Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017

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

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

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

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

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

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

8. RESULTS *indicates significant difference at p<0.000

9. RESULTS Patients with Femoral Head Specimen Positive for Neoplastic Process CLL = Chronic Lymphocytic Leukemia SLL = Small Lymphocytic Lymphoma GLF = Ground Level Fall

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

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

12. Extra Corporeal Membrane Oxygentation: Why A Dedicated Team Improves Outcomes Department: Internal Medicine CRMC Collaborating Department(s): Pulmonary/Critical care Presenter Name(s): DeeptiMundkur; ChiragRajyaguru; Faye Pais; KaramjitDhaliwal-Binning; Mohammed Fayed; Timothy Evans

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

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

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

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

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

18. RESULTS

19. RESULTS

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

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

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

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

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

25. results • During the study period, there were 1505 patients with pelvic fractures, 87 (6%) were open. Of these, 25 were due to blunt mechanisms and made up the study population. • Use of angiography was higher (44% vs 16%; p=0.011) and mortality was lower (16% vs 45%; p=0.014) than in the 2005 study • Fourteen patients (56%) were hemodynamically unstable, and 12 had MTP initiated. • Most deaths (75%) occurred from exsanguination in the first 24 hours. No patients underwent pre-peritoneal packing.

26. BASELINE PATIENT CHARACTERISTICS

27. CHANGES IN CARE FOR OPEN PELVIC FRACTURES

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

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

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

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

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

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

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

35. RESULTS • Data from the Massachusetts General Hospital (MGH) PERT team showed that in 30 months, there were 394 unique PERT activations, 314 (80%) for confirmed PE. PERT activations increased by 16% every 6 months. Most confirmed PEs were submassive (n = 143, 46%) or massive (n = 80, 26%). The PERT treated a relatively large proportion of patients with PE and systemic or catheter-directed thrombolysis (n = 35, 11%), though the most common treatment was anticoagulation alone (n = 215, 69%). Hemorrhagic complications were rare overall, especially among patients treated with catheter-directed thrombolysis. The all-cause 30-day mortality of PERT patients with confirmed PE was 12%. Chest. 2016 Aug;150(2):384-93. doi: 10.1016/j.chest.2016.03.011. Epub 2016 Mar 19.

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

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

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

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

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

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

42. RESULTS: demographics

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

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

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

46. Thank you

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

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

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

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