Poster Day 2022: Abstracts: Clinical & Quality Improvement

Ryan Pearman, Angelica DesPain, Rana Hamdy, Gia Badolato, Kristen Breslin 

The BioFire® FilmArray Meningitis/Encephalitis Panel (MEP) provides a one-hour turnaround time for detection of 14 common viral and bacterial pathogens in cerebrospinal fluid (CSF). This test became available at our institution in July 2017.  

Retrospective review of the electronic medical record of pediatric emergency department (ED) encounters from July 2017 to April 2019. We included all encounters involving febrile infants 60 days and younger with CSF cultures. Provider training categories were defined as pediatrics residency without pediatric emergency medicine (PEM) fellowship, emergency medicine (EM) residency with or without PEM fellowship, and pediatric-trained, board-certified PEM. We evaluated bivariable associations between categorical variables and the outcome of MEP testing using logistic regression. We report odds ratios (OR), adjusted odds ratios (aOR), and 95% confidence intervals.

There was no significant difference in MEP ordering between PEM and Pediatrics providers (OR 0.9, [95% CI 0.6-1.4]). Encounters involving EM providers were more likely to have MEP ordering than encounters involving Pediatrics providers (58.8% vs. 30.2%, OR 3.3, [95% CI 1.2-9.1]). Years of provider experience was not associated with MEP. Providers were more likely to order MEP when a trainee participated in patient care (OR 2.7, [95% CI 1.6-5.0]). In multivariable analyses, patients were more likely to have MEP ordering when seen by a trainee (aOR 2.7, [95% CI 1.5-5.0]) and when their provider was EM trained (aOR 3.1, [95% CI 1.0-9.7]).

Rates of MEP use were higher for febrile infants seen by EM-trained providers and for encounters involving trainees.

Trevor Decker, OMS-III and Emma Schnittka OMS-III 

Early and accurate diagnosis of Hashimoto’s Thyroiditis (HT) is essential in the pediatric population to prevent cognitive and physical growth impairment. Current diagnostic methods are complicated by a lack of specificity and delayed aberration in laboratory values and imaging. Shear-wave elastography (SWE) has emerged as a novel ultrasonographic technique for the diagnosis of HT and other disease states. This systematic review and meta-analysis aim to synthesize current evidence to determine the diagnostic value of SWE for HT in the pediatric population.  

MEDLINE, Cochrane Library, and Clinicaltrials.gov were searched. Search results were filtered by inclusion and exclusion criteria. A meta-analysis was conducted utilizing Meta-Essentials Excel Workbook. Cohen's d-value was the primary measure of interest. A value of greater than 1.0 were considered significant.

Five studies complied with all inclusion and exclusion criteria and were inclusive of 392 subjects—223 in the experimental group and 169 in the control group. A meta-analysis comparing SWE values (in kPa) between these groups yielded a Cohen’s d- value of 1.36 (CI 1.64 to 1.07), suggesting significant differences. A high Z-value of 13.24 confirms significant findings.

SWE values differ significantly between children with HT and healthy controls. Such evidence suggests that SWE may serve as a valuable tool in diagnosing HT in the pediatric population and may aid in overcoming the barriers of current diagnostic approaches. Application of this technology can ensure the proper detection of fibrotic changes within the thyroid to prevent unnecessary disease progression and promote pediatric growth and development.

Austin Huang*, Laurence Stolzenberg*, Mohammad Usman*, Martin Clemmons, Justin Hovey, Gordon G MacGregor 

The purpose of this study was to explore the general public’s opinions and experiences of general anesthesia, as well as any change in their perception after having undergone a procedure requiring it. Our online anonymous survey, although based on a limited population, shows that there is a significant amount of anxiety related to anesthesia, but that most people describe a significant decrease after having undergone it.  

The survey specifically targeted people 21 and older who have already or who will undergo general anesthesia within 6 months. We also explored the different interventions that participants felt would make them more comfortable and reduce anxiety prior to anesthesia.

Noticeably, people were made more comfortable by discussing anesthesia with people that had lived through the experience, and people believe they would be significantly comforted by the presence of therapy animals prior to beginning their procedures.

We hope that our exploratory research will promote future research into this topic in order to improve the healthcare outcomes of a significant number of patients.

Austin Huang*, Laurence Stolzenberg*, Mohammad Usman*, Gordon G MacGregor**

Patient satisfaction and perceptions of medicine have received increased attention over the last decade in the literature, however, more research needs to be done. Not only have surveys regarding satisfaction and perceptions in medicine been focused on the point of view of the clinician, but with the recent Covid-19 pandemic, healthcare opinions of patients may have drastically changed.  

We created our own online, anonymous survey, that received a total of 181 responses, including 19 that indicated that they were current healthcare workers.

The average level of perceived trustworthiness of healthcare workers prior to the pandemic was 7.31/10 which decreased to an average of 6.55 after the pandemic. The level of respect towards healthcare professionals also decreased but not as significantly from an average of 7.84 to 7.34. We also asked participants how likely they would consider becoming a healthcare worker on a scale of 1-10, which was at an average of 7.14 prior to the pandemic and then significantly decreased to 1.5 after.

Overall, we found that the participants experienced a decrease in their perceived level of trustworthiness of healthcare professionals and respect. We believe our findings are an important glimpse into patients’ current thoughts about healthcare professionals. By gaining such insight, we hope to improve patient outcomes by providing clinicians with possible perceptions of their patients and promote a better physician patient relationship. 

Keana-Kelley Swanner, Jordan Blackstone, Amanda Gibbons, Savannah Laird, Kim Davey PhD  

We examine emotional intelligence, also known as an emotional quotient, and how it is a multi-dimensional concept that can be applied to the realm of healthcare disciplines. Healthcare leaders, who are keen on emotional intelligence, are better able to empathize and assess the physiological and emotional state of their staff members.

The objective of this analysis was to look at how emotional intelligence is utilized by clinical dietetics, physicians, and pharmacists in their respective practices to provide a better understanding of what it looks like to apply the emotional intelligence model within healthcare leadership. The four-quadrant “Emotional Intelligence Model” was presented and supported through examples within the three healthcare disciplines mentioned.

This model and the proceeding examples were used to display the relevance of emotional intelligence in each healthcare discipline. Our analysis supports that healthcare leaders benefit from having the ability to understand and manage emotions while further modeling that behavior to their teams. We discovered that there is a strong correlation between employee retention and high emotional intelligence in the leadership of the organization.

We conclude that healthcare organizations should support the implementation of emotional intelligence education for their leaders. Our project supports that healthcare leaders, with the proper tools and education in emotional intelligence, are more likely to have teams with high performance standards, collaboration, clear and consistent communication, and the ability to work together to resolve problems.  

Donna L. Yost, DNP-ENA, MSN-CNL, RN, OCN, CNE, Melissa L. Owens, CNS, RN, CNO, and Devesh Dahale, MS, MBA  

Following the COVID19 Pandemic, bedside nurses expressed feeling overwhelmed and under-motivated, turnover increased, as well as voicing concern in meeting workplace and home life needs.  An organizational ‘oasis’ was created and in October of 2021, Nursing Administration worked proactively with Clinical Education to develop a program focused on providing healthcare staff with tools and methods to build resilience, increase well-being, and result in retention. Healthcare provider burnout is a significant threat to US health care…... (Shah, M.K., Gandrakota, N., Cimiotti, J.P., Ghose, N., Moore, M., Ali, M.K., 2021). Burnout is not a new phenomenon; 2018 statistics show 31.5% or 3.9 million nurses left their positions as a result of feeling ‘burned out’. (Shah, M.K., Gandrakota, N., Cimiotti, J.P., Ghose, N., Moore, M., Ali, M.K., 2021). The well-being of healthcare providers is directly correlated with safety and quality of care delivered to patients. (Knill , K., Warren, B., Melnyk, B., & Thrane, S. E. 2021). 
Building resiliency in health care staff is the equivalent of keeping a car battery charged.  Without the ‘spark’, the vehicle simply quits working.  The Building Resilience Program provides tools to assist staff in recognizing the subtle warning signs of a ‘low charge’.  Methods/tools related to self-care and mindful reflection integrated with holistic methods of personalized supportive therapies- such as massage, yoga, aromatherapy, fitness and nutritional services, are program focal points.  The ‘oasis’ room for quiet reflection in conjunction with these other methods/tools provide participants with the keys to re-kindle the spark and avoid ‘burnout’.  

Nicole Grigoryants and Sarah Sass  

Breast cancer is the one of the leading causes of death in the United States and causes immense suffering for not only the patient but their families as well. The mainstay of screening currently is mammography, although this screening modality has its drawbacks. Multiple technologies have been recently utilized and researched that can not only increase detection rates but also decrease false positive rates thus decreasing anxiety. This review discusses multiple modalities including Digital Breast Tomosynthesis (DBT), Contrast-Enhanced Dual-Energy Digital Mammography, Diffusion Weighted Imaging, Proton Magnetic Resonance Spectroscopy. Each of these techniques have advantages as well as drawbacks that are discussed below.   

Kathryn Kimsey, BS Molly Kidder, MD, Claudia Phen, MD, Jerry Brown,  BS, Benjamin Oshrine, MD,  Sharon Ghazarian, PhD, Jazmine Mateus, MPH, Ernest Amankwah, PhD,  Michael Wilsey, MD 

Malnutrition is a significant issue for pediatric patients with cancer. We sought to evaluate the effectiveness of percutaneous endoscopic gastrostomy (PEG) placement in pediatric oncology patients.    

A retrospective chart review was performed on 49 pediatric oncology patients who underwent PEG placement at Johns Hopkins All Children’s Hospital between 2000 and 2016. Weight-for -age Z-scores were evaluated at time of- and six months post-PEG placement. 

The overall mean weight-for-age Z-score improved by 0.73 (p<0.0001) from pre- (-1.11) to post- (-0.38) PEG placement. A statistically significant improvement in Z-score was seen in patients who were malnourished at time of PEG placement (1.14, p<0.0001), but not in those who were not malnourished (0.32, p=0.197). 

The results of this study may suggest that PEG placement is an effective modality for improving nutritional status in malnourished pediatric oncology patients. However, a larger prospective study with appropriate controls and adjustment for potential confounders is warranted to confirm this finding.

Monica Whaley; OMS-II, Benjamin Crews; OMS-II, Robert Wayne Parker; PharmD

The number of opioid prescriptions and overdoses has steadily increased over the last 30 years.  Many papers have studied the respiratory center depressive effect of opioids with concurrent benzodiazepine use, but few have studied the impact of concurrent muscle relaxer use.  As both opioids and muscle relaxants act as CNS depressants, we wanted to explore a connection between their concomitant use and the risk for opioid overdose. 

A retrospective cohort study was conducted analyzing naloxone administration in the Emergency Department of Southeast Health to patients aged 18-89. Data collected included the amount of naloxone administered, response to naloxone, hospital outcome, past medical diagnoses, and listed medications. Statistical analysis was performed using SAS system utilizing the FREQ procedure test comparing overdose rates in patients taking and not taking muscle relaxers, with a focus on naloxone administration above and below 4mg. 

No statistical significance was found when comparing overdose rate and amount of naloxone administered between patients taking and not taking muscle relaxers. 

Our lack of statistically significant outcomes could be attributed to our small sample size or different mechanisms of action of opioids and muscle relaxers. There was, however, a significant correlation in our patient sample for concurrently taking an opioid, benzodiazepine, and muscle relaxer with a documented diagnosis of chronic pain. This finding highlights the importance of educating patients about the dangers of polypharmacy, as well as exploring adjuvant modalities to manage chronic pain, not just prescription medications. 

Naziyya Haque OMS-II, MPH, CHES, Lei Wang MPhil, Xeimeng Zhang, You Chen PhD FAMIA, Robb Flynn PhD, Wayne English MD, FACS, Danxia Yu PhD 

Bariatric surgery is currently the most effective treatment for severe obesity and related metabolic disease; subsequent weight loss is also associated with a significant reduction of cardiovascular risk factors. Ten-year and lifetime atherosclerotic cardiovascular disease (ASCVD) risk scores clinically evaluate the overall cardiometabolic benefit of bariatric surgery. We hypothesize bariatric surgery reduces ASCVD risk among bariatric surgery patients at Vanderbilt University Medical Center (VUMC) and certain pre-surgery factors are associated with reduced ASCVD risk.  

We analyzed ASCVD risk factors including age, sex, race, blood pressure, cholesterol levels, diabetes status, hypertension status, and smoking status from patients’ electronic medical records, using SAS and Microsoft Excel.

Our analysis included 5,127 first-time bariatric surgery VUMC patients 20 years or older without prior ASCVD history. 1-year post-surgery, patients’ mean body mass index (BMI) decreased from 48.3kg/m2 to 32.93kg/m2 with mean post-surgery HbA1c of 5.7% (all P<0.001). Patients’ mean HDL was 57.8 mg/dL, LDL was 89.5 mg/dL, and total cholesterol was 167.5 mg/dL; diabetes and hypertension status significantly decreased (all P<0.001). Most patients reported no statin use (92%) and no aspirin use (95%) (all P<0.001).

We observed substantial weight loss and improvements in ASCVD risk factors 1-year post-surgery including BMI, average Hb1AC, HDL and LDL levels, and prevalence of diabetes, hypertension, and dyslipidemia. This indicates potential reductions in 10-year and lifetime ASCVD risk scores, which can guide treatment for patients at higher risk for 10-year and lifetime ASCVD.

Donna L. Yost, DNP-ENA, MSN-CNL, RN, OCN, CNE and Devesh Dahale, MS, MBA 

Due to the complex and individualized nature of falls, a standardized risk assessment to optimize interventions based on patient needs is critical (Agency for Healthcare Research and Quality (2022)).
Importantly, falls pose significant challenges for health care organizations with nurses playing a key role in risk factor identification and application of appropriate interventions Juriskovic and Smrekar, (2020)).
A review of the electronic health record was conducted noting inconsistencies in the completion of fall-risk assessments and applied interventions.  Additionally, tracking of fall events revealed an increasing rate month over month for the 2021-22 fiscal year versus 2020-21.
In July of 2022, an initiative was implemented reeducating unit nursing staff and leaders on completion of the fall-risk assessment tool as well as supplying unit leaders with a reporting tool to monitor compliance with timely and accurate fall risk assessment and applied interventions.  

Descriptive study design developed to capture/analyze the data collected.
Results: Data collection over a 3-month period has shown as consistency in assessment and application of interventions increased fall events decreased.

Review of data from October 2021 through October 2022 revealed eight fewer falls than the average of 26 events. This data leads to a preliminary conclusion the positive outcomes are correlated with the improvement process.
Limitations do exist relative to the short time period of the study as compared to the overall yearly falls events.  Further study is in progress to determine long-term correlations with positive outcomes.

Milan Lanier, Margarita Vazquez Almonte, Guillen Perez, Kevin Morales, Kevin Ndukwe, Ashley Thornton; under Leon Bernal-Mizrachi, MD  

Clinical trials (CTs) are research studies needed to evaluate the effectiveness of therapeutic interventions, which have historically suffered from a lack of diversity. Without representation, it is uncertain how meaningful interventions can be provided to all populations. Many barriers exist that prevent African-American and Hispanic/Latinx populations from participation in CTs. Despite the NIH Revitalization Act of 1993, marginalized groups have higher disease burden but lower participation rates.  

• Two focus groups of patients (enrolled vs. not enrolled)
• Self-reported demographics (race, age, gender)
• 12 yes/no questions in categories based on barriers to participation

A total of 119 patients were surveyed—those not enrolled in a clinical trial ( N= 93; mean age = 54 years; 47% male; 53% female; Black/AA: 79.6%), and those currently/previously enrolled in a clinical trial within the Grady Health System ( N= 26; mean age= 60 years; 65% male; 35% female; Black/AA: 80.8%). Further T-tests indicated that patients who understood the nature of the CT study (Question 5, p=0.0354), had no fear of possible symptoms (Question 10, p=0.0219), and had no fear of the CT failing to work (Question 11, p= 0.0012) showed greater rates of clinical trial enrollment.

Results indicate that while  92.4% of patients not-enrolled reported that their providers effectively explained their illnesses, few had an adequate understanding of CTs and many revealed never having been asked to participate in CT. Comparatively, 100% of enrolled patients expressed satisfaction with their provider’s explanations, in addition to fewer fears about risks of participation.

Fahad Abid. Veronica Hill, DNP, CRNP. Justin Hovey, MD 

There is an estimated 2.4 million people living with Hepatitis C virus (HCV) in the United States, and the actual number may be as high as 4.7 million. Diagnosis and treatment of acute HCV is challenging due to the asymptomatic nature of the acute phase of the virus. Due to low screening rates, many asymptomatic patients are left untreated. The purpose of this project is to increase the screening frequency of HCV in a rural health clinic in accordance with new guidelines set by the U.S Preventative Services Task Force.  

Osteopathic medical students on clinical rotation at a rural health clinic were trained on how to room and triage patients. HCV screening implemented as part of this process. If a patient was deemed eligible for screening, an opt-out approach was implemented, and the medical student placed an order for HCV screening in the electronic medical record (EMR). When the clinician saw the patient, the need for screening was discussed and if the need was validated, the patient was screened before the end of the visit. If the clinician and/or the patient deemed the screening unnecessary, the order was cancelled in the EMR.

2054 patients were triaged during the dates of project implementation and 1769 were screened for HCV. Four patients were HCV antibody reactive.

Intentional screening with use of medical students increases screening rates for HCV and increases detection of asymptomatic HCV positive patients.

Javier Cintron, Stephanie Rowan, Cesar Ramirez, Amelie Ramirez, Joel Michalek

This paper examines the relationship between religiosity and allostatic load amongst Hispanic/Latino cancer survivors. The number of Hispanic/Latinos (H/L) in the Unites states is 60.5 million, accounting for 19% of the population. Although H/L have a lower incidence for most types of cancer, it is the number one cause of death within the population. Spirituality and religiosity play a significant role in H/L cultural values and have varying correlations with health, including potential effects on allostatic load. Allostatic load is the result of constant exposure to variable or amplified neural endocrine responses stemming from repeated or chronic environmental challenges that an individual reacts to as being acutely stressful.  

To measure religiosity, we asked participants to complete the Duke University Religion Index (DUREL). To measure allostatic load (AL) we collected clinical biomarkers of stress and used them to calculate AL. We then compared religiosity and AL load using a linear regression model.

Our results show no relationship with the more behavioral aspects of religion. However, when compared to the more cognitive facet of religiosity, intrinsic religiosity (IR), there was a modest relationship,  P=0.14, R2=0.0726.

A strong association between religion and health has long been established. Our study emphasizes this relationship and serves to provide further clarification of how religion can impact our body’s physiological response to stress, especially in those who have been diagnosed with life-threatening illnesses.

Edward Wu, MS, Jillian Weiss, BS, Alyssa B. Barefield, MS, Vincent S. Alexander, BS, Nora Kassis, BS, Mohammed D. Akbar, MS, Audrey A. Vasauskas, PhD    

Patient portal systems (PPS) have been recognized as an effective mechanism for incorporating patients into their healthcare management. Patients report psychological and logistical benefits from having access to their medical information, including increased trust with their healthcare team, and better documentation. Despite these benefits, adoption has lagged. We propose that the deployment of dedicated staff in the inpatient setting can help reduce barriers and facilitate use among adults.  

This quality improvement project was performed in an urban, academic setting. Adolescent patients (>18 years) were approached by staff to assist with enrolling in MyChart (Epic Systems, Verona, WI). Patients were invited to partake in a survey to assess technological access. 

From 8/26/2022 to 10/25/2022, 67 patients were approached. Of those encountered, 30 (44.8%) were male and 26 (38.8%) were non-Caucasian, with mean age 60.3 (17.1). Overall, 38 (56.7%) agreed to register. Of those that registered, 24 (63.2%) did not know of MyChart prior to encounter and 34 (89.5%) stated that they would not have registered had the volunteer not been there. Patients that activated their account were more likely to be younger (p=0.002), female (p=0.017), own a smartphone (p<0.001), and have access to a computer (p<0.001) and to internet (p<0.001). 

The preliminary results of our feasibility study show that patients were receptive of proactive patient portal recruitment. Younger patients and females were more receptive. Despite the benefits of PPS, lack of access to smartphones, computers, and internet remains a barrier to adoption of patient portals. 

Nathan Zhang, Nicolas Gargurevich, Susan Murray, ScD., Meilan K. Han, MD, Wassim W. Labaki, MD 

Tobacco cigarette users experience variable rates of lung functional decline that may progress to COPD. Recently, a classification system based on symptom, function, and structure markers has been proposed for evaluating COPD development in these individuals. We hypothesized that this classification is associated with COPD incidence in the COPDGene cohort.  

We classified 5649 COPDGene participants with post-bronchodilator FEV1/FVC > 0.7 into 3 categories based on symptom, function, and structure markers.
Symptom categorization included a dyspnea score > 2, a SGRQ score > 25, or > 1 respiratory exacerbation requiring pharmacology treatment in the past year.
Structural categorization was defined as chest CT emphysema, small airway disease, or airway wall thickness above the 3^rd quartile.
Functional categorization was defined as  (FEF25-75) < 70% predicted or a total lung volume on chest CT > 120% predicted. 5-year COPD incidence was then described by these categorizations.

From the initial cohort, 2324 participants died or were lost to follow up. The remaining 3325 participants were 47.8% women, (mean age of 57.7 +/- 8.4 years, mean pack-years of 37.7 +/- 20.9). Only 3.2% of individuals with no categorizations COPD diagnosis at 5 years. Participants with only 1 qualifying category had, 2.3%, 6.2% and 10.8%,  5-year COPD incidence based on symptoms, structure, and function, respectively. 19.8% of participants who qualified for all 3 categories, had 5-year COPD incidence.

5-year COPD incidence increases in a dose-response manner as qualifying categories of a participant increases. Future work will include multivariable regression models with age, sex, and baseline lung function adjustments.

Majd Abuaita, Malika Shahzad, Chelsey Vincent, Ayaa Woday

Biobank research is essential for the progression of scientific research and clinically relevant application. Biobanking consists of extraction and evaluation of human tissue samples, which can then be used to observe cellular changes in disease and thus also be used to invent new therapies against these diseases. There are hesitations in the general population which are exacerbated in underrepresented groups with varying concerns with the most common being a general mistrust of biobanks.  

We used PubMed and ACOM library to find reputable articles online explaining the need and lack of biobank diversity. Our findings highlighted underrepresented groups in biobanks, including African Americans, Native Americans, and Hispanics, which are partially due to mistrust of scientific researchers, and barriers to participating in research, like language, literacy, and cultural differences.

A 2022 cancer study found that of the participants sequenced for cancer genetics, only 17.4% were of underrepresented groups (Halmai, 2022). In general, many groups avoided biobank research opportunities due to mistrust of organizations, historical abuse from the government, or concerns that the data would be used against them in some way (Edwards, 2013).

In conclusion, there is an apparent need for diversifying biobank collections and research, which has not yet been fulfilled. These disparities are attributed to various cultural and religious groups who have been historically marginalized throughout American history and/or are currently facing discrimination in every day life. Healthcare workers can educate patients and address hesitancy in regards to mistrust in medical research to encourage participation.