Using a Frontline Staff Intervention to Improve Cervical Cancer Screening in a Large Academic Internal Medicine Clinic

BACKGROUND: Cervical cancer is the third most common malignancy affecting women. Screening with Papanicolaou (Pap) tests effectively identifies precancerous lesions and early-stage cervical cancer. While the nationwide rate of cervical cancer screening (CCS) is 84%, our urban general internal medicine (GIM) clinic population had a CCS rate of 70% in 2016. OBJECTIVE: To improve our clinic\u27s CCS rate to match or exceed the national average within 18 months by identifying barriers and testing solutions. DESIGN: A quality improvement project led by a multidisciplinary group of healthcare providers. PARTICIPANTS: Our GIM clinic includes 16 attending physicians, 116 resident physicians, and 20 medical assistants (MAs) with an insured and underserved patient population. INTERVENTION: Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period. MAIN MEASURES: Our primary outcome was the number of Pap tests completed per month during the 2 study phases. Our secondary outcome was the clinic population\u27s CCS rate for all eligible clinic patients. KEY RESULTS: After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64-2.10; P \u3c 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40-3.02; P \u3c 0.001). Our clinic\u27s CCS rate improved from 70% to 75% after the 18-month intervention. CONCLUSIONS: The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS

Derivation and validation of the ED-SAS score for very early prediction of mortality and morbidity with acute pancreatitis: a retrospective observational study

BACKGROUND: Existing scoring systems to predict mortality in acute pancreatitis may not be directly applicable to the emergency department (ED). The objective of this study was to derive and validate the ED-SAS, a simple scoring score using variables readily available in the ED to predict mortality in patients with acute pancreatitis. METHODS: This retrospective observational study was performed based on patient data collected from electronic health records across 2 independent health systems; 1 was used for the derivation cohort and the other for the validation cohort. Adult patients who were eligible presented to the ED, required hospital admission, and had a confirmed diagnosis of acute pancreatitis. Patients with chronic or recurrent episodes of pancreatitis were excluded. The primary outcome was 30-day mortality. Analyses tested and derived candidate variables to establish a prediction score, which was subsequently applied to the validation cohort to assess odds ratios for the primary and secondary outcomes. RESULTS: The derivation cohort included 599 patients, and the validation cohort 2011 patients. Thirty-day mortality was 4.2 and 3.9%, respectively. From the derivation cohort, 3 variables were established for use in the predictive scoring score: ≥2 systemic inflammatory response syndrome (SIRS) criteria, age \u3e 60 years, and SpO2 \u3c 96%. Summing the presence or absence of each variable yielded an ED-SAS score ranging from 0 to 3. In the validation cohort, the odds of 30-day mortality increased with each subsequent ED-SAS point: 4.4 (95% CI 1.8-10.8) for 1 point, 12.0 (95% CI 4.9-29.4) for 2 points, and 41.7 (95% CI 15.8-110.1) for 3 points (c-statistic = 0.77). CONCLUSION: An ED-SAS score that incorporates SpO2, age, and SIRS measurements, all of which are available in the ED, provides a rapid method for predicting 30-day mortality in acute pancreatitis

Minor respiratory compromise and emergency department predictors of mortality in acute pancreatitis

Background: Data looking at the first 48-hours of hospitalization for acute pancreatitis shows that lung injury predicts mortality. The objective of this study was to test if early respiratory compromise in the ED predicts mortality in acute pancreatitis. We secondarily assessed the addition of the quick sequential organ failure assessment (qSOFA) in predicting mortality. Methods: We performed a retrospective observational study across 8 EDs and 5 hospitals that was inclusive of consecutive adult patients hospitalized for acute pancreatitis. We excluded patients with lipase levels \u3c 3-times the upper limit of the normal laboratory range. The primary outcome was inpatient mortality. We performed univariate and multivariate logistic regression to determine clinical predictors of these outcomes, in which the main variable of interest was respiratory compromise defined by an initial ED SPO2 ≤ 92%. We further combined key ED variables to derive an area under the curve (AUC) for predicting mortality. Results: The study included 2,090 patients, of whom 51.5% were female and the mean age was 55.5 (SD 17.5) years. The median presenting lipase was 976 u/ L (IQR 281 - 2500). Death was uncommon (n=34, 1.6%). In univariate analysis, highly significant predictors of mortality were SPO2 ≤ 92%, qSOFA score, and low albumin. Patients with a presenting SPO2 ≤ 92% had 9.2% vs. 1.3% mortality (OR 7.5, 95% CI 3.1 - 17.7). Those with a qSOFA score ≥ 2 had 9.8% vs. 1.3% mortality (OR 8.6, 95% CI 3.9 - 18.9). Adjusting for age, gender, race, leukocytosis, hematocrit, and major comorbidities, qSOFA ≥ 2 remained a significant predictor of mortality (OR 2.6, 95%CI 1.7 - 4.1, p\u3c0.001). Low albumin (OR 2.7, 95% CI 1.2 - 6.2, p=0.02) and SPO2 ≤ 92% (OR 2.6, 95% CI 1.0-7.1, p=0.05) also remained significant predictors. By combining qSOFA with the presence of low albumin or SPO2 ≤ 92% into a novel ED acute pancreatitis score (EDAPS), the EDAPS score had good accuracy for predicting mortality (AUC 0.80, 95% CI 0.72-0.89). Conclusion: Across a large cohort of patients admitted for acute pancreatitis, mortality is markedly lower than previous data has shown. Independent predictors of mortality present in the ED include low albumin, SPO2 ≤ 92%, and a qSOFA score ≥ 2

Minor respiratory compromise and emergency department predictors of mortality in acute pancreatitis

Background: Data looking at the first 48-hours of hospitalization for acute pancreatitis shows that lung injury predicts mortality. The objective of this study was to test if early respiratory compromise in the ED predicts mortality in acute pancreatitis. We secondarily assessed the addition of the quick sequential organ failure assessment (qSOFA) in predicting mortality. Methods: We performed a retrospective observational study across 8 EDs and 5 hospitals that was inclusive of consecutive adult patients hospitalized for acute pancreatitis. We excluded patients with lipase levels \u3c 3-times the upper limit of the normal laboratory range. The primary outcome was inpatient mortality. We performed univariate and multivariate logistic regression to determine clinical predictors of these outcomes, in which the main variable of interest was respiratory compromise defined by an initial ED SPO2 ≤ 92%. We further combined key ED variables to derive an area under the curve (AUC) for predicting mortality. Results: The study included 2,090 patients, of whom 51.5% were female and the mean age was 55.5 (SD 17.5) years. The median presenting lipase was 976 u/ L (IQR 281 - 2500). Death was uncommon (n=34, 1.6%). In univariate analysis, highly significant predictors of mortality were SPO2 ≤ 92%, qSOFA score, and low albumin. Patients with a presenting SPO2 ≤ 92% had 9.2% vs. 1.3% mortality (OR 7.5, 95% CI 3.1 - 17.7). Those with a qSOFA score ≥ 2 had 9.8% vs. 1.3% mortality (OR 8.6, 95% CI 3.9 - 18.9). Adjusting for age, gender, race, leukocytosis, hematocrit, and major comorbidities, qSOFA ≥ 2 remained a significant predictor of mortality (OR 2.6, 95%CI 1.7 - 4.1, p\u3c0.001). Low albumin (OR 2.7, 95% CI 1.2 - 6.2, p=0.02) and SPO2 ≤ 92% (OR 2.6, 95% CI 1.0-7.1, p=0.05) also remained significant predictors. By combining qSOFA with the presence of low albumin or SPO2 ≤ 92% into a novel ED acute pancreatitis score (EDAPS), the EDAPS score had good accuracy for predicting mortality (AUC 0.80, 95% CI 0.72-0.89). Conclusion: Across a large cohort of patients admitted for acute pancreatitis, mortality is markedly lower than previous data has shown. Independent predictors of mortality present in the ED include low albumin, SPO2 ≤ 92%, and a qSOFA score ≥ 2

Simple Predictors of Mortality in Acute Pancreatitis

Background: Various historical studies have found that hypoxia portends a poor prognosis in patients hospitalized with acute pancreatitis. The objective of this study is to test early respiratory compromise on hospital presentation as a mortality predictor in acute pancreatitis. Secondary aims of the study were assessing prognostication abilities of the quick sequential organ failure assessment (qSOFA) and hypoalbuminemia in acute pancreatitis. Methods: This is a retrospective observational study based on adult patients hospitalized for acute pancreatitis. The data were collected from eight standalone emergency departments and five hospitals within Henry Ford Health System of Southeast Michigan. Patients with lipase levels less than three times the upper limit of the normal laboratory range were excluded. The primary outcome was inpatient mortality. Univariate and multivariate logistic regression was performed to determine predictors of adverse outcomes. The main variable of interest was respiratory compromise, defined as an initial SpO2 of 92% on presentation. We combined other key variables on presentation to derive an area under the curve (AUC) for predicting mortality. Results: The study included 2,090 patients, mean age 55.5 years (SD 17.5) and 51.5% female. The median presenting lipase was 976 U/L (IQR 281-2500). Death was uncommon (n=34, 1.6%). Via univariate analysis, highly significant predictors of mortality were SpO2 92%, qSOFA score 2, and low albumin. Patients with a presenting SpO2 92% had 9.2% mortality, in contrast to a 1.3% mortality rate among those with an SpO2 above 92% on presentation (OR 7.5, 95% CI 3.1-17.7). Those with a qSOFA score 2 suffered 9.8% mortality, compared to an average 1.3% mortality rate among those with a qSOFA of 0 or 1 (OR 8.6, 95% CI 3.9-18.9). Adjusting for age, gender, race, leukocytosis, hematocrit, and major comorbidities, qSOFA 2 remained a significant predictor of mortality (OR 2.6, 95% CI 1.7-4.1, p \u3c 0.001). Low albumin (OR 2.7, 95% CI 1.2-6.2, p 0.02) and SpO2 92% (OR 2.6, 95% CI 1.0-7.1, p 0.05) also remained significant predictors. By combining qSOFA with the presence of low albumin and SpO2 92% into a novel early acute pancreatitis score (EAPS), the EAPS score had good accuracy for predicting mortality (AUC 0.80, 95% CI 0.72-0.89). Conclusions: Independent predictors of mortality on initial presentation include low albumin, SpO2 92%, and a qSOFA score 2. Perhaps these simple prognosticators can guide clinical practice by more precisely identifying those with acute pancreatitis who are more critically ill and could benefit from closer monitoring