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Poster Day 2021: Abstracts: Clinical & Quality Improvement

QI 101: Risk Factors for Community Acquired Pediatric Urinary Tract Infection with Extended-Spectrum-β-lactamase E. coli: A Case-Control Study

Authors:

Joshua D. Collingwood, B.S., Lingling Wang, M.S., Inmaculada B. Aban, Ph.D., April H. Yarbrough, Pharm.D., BCPS, Suresh B. Boppana, M.D., Pankaj P. Dangle, M.D.

Background: Community-acquired (CA) infections caused by extended-spectrum beta-lactamase-producing gram-negative bacilli (ESBL-GNB) have become increasingly prevalent, posing a serious threat to public health. Risk factors for ESBL-GNB urinary tract infections (UTI) have not been extensively studied in the pediatric population. We report findings from a case control study to identify risk factors for CA ESBL-GNB UTI in children.
Results:

The cohort included 392 children with CA E. coli UTI (98 children with ESBL UTI and 294 with non-ESBL UTI). The median age was 11.78 months (0.1-94.63) and 82% were female. Logistic regression identified male sex (OR: 2.53; 95% CI: 1.43, 4.50; P=0.002), hydronephrosis (OR: 2.66; 95% CI: 1.34, 5.26; P=0.005), vesicoureteral reflux (VUR) (OR: 2; 95% CI: 1.04, 3.84; P=0.037), and prior Urology care (OR: 4.17; 95% CI: 2.23, 7.80; P<.001) as significant risk factors for ESBL E. coli UTI. Children with an underlying renal abnormality (OR: 1.79; 95% CI: 1.05, 3.05; P=0.033), history of previous hospitalization (OR: 3.26; 95% CI: 1.95, 5.46; P<0.001) or intensive care unit (ICU) admission (OR: 3.74; 95% CI: 1.64, 8.57; P=0.002), as well as have been hospitalized (OR: 3.41; 95% CI: 1.86, 6.26; P<0.001), underwent surgery (OR: 3.49; 95% CI: 1.44, 8.47; P=0.006), or received antibiotics (OR: 4.37; 95% CI: 2.16, 8.81; P<0.001) within 30 days prior to positive culture were more likely to have ESBL UTI.

Conclusion:

Findings from our case-control study suggest that the male sex, history of Urology care, and previous antibiotic exposure are independent risk factors for CA ESBL-GNB UTI.

QI 102: An Effort to Reduce Length of Hospital Stay: A Quality Improvement Project

Authors:

Gulzar Q; Zafar T; Liaqat A; Gregory G; Dahale D; Skandhan A; and Nallamothu R.

Background:

Average length of stay (ALOS) can have profound effects on hospital capacity and the ability to manage acute healthcare care needs of the community. An increased ALOS (influenced by clinical and non-clinical factors) may also has have potential negative effects on patient quality of care outcomes (e.g. incidence of hospital-acquired infections, adverse medication events, patient financial burden) as well as hospital profit.

Objective: We did a study to assess the impact on ALOS and the associated quality and efficacy of care delivered to patients by implementing an intervention in the form of a daily multidisciplinary team (comprised of clinical and administrative leaders) meetings.
Methods:

The study focused on patients admitted to a tertiary care community hospital during the time-period of January 2020 to September 2021. A number of PDSA (Plan – Do – Study – Act) cycles of tests of change were conducted to fine-tune the daily multidisciplinary team meeting initiative aimed at removing patient care barriers and enabling safe and effective discharge. We used statistical process control (SPC) charts to evaluate changes in ALOS throughout this time, and applied SPC rules to determine statistical significance.

Results:

From January to September 2020, the hospital ALOS decreased from a baseline of 4.8 days to 4.4 days (8.3% relative reduction).

Conclusion: This finding suggests that interdisciplinary team meetings can have a significant impact on ALOS. This may also lead to improved outcomes in quality and safety of inpatient care, as well as post discharge outcomes, while effectively managing hospital resources.

QI 103: Optimizing Guideline Directed Medical Therapy for Patients with Heart Failure with Reduced Ejection Fraction in Souh Alabama: A Quality Improvement Project

Authors:

Veronica Hill; and Madalyn Acker

Background:

Guidelines from the American College of Cardiology and the American Heart Association (ACC/AHA) specify the pharmacological management of patients with heart failure with reduced ejection fraction (HFrEF). Many heart failure registries show suboptimal use of recommended medications in clinical practice, especially in rural communities. Without novel approaches to improve prescribing and guideline adherence, the benefits of HFrEF treatments will be unrealized. The purpose of this project is to increase the adherence rate of adult patients with HF to existing guidelines by implementing the ACC/AHA HF practice guidelines for HFrEF in a rural health clinic in south Alabama.

Design: A team of nurse practitioners and osteopathic medical students contacted the project participants via telephone to adjust their beta blockers and/or renin angiotensin system blockers to the treatment algorithm. The medications were titrated biweekly, and surveillance of blood pressure, pulse, and symptoms were conducted every Monday, Wednesday, and Friday. Outcomes measured included percent of participants optimized to guideline directed therapies and overall health status.
Results:

16 patients with HFrEF were offered optimization of beta blockers and/or ACE-I/ARB/ARNIs, 7 of the 16 agreed to participate, and 5 of the 7 completed the project. 5 of 5 patients were both optimized to guideline directed therapies for both beta blockers and ACE-I/ARB/ARNIs and showed an improvement in their overall health status as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ).

Conclusion:

This supports the use of multidisciplinary teams to attain greater adherence to evidence-based pharmacological management in patients with HFrEF living in rural areas.

QI 104: Increasing Pediatric Urinary Tract Infections by Extended Spectrum-β-lactamase Producing Bacteria: Cause for Concern

Authors:

Joshua D. Collingwood, B.S., April H. Yarbrough, Pharm. D., BCPS, Suresh B. Boppana, M.D., Pankaj P. Dangle, M.D.

Background:

Antimicrobial resistance and emerging extended-spectrum-β-lactamase (ESBL) infections is a rising concern in public health, limiting therapeutic options. We assessed the trend in ESBL UTI’s at a tertiary pediatric hospital and antimicrobial resistance patterns associated with it over the past 5 years.

Methods: After IRB approval, 168 pediatric urine cultures (2015-2020) positive for ESBL E. coli were reviewed; annual percent change and total percent change in number of ESBL E. coli UTI cases were analyzed. Resistance patterns were assessed for all ESBL E. coli isolates during the study period. 
Results:

A total of 168 urine samples collected from 135 children (77, 57% males) with a median age of 82.6 ± 74.7 months. There was a marked increase in pediatric ESBL E. coli urinary tract infections by 512% over 5 years with an average percent increase of 53% each year at our hospital.

Antibiotic resistance patterns were assessed; 106 (59%) of isolates demonstrated resistance to Ciprofloxacin, 63 (35.2%) resistant to Gentamicin, 64 (35.8%) resistant to Tobramycin, 113 (63.13%) resistant to Trimethoprim Sulfamethoxazole, and 28 (15.64%) resistant to Nitrofurantoin. All ESBL E. coli isolates remained susceptible to Meropenem over 5 years.

Conclusion:

These findings demonstrate an alarming increase in ESBL urinary tract infections in children. We also observed that a majority of isolates were resistant to at least 3 different classes of antibiotics. As ESBL UTI infections are associated with prolonged hospitalization and increased morbidity, our findings highlight the challenges in the management of the children with ESBL UTI.

QI 105: Quality Improvement and Implementation in the Rural Health Setting: Detecting Lung Cancer with LDCT

Authors:

Jonathan Carbungco, M.S., OMS-IV; Brittany Woody, M.S.; Britni Smith, D.O.; Veronica Hill, M.S.N.; Robin Fischer, D.N.P.; Justin Hovey, M.D.

Background:

In 2017, lung and bronchus cancers represented the highest incidence of cancer related deaths in the United States. In 2013, the U.S. Preventative Services Task Force (USPSTF) issued a Grade B recommendation, advising all patients between age 55 and 80 years with a 30-pack-year or greater smoking history who have smoked in the last 15 years should receive an annual Low Dose CT (LDCT) scan. The goal of LDCT is to identify malignancy early to improve prognosis and treatment efficacy. 

Design:

The Alabama College of Osteopathic Medicine (ACOM) Ashford Clinic developed and implemented a quality improvement study to systematically improve the identification of individuals in its patient population meeting the 2013 USPSTF criteria for LDCT and to develop a method of capturing, educating, and screening them for lung cancer. Using a generated report from the electronic medical record and phone calls, patients eligible for LDCTs were identified. A shared decision making document from the Agency of Healthcare Research and Quality, published in 2016, was given to providers before seeing these patients. The document includes a clinician’s checklist for steps to be taken before, during, and after patient encounters. This included discussion points to educate patients on the risks, benefits, and importance of annual LDCT screenings.

Results:

The changes implemented during this study were seen to have significantly increased the clinic’s compliance with the USPSTF lung cancer screening guidelines.

Conclusion:

Improving a provider’s awareness of LDCT guidelines and providing a tangible document to share with patients improved the rate of compliance.

QI 106: Analysis of Trends and Clinical Challenges in Baclofen-Related Brain Death Mimicry

Authors:

Guo Qian and Starla Meighan, PhD.

Background:

Brain death is a clinical diagnosis made in the absence of drug intoxication that determines irreversible cessation of all functions of the entire brain, including the brainstem. Brain death mimicry occurs when clinical examination results in a brain death diagnosis; however, unrecognized alternative diagnoses or confounders like drug intoxication have not been eliminated. The second most common cause of brain death mimicry is the prescription skeletal muscle relaxant baclofen. The purpose of this project was to analyze baclofen use trends and clinical challenges regarding baclofen-related brain death mimicry.

Design:

A PubMed literature search and epidemiological statistics through the Annual Reports of the American Association of Poison Control Center’s National Poison Data System (NPDS) between 2012-2019 was conducted. Furthermore, a survey of United States physicians about brain death awareness and training was conducted.

Results:

The NPDS reported an increase in baclofen overdose calls to nationwide poison control centers from 144 to 5,347 between 2013 and 2019, respectively. During this period, there was an increase in off-label use of prescribed baclofen to treat alcohol-dependence syndrome. Malfunctioning intrathecal pump or polydrug administration may cause unintentional overdose. Additionally, recent studies indicate five half-lives may be insufficient for estimating complete clearance of baclofen from the central nervous system (CNS). Physician survey data is pending.

Conclusion:

The results show an increase in baclofen prescriptions and overdoses and highlight challenges in detection that lead to brain death mimicry. Longer supportive times for CNS clearance, comprehensive review of baclofen use history, and increasing awareness may decrease baclofen-related brain death mimics.

QI 107: Inpatient Naloxone Administration at Southeast Health from 2019 to 2020

Authors:

Parker, Wayne; Hobbs, Caitlin; Le, Samantha; Beery-Matthews, Rachel

Background:

Opioid overdose events may present with sedation and respiratory depression. Naloxone is an opioid reversal agent indicated for use in both inpatient and outpatient settings. The aim of this study was to identify and evaluate trends between sedation and naloxone administration in an inpatient setting.

Design:

Data was collected from 2019 and 2020 at the Southeast Health Hospital. Entries were categorized as confirmed, possible, not opioid overdose-related, and outpatient administrations. Entries were then categorized into post-surgical and inpatient procedural events.

Results:

108 entries were analyzed from 2019 and 2020. In 2019, 85.9% patients received naloxone while inpatient in 2019 and 75.0% in 2020. 

In 2019, the average age was 62.8. Around 68.8% of patients were female and 73.4% identified as White. Overall, 41.8% patients experienced a confirmed oversedation event, 45.5% had a possible oversedation event and 12.7% did not improve. In patients who received inpatient naloxone, 23.6% occurred post surgery or during a procedure which required anesthesia.

In 2020, the average age was 60.8. 68.2% of patients were female and 63.6% identified as White. 48.5% of patients experienced a confirmed oversedation event, 45.5% possible oversedation, and 6% had no response to naloxone use. 24.2% of these events occurred post surgery or during a procedure which required anesthesia.

Conclusion:

In conclusion, approximately half of patients administered naloxone inpatient experienced a confirmed oversedation event.  Our study highlights the importance of understanding inpatient naloxone administration and oversedation. 

QI 108: AMPLIFI: Subjective vs Objective Measures of Functional Decline

Authors:

Emily McCoy MS, Maria Pisu Ph.D., and Bob Oster Ph.D.

Background:

Compared to others of the same age, cancer survivors face accelerated functional decline, (FD) i.e., limitations in performing self-care activities because of decreasing physical functioning.

FD objective measures may be unavailable, but subjective measures can be used if they correlate to objective measures. FD is correlated with gait speed, whether it correlates with other physical functioning is less understood.

The objective is to better understand how subjective measures of FD correlate with objective measures.

Design:

Participants recruited to The AiM Plan and act on LIFestYles: AMPLIFY Survivor Health, a randomized clinical trial, were age 50 or older and at least one year post diagnosis of breast, prostate, kidney, myeloma or endometrial cancer. At screening, participants completed 10 items of the 36-Item Short Form Survey, (e.g., how does your health limit you in vigorous or moderate activities). FD was scored from 0-100, with 100 being no limitations. Participants completed a baseline assessment where objective measure were recorded using the 8-foot walk (seconds), the 2 min step test (steps), and the 8-foot get up and go (seconds).

Results:

Significant relationship between functional decline and 8-foot walk (r=-0.44, p=0.001), 8-foot get up and go (r=-0.48, p<0.001), and 2-min step test (r=0.27, p=0.0289). An increase in functional decline was associated with a decrease in 8-foot get up and go speed, 8-foot walk speed, and an increase in 2-minute step test.

Conclusion:

This study suggests self-reported limitations correlate to objective findings; self-reported questionnaires can be used when objective findings are unavailable.

QI 109: Consideration of the Impact of Statins on Atrial Fibrillation

Authors:

Audrey Flower; and Tudor Scridon, MD

Background:

Atrial fibrillation (AF) is responsible for approximately 1 in 7 cerebrovascular accidents (CVAs), otherwise known as strokes. Pathologies responsible for CVAs, including AF, have evidenced ties to inflammation and AF further contributes to stroke risk by creating stasis of blood within the left atrium, allowing time for emboli to form. While the latter is difficult to modify, inflammation is a modifiable risk factor that we chose to investigate through the observed use of statins. Statins are commonly prescribed for lowering inflammation and atherosclerosis-producing lipids.

Design:

We used AF burden, defined as time spent in AF (minutes of AF per month), to measure potential proportional CVA risk. Patients taking antiarrhythmics were excluded from the study to avoid the potential of a major confounding factor. Patients with permanent AF were also excluded due to the unremitting, non-modifiable nature of their AF burden.

Results:

Upon reviewing electronic medical records (EMRs) from forty-six (n = 46) patients matching these criteria, the 19 patients on statins showed an average AF burden of 133.53 minutes (p < 0.047), while the patients not on statins yielded an average of 55.33 minutes (p < 0.047) spent in AF per month. Five patients were evidenced to be progressing towards persistent and/or permanent AF and were preserved within the study, though excluded from the final analysis.

Conclusion:

Overall, the results of the study showed a positive association between the use of statins and the amount of time spent in AF, approximating a greater CVA risk.

QI 110: #TopDocs: The Top 50 Instagram Physician Influencers

Authors:

Jordan H. Jay, B.S.; Franz Vergara, DNP, PhD, RN; Audrey A.Vasauskas, PhD; and Matthew Hanserd, MD

Background:

Social media has a profound impact on various aspects of life, including medical practices. Instagram has grown to be one of the most widely used forms of social media. This study identifies the Top 50 Instagram accounts belonging to U.S. physicians. We hypothesized that the prototypical account would belong to a board-certified plastic surgeon who publishes primarily practice centered content (patient testimonials, procedural results). 

Methods:

Heepsy’s Instagram influencer search engine was utilized on August 3, 2021. We composed our list of 50 accounts based on the number of followers. The Pearson correlation and Chi-square were used to analyze each account holder’s demographics.

Results:

Of the top accounts, 40% were plastic surgeons and 22% were internal medicine doctors. 42% published predominantly practice centered content. Accounts with 300k-499k and 100k-299k followers produced significantly (p<.01) more educational content. 54% lived in the western United States. 24% were female. 10% were not board-certified. 4% of physicians practice a specialty that they were not formally trained in. The number of Instagram followers positively correlated (p<.01) with the number of likes, comments, follower engagement and subscribers on Facebook, YouTube and Twitter. The number of female Instagram followers negatively correlated (p<.01) with the number of Facebook followers.

Conclusion:

Plastic surgery was the most represented specialty. Interestingly, the top two accounts were held by influencers who were not plastic surgeons (dermatology, family medicine). Five influencers were not board-certified and two of them were not trained in the specialty they practiced. Physicians predominantly posted practice centered content.

QI 111: Obstructive Sleep Apnea

Authors:

William C. Grant, OMS-III; Maria Kewish, M.D.; Erica M. Roman, M.D.; Amith Skandhan, M.D.; and James Robeson Jr., M.D.

Background:

Obstructive sleep apnea is known as the silent killer for it can significantly impact the quality of life as well as exacerbate co-morbidities such as heart failure, cardiac arrhythmias, and hypertension. Untreated obstructive sleep apnea negatively impacts patient outcomes and places a strain on healthcare resources. The goal of this study is to properly screen for patients with potential obstructive sleep apnea in the clinic and confirm via a sleep study in order to direct resources and care where they are most needed.

Design:

Patients will be properly screened for obstructive sleep apnea using the STOP-BANG questionnaire in the primary care setting. Following identification, the patient will be fitted for a positive airway pressure device and the selected population will be monitored for progression of obstructive sleep apnea as well as the impact of obstructive sleep apnea treatment on co-morbid conditions.

Results:

In the 2020 plan year, there were 4,097 patients diagnosed with OSA in the Statera Network in the period of 7/1/2018 through 12/31/2020. This equates to 17.44% of the target patient population and a total increase of 742 (22.12%) members of the Statera Network that were positively identified and subsequently treated. This is a significant improvement when compared to the 2019 data, which showed a 14.98% of patients were identified and treated.

Conclusion:

Patients with undiagnosed obstructive sleep apnea constitute a significant portion of our population. There is considerable benefit in patient outcomes and healthcare costs if we are able to properly identify, manage, and treat these patients.

QI 112: Breast Cancer Screening Initiative in Medicare Patients

Authors:

Erica M. Román, MD; Sasha-Kay D’Aguilar, MD; Maria Kewish, MD; and Amith Skandhan, MD

Background:

Breast cancer incidence peaks in females within the age group of 70-74 years. Early detection of breast cancer in the elderly population allows for better patient outcomes and overall improvement in survival. This project aims to compare a three-year progression of providers within the Wiregrass area with respect to the implementation of routine breast cancer screening in the Medicare population.

Design:

Timeline: January 2021 to August 12, 2021

Inclusion criteria: Women ages 50-74 with screening mammogram performed 27 months prior to the end of the measurement period, with acceptable documentation of results. Exclusion criterion included but were not limited to bilateral mastectomy and age 66 and older in Institutional Special Needs Plans (SNP) or residing in long-term care for more than 90 days.

Methodology: Analyzed satisfaction rates, data on total number of patients in a given year and total number of patients that satisfied criteria.

Results:

Total number of patients analyzed were 3,030, of which 1927 satisfied the measure. Satisfaction rate was 63.6% in 2021. When compared to 2019 and 2020, satisfaction rate was lower than both years. The breast cancer satisfaction was higher in 2020.

Conclusion:

Based on the data provided in this study we are able to identify a significant gap in care in the Wiregrass area concerning primary prevention of breast cancer. This will pave the way for future investigations focused on assessing these barriers and improving routine breast cancer screening in the Medicare population amongst local providers.

QI 113: Avoiding Unnecessary EKG Testing for Low-Risk Asymptomatic Patients

Authors:

William C. Grant, OMS-III; Devam Parghi, M.D.; Erica M. Roman, M.D.; Amith Skandhan, M.D.; and James Robeson Jr., M.D.

Background:

A common screening modality amongst primary care providers is performing routine EKGs on their patients in order to assess for underlying coronary heart disease. The 2011 update to the U.S. Preventive Services Task Force (USPSTF) advises against EKG screening for coronary heart disease in asymptomatic, low-risk patients. The goal of this study is to reduce unnecessary EKG testing for low-risk patients by 75%.

Design:

Initial analysis of the data from prior claims will determine the amount of unnecessary EKG within the total amount of EKG performed. The patient cohort will be notified of their personal cardiac health as well as the purpose of this initiative and patient education will reinforce the initiative. At the end of the calendar year, we will tally the amount of EKGs performed and assess the necessity of this diagnostic intervention on those who had it done. 

Results:

The amount of potentially unnecessary EKGs in 2019 was of 32.45% of the total EKGs performed. A significant reduction in testing was noted in 2020 with a total of 66 EKGs of which only one was determined to be unnecessary. This represents 1.52% of the total EKG testing in 2020.

Conclusion:

While EKG testing is often a useful diagnostic measure, unnecessary testing has the potential to cause additional stress on the patient and increase the financial burden on healthcare. A more conservative approach should be encouraged specifically in low-risk asymptomatic patients in whom routine EKG has shown no benefit.

QI 114: Improving Diabetic Management in Order to Improve Health Outcomes

Authors:

Katherine Ellen Whalen, OMS-I; Rafaela Basso, MD; Erica M. Román, MD; Amith Skandhan, MD, and James Robeson Jr., MD

Background:

The outcomes of patients with diabetes are dependent on how well the disease is managed. Poor management of diabetes can result in a wide array of complications as well as increase healthcare costs. This study focuses on identifying the areas of improvement in clinical practice that can lead to a well-controlled diabetic patient population.

Design:

This study is a multi center study comparing diabetic management in clinics within the Wiregrass area. The providers and clinics are blinded and compared based on the completion of diabetic measure targets addressed in a regular visit including: BMI, blood pressure, hemoglobin A1c, cholesterol and LDL documentation, yearly eye exam, and foot exam. The data is then retrospectively compared to assess for improvement in completing these target quality measures. The study includes diabetic patients under the Statera Network.

Results:

In 2018-2019, BMI and blood pressure targets for diabetics were 96% to 98%. Hemoglobin A1c result increased from 85% to 91% from 2018-2019. LDL target improved from 74% on 2018 to 83% in 2019. The targets that require the most improvement include Eye exam, 70-73%, and foot exam, which demonstrated a drop from 52% on 2018 to 49% on 2019.

Conclusion:

This study allows us to identify gaps in the care of diabetic patients, which can worsen outcomes, and increase healthcare costs. Future areas of investigation can be geared towards identifying where this disconnect occurs as well as implementing further ways to improve the completion of these measures in the future.

QI 115: Improving Patient and Hospital Healthcare Costs by Incentivizing Generic Drug Prescription

Authors:

Maria Fernanda Kewish M.D; Erica M. Román M.D; Amith Skandhan MD; and James Roberson Jr. MD

Background:

Generic prescription under usage can lead to increase patient expenditure in medications and have potential effects of poor compliance due to the increasing cost of medications in healthcare.  This project aims to decrease both patients and healthcare costs by increasing prescriptions of generic medications among local providers.

Design:

Southeast Health partnered with Southeast Health insurance care plan to incentivize generic prescription amongst hospitalists in Southeast Health and in turn costs of generic medications would be fully covered by the insurance. In order for the initiative criteria to be met by the providers they would require to reach a minimum of 90% generic prescription drugs filled where a generic option was readily available and a minimum of 80% of all drugs filled had to be generic.

Results:

In comparison to 2019, the amount of Statera Network Physicians who would prescribe generic prescriptions when readily available was maintained around the 99.6% range. Amongst the physicians in 2019 prescribing generic medications out of all drugs filled there was slight improvement with a measure of 87.1% in 2019 and 88% in 2020. This resonated with all Statera Network providers, both NPs and PAs, who demonstrated a 99.5% generic prescription rate when generic version is readily available and an 87% prescription rate of generic medications out of all drugs filled.

Conclusion:

The generic prescription initiative can allow for better allocation and distribution of resources as well as improve patient compliance due to the improvement in costs leading to overall improved patient outcomes.

QI 116: Inappropriate Use of Antibiotics in the Treatment of Acute Sinusitis and Uncomplicated Otitis Media

Authors:

Sanjida Jahan, MD; Sheila Hernandez, MD; Erica Roman, MD; Amith Skandhan MD; and James Robeson Jr., MD

Background:

Acute upper respiratory infections are a common cause of primary care and emergency department visits. Sinusitis and uncomplicated Otitis Media infections are usually of viral etiology and require supportive treatment. Antibiotic overuse in these cases can further increase antibiotic resistance within the healthcare system.

Design:

This is a cross-sectional 1-year observational study. The primary goal is to identify inappropriate antibiotic use by identifying encounters with a diagnosis of mild to moderate sinusitis and uncomplicated otitis externa that resulted with a prescription on the date of the visit and were filled within 5 days of the encounter. Patients must meet the inclusion criteria of not having prior visits within 30 days with a similar diagnosis. The data was retrospectively compared with the prior two years. Study limited to patients of Primary care and emergency medicine physician participating in Statera Network and had at least one Southeast health plan beneficiary with a primary care and emergency department visit for mild to moderate sinusitis or uncomplicated otitis externa from January 2020 to December 2020.

Results:

Although the use of inappropriate antibiotic use for mild to moderate sinusitis decreased from 73-79% to 30%, the use of oral antibiotics for uncomplicated otitis externa increased from previous years from 28-33% to 56%.

Conclusion:

Antibiotic overuse can be potentially harmful and cause complications such as increased susceptibility to C. difficile colitis, acute kidney Injury, and antibiotic resistance while providing minimal relief. Antibiotics stewardship is encouraged in patients with acute upper respiratory infections.

QI 117: Predictors of ICU Mortality Related to COVID-19: A Retrospective, Single-Center, Observational STudy

Authors:

Gulzar Q, Liaqat A, Mason M,  Patak P, Swammiappan R, and Dahale D

Background:

In December 2019, a local outbreak of respiratory illness of unknown etiology, transmission, and treatment occurred in Wuhan, China. It was later discovered to be a novel severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) that caused a wide spectrum of clinical presentations known as coronavirus disease 2019 (COVID-19). Since that time, COVID-19 has spread globally with unprecedented impact causing over 4.5 million deaths worldwide.

Objective:

To describe the experience in Critical care unit here at Southeast Health, this study examined associations between underlying conditions and the mortality among those infected with COVID-19.

Methods:

Single-center, retrospective, observational study at Southeast Health hospital. Study population included those who were confirmed COVID-19 cases and required ICU admission for any period of time during the course of their hospitalization between March, 2020 to January 2021.

Results:

Patients with heart failure, atrial fibrillation, obesity, CKD, and COPD/asthma had mortality rates of 60%, 56%, 46%, 51%, and 51%, respectively. Patients with heart failure (+25%, p<0.05), atrial fibrillation (+16%, p <0.05), and obesity (+23%, p<0.05) had the strongest association with higher mortality rates. Additionally, we found a dose-response relationship with the number of comorbidities and increased mortality.

Conclusion:

Among laboratory-confirmed cases of Covid-19, patients with any comorbidity yielded poor clinical outcomes than those without. A greater number of comorbidities also correlated with poorer clinical outcomes.

QI 118: NSAIDs Use in Chronic Kidney Disease: A Rising Problem

Authors:

Sasha-Kay D'Aguilar; Nowoghowenma Charles Ibie; and Amith Skandhan

Background:

Chronic kidney disease defined as EGFR <60 mL/minute per 1.73 meter sq and/or markers of kidney damage for at least 3 months.  It has a prevalence of 10% globally.  Inability to monitor the progression of chronic kidney disease can be detrimental on patient's health.  It is imperative to avoid nephrotoxic medications in these patients including NSAIDs.  Despite contraindications, NSAIDs are likely prescribe in patients with CKD.  In this study, we intend to imply a method of physician education to improve awareness of fore-mentioned problem and analyze the impact on CKD management.

Design:

In a retrospective cohort study with chart review, we have tried to identify the percentage of patients who received annual creatinine check/renal function test post CKD diagnosis, the percentage of CKD patients who were started on NSAIDs without acquiring a renal function test, and patient with diabetes mellitus who had evaluation of EGFR.  We compared these numbers with post-educational intervention numbers to identify the impact of increasing awareness.

Results:

A significant improvement in awareness and monitoring of renal function through labs was noted post educational intervention (67% versus 26%).  An improvement in renal function monitoring before NSAID administration was noted (77% versus 60%).  The number of diabetes mellitus patient without renal function testing was decreased significantly (24% versus 87%).

Conclusion:

An educational intervention for increased awareness was noted to have a huge impact in the management of CKD patients, decreasing NSAID use with CKD, and leading to frequent monitoring of the renal function.

QI 119: Reducing Unnecessary Imaging Studies for Uncomplicated Headaches

Authors:

Stephen Valle, MD; Adnan Liaqat, MD; Barsbold Ganbat OMS-4; Anthony D. Holman, MD; and Amith Skandhan MD

Background:

Headaches rank in the top 15 chief complaints in the primary care setting. Studies show that imaging tests in the setting of a normal neurological exam are rarely helpful. This quality improvement project was designed to reduce unnecessary imaging ordered by physicians in our network for patients presenting with uncomplicated headache.

Design:

In this project, we analyzed imaging studies for uncomplicated headaches in 2017 as a baseline. Classified as high, medium, and low value exams based on benefit it provided in clinical scenarios.

Results:

This baseline data noted 15% low value and 15% medium value likely unnecessary studies. A reduction in 50% of unnecessary studies would save approximately $7,500. We distributed evidence-based documents on imaging protocols for headaches to our physicians’ offices, analyzed unnecessary studies every three months and yearly with target education. Our latest yearly data from 2020 showed that low value studies decreased to 7.7% (N= 366) compared to 15% in 2017 (N= 79); decreasing low value studies by approximately 49%. In terms of both low and medium value likely unnecessary studies, data showed 34.2% in 2020 (N= 366) vs. 63% in 2017 (N=79), reducing the total utilization of unnecessary imaging by 46%.

Conclusion:

We were able to achieve our goal of improving utilization and cost savings in patients with uncomplicated headache following the implementation of these guidelines. This approach can be utilized in other areas of medicine to help reduce unnecessary spending and improve overall quality of care.


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