Improving Inpatient Tobacco Treatment Measures: Outcomes Through Standardized Treatment, Care Coordination, and Electronic Health Record Optimization.

INTRODUCTION: The Centers for Disease Control and Prevention states that tobacco use is the largest and most preventable cause of disease and mortality in the United States. The Joint Commission implemented inpatient tobacco treatment measures (TTMs) in 2012 to encourage healthcare systems to create processes that help patients quit tobacco use through evidence-based care. METHODS: A tobacco cessation care delivery system was implemented at James A. Haley Veterans' Hospital and Clinics, which included: standardized pathways within the Veterans Health Administration (VHA) electronic health record system to improve nicotine replacement therapy ordering; evidence-based tobacco cessation counseling; and improved care coordination for tobacco cessation treatment through the use of technological innovation. RESULTS: Outcomes were obtained from the VHA quality metric reporting system known as Strategic Analytics for Improvement and Learning (SAIL). TOB-2 and TOB-3 (two Joint Commission inpatient TTMs) equivalent to tob20 and tob40 within SAIL improved by greater than 300% after implementation at James A. Haley Veterans' Hospital and Clinics. CONCLUSION: Implementation of a tobacco cessation care system at James A. Haley Veterans' Hospital and Clinics enhanced interdisciplinary coordination of tobacco cessation care and resulted in improvements of The Joint Commission inpatient TTMs by greater than threefold.

Improving Unadjusted and Adjusted Mortality With an Early Warning Sepsis System in the Emergency Department and Inpatient Wards.

BACKGROUND: Mortality reduction has been a major focus of improvement for health care systems. Although several studies have noted improved sepsis-related mortality with the use of electronic health record (EHR) systems, there are no known published early warning sepsis systems using the Veterans Health Administration (VHA) EHR system. METHODS: The Malcom Randall Veterans Affairs Medical Center (MRVAMC), a large academic 1a VHA facility within the North Florida/South Georgia Veterans Health System (NF/SGVHS), was identified as having opportunities for improvement related to inpatient mortality outcomes. Sepsis was discovered as the primary contributor to inpatient mortality for MRVAMC's acute level of care (LOC). Education along with implementation of an early warning sepsis system (EWSS) was subsequently integrated in the VHA EHR known as the Veterans Information Systems and Technology Architecture/ Computerized Patient Record System (VistA/CPRS) at NF/SGVHS, which applied a combination of informatics solutions within a Lean Six Sigma quality improvement framework. RESULTS: At MRVAMC, there was an observed decrease in the number of inpatient deaths for the acute LOC from a high of 48 in fiscal year (FY) 2017, quarter 3 to a low of 27 in FY 2019, quarter 4. This resulted in as large of an improvement as a 44% reduction in unadjusted mortality with education and implementation of an EWSS from FYs 2017 to 2019. Additionally, the MRVAMC acute LOC risk-adjusted mortality (standardized mortality ratio) improved from > 1.0 to < 1.0, demonstrating fewer inpatient mortalities than predicted from FYs 2017 to 2019. CONCLUSIONS: Education along with the possible implementation of an EWSS within the VHA EHR was associated with improvement in unadjusted and adjusted inpatient mortality at MRVAMC. This may be an effective approach for patients with sepsis.

Template Design and Analysis: Integrating Informatics Solutions to Improve Clinical Documentation.

BACKGROUND: Electronic health record templates have served a variety of functions, such as improving documentation for reliable reporting of health care outcomes. Standardizing template documentation has been important for accurately capturing case workload and supporting quality improvement initiatives. METHODS: North Florida/South Georgia Veterans Health System consists of 2 Florida-based hospitals: Malcom Randall Veterans Affairs Medical Center (MRVAMC) in Gainesville, and Lake City Veterans Affairs Medical Center (LCVAMC). In the first quarter of fiscal year 2017, MRVAMC and LCVAMC had a below-average case severity index (CSI) of 0.76 and 0.81, respectively, compared with that of the 0.96 national average for the Veterans Health Administration (VHA). An innovative history and physical template design with embedded informatics tools was created to improve clinical documentation. RESULTS: Compliance with standardized history and physical medicine template use was monitored for about 1 year after standardized template implementation. Compliance improved from 43.2% in June 2018 to 89.9% in June 2019 at MRVAMC and increased from 48.2% in June 2018 to 96.9% in June 2019 at LCVAMC. CSI improved to 0.97 at MRVAMC and 1.07 at LCVAMC in the first quarter of fiscal year 2019, which exceeded the VHA national average of 0.89 during the same period. CONCLUSIONS: NF/SGVHS integrated informatics solutions within template design was associated with an increase in CSI via improved clinical documentation.

Advancing Order Set Design.

Order set design using evidence-based medicine, quality improvement techniques, and standardization increases the likelihood of provider order set adherence and potentially better patient outcomes.

Inflammatory myofibroblastic tumor of the midesophagus.

An inflammatory myofibroblastic tumor (IMFT) is a rare entity that can arise in a multiplicity of organs including the lung, liver, and at any location within the gastrointestinal tract. Typically, an IMFT presents as a localized mass with clinical symptoms dependent upon its site of origin. IMFTs pathologically resemble a neoplastic process but are theorized to arise from an unknown inflammatory event. We present a case of a midesophageal IMFT in a 12-year-old female.