, 30-day postoperative DVT/PE rate, and 30-day readmission rate. A change in these outcomes metrics over time compared to historical controls was noted. Results/Outcome(s): The protocol was implemented in February 2020, with improvements in outcomes beginning in July 2020 following extensive re-education for nursing staff. Adherence to the post-operative ambulation regimen increased from 36% at baseline to 75%. This was associated with an improvement in postoperative return of bowel function (2.13 days vs 1.44 days), post-operative length of stay (6.36 days vs 3.33 days), postop VTE/PE rates (1.64% vs 0%) and readmission rate (6.56% vs 0%) over a period of 12 months. Limitations: The outcomes of this study may have been influenced by other uncontrolled measures during the COVID crisis but most if not all led to decreased personnel and resources making success of such a project difficult. A standard ERAS protocol was in place with good compliance (>95%) for over 2 years prior to the initiation of this study. Conclusions/Discussion: A novel, structured, aggressive early postoperative ambulation protocol is feasible during times of strained personnel resources such as the COVID-19 pandemic, and leads to improvement in postoperative outcomes such as postoperative length of hospital stay, return of bowel function, VTE/PE rates, and postoperative ambulation without an increase in the readmission rate.

PATIENT PERCEPTIONS ON TRANSITION FROM CLINIC-BASED INFUSIONS TO HOME-BASED INFUSIONS FOR INFLAMMATORY BOWEL DISEASE PATIENTS DURING THE COVID-19 PANDEMIC: A QUALITATIVE QUALITY IMPROVEMENT STUDY

Background: Biologic therapy represents the mainstay of treatment for moderate-to-severeinflammatory bowel disease (IBD). Payer-mandated migration of clinic-based infusions (CBI)to home-based infusions (H-BI) has been implemented as a cost-containment strategy,but evaluations of the clinical and economic impact of this policy are limited. In responseto the COVID-19 pandemic, the CDC issued a guidance advising patients and providers toadopt social distancing practices such as H-BI strategies. This study aimed to explore patientperceptions associated with the sudden transition to H-BI during the COVID-19 pandemic.Methods: Using a qualitative approach, semi-structured interviews were conducted amonga sample of IBD patients at a tertiary care center who transitioned to home-based infliximabor vedolizumab infusions between March to July 2020. Interviews were audio recorded andtranscribed. Transcripts were analyzed using thematic analysis, including independent codingby two members of the research team. Codes were grouped into categories and categorieswere related to one another to develop themes. Themes were reviewed by team membersto ensure that the data was adequately reflected. Demographic and safety data were extractedby chart review.Results: Of the 59 IBD patients who acutely transitioned to H-BI, 20 patients (33%)responded. Table 1 provides demographic characteristics of the participants. Inductivethematic analysis revealed three major themes. (1) Patients’ initial reactions to H-BI transitionwere a mixture of both excitement and concern;however, after the transition, the majorityof participants were pleased with H-BI and stated that they would continue H-BI even afterthe COVID-19 pandemic (only 3 participants returned to C-BI). (2) Participants identifiedbenefits related to logistic factors such as the convenience of being at home, reduced travel,and 1:1 patient to nursing ratios. (3) Participants identified concern with H-BI related to acombination of logistical factors (scheduling, communication between nursing and pharmacystaff, access to blood draws, and ability obtain vascular access) as well as emotional factors(perceived nursing quality, and anxiety around lack of access to rescue medications andphysicians, as well as having strangers in their house). Overall, no major adverse eventsoccurred during the study period and no patients acquired COVID-19 (Table 2).Discussion: Home-based infusions appear to be a safe alternative to clinic-based infusionsduring the COVID-19 pandemic. While participant initial perceptions regarding home-basedinfusions were mixed, overall participants had a positive experience with many participantsplanning to continue after the pandemic. Several areas of weakness (largely logistical) wereidentified to improve patient satisfaction in future infusion transitions.(Table Presented)Table 1: Patient Demographic Characteristics(Table Presented)Table 2: Patient Outcomes

Improving Feedback for Hematology and Oncology Fellows Via Virtual Workshops: Sustainability Analysis

Background Effective feedback is an important tool in medical education for the learning and growth of trainees and for faculty development. It allows learners to remain on course in reaching competence in clinical, research, and interpersonal skills, yet the impact of teaching feedback during hematology-oncology training has not been studied in depth. To tackle the lack of effective constructive feedback within our hematology oncology fellowship program, we initiated a quality improvement (QI) project to identify barriers in delivering and receiving high-quality feedback in the program and to create a curriculum aimed at teaching fellows and faculty how to engage in more effective feedback conversations. In the initial phase of the pilot study, a pre-intervention survey identified the two main barriers for effective feedback in our program as discomfort in giving feedback and lack of protected time. A virtual workshop improved quality of feedback by addressing these barriers and providing tools necessary to give and receive constructive feedback. We aimed to highlight the sustainability of these interventions. Methods Utilizing the results of the pre-intervention survey, we built three 2-hour interactive virtual workshop sessions conducted through the ASCO Quality Training Program. Skills that were emphasized and practiced included appropriate set-up, low-inference observations, dialogic feedback conversations and a structured approach to reinforcing and modifying feedback. A follow up session was conducted three months later allowing for reinforcement of the skills. Post-intervention surveys were given immediately after the initial workshop and after the follow-up session. All surveys were identical employing Likert scale and open-ended questions. Weekly email reminders for protected feedback time were also set up. This project was developed through the ASH Medical Educators Institute. Results Eleven out of 15 attendees completed each of the questionnaires. At baseline, 81.8 % of the participants reported they do not have protected time to complete evaluations. This decreased to 63.6% immediately post-intervention and to 27.3% at the three-month point. Similarly, only 65.5% of the participants reported they were comfortable giving feedback prior to the workshop, increasing to 81.8% immediately after the intervention and was sustained at 81.8% at three months. Half of the participants reported that the feedback was not actionable in the initial questionnaire, decreasing to 10% post-intervention. Majority of the participants agreed that the workshop helped address barriers for effective feedback in our program. Conclusions This study showed the sustainability of positive changes, even during the COVID-19 pandemic, for giving and receiving quality feedback implemented in our fellowship program. Its outcomes are salient given that it utilizes a simple intervention that could be expanded to other training programs as feedback is a systemic problem in medicine. It also underscores the importance of formal workshops in overcoming barriers for effective feedback. Limitations of this QI study include the small sample size and single-institutional design. Our future goals include incorporating a formal yearly curriculum assigning weekly protected time for feedback to ensure these results are sustainable and reproducible with incoming fellows. Disclosures: No relevant conflicts of interest to declare.