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

Cross-Cover Documentation: Multicenter Development of Assessment Tool for Quality Improvement

Construct: We aimed to develop an assessment tool to measure the quality of electronic health record inpatient documentation of cross-cover events. BACKGROUND: Cross-cover events occur in hospitalized patients when the primary team is absent. Documentation is critical for safe transitions of care. The quality of documentation for cross-cover events remains unknown, and no standardized tool exists for assessment. APPROACH: We created an assessment tool for cross-cover note quality with content validation based on input from 15 experts. We measured interrater reliability of the tool and scored cross-cover note quality for hospitalized patients with overnight rapid response team activation on internal medicine services at 2 academic hospitals for 1 year. Patients with a code blue or a clinically insignificant event were excluded. The presence of a note, writer identity (resident or faculty), time from rapid response to documentation, note content (subjective and objective information, diagnosis, and plan), and patient outcomes were compared. RESULTS: The instrument included 8 items to determine quality of cross-cover documentation: reason for physician notification, note written within 6 hours, subjective and objective patient information, diagnosis, treatment, level of care, and whether the attending physician was notified. The mean Cohen\u27s kappa coefficient demonstrated good interrater agreement at 0.76. The instrument was scored in 222 patients with cross-cover notes. Notes documented by faculty scored higher in quality than residents (89% vs. 74% of 8 items present, p \u3c .001). Cross-cover notes often lacked subjective information, diagnosis, and notification of attending, which was present in 60%, 62%, and 7% of notes, respectively. CONCLUSIONS: This study presents reliability evidence for an 8-item assessment tool to measure quality of documentation of cross-cover events and indicates improvement is needed for cross-cover education and safe transitions of care in acutely decompensating medical patients

Is the new orleans criteria for head ct useful for inpatient falls?

Background: Inpatient falls are a patient safety concern in all healthcare facilities. There is currently limited data on the utility of head computed tomography (CT) for inpatient falls. The New Orleans Criteria (NOC) is a validated tool used to determine the appropriateness of neuroimaging in the emergency department after sustaining a fall with minor head injury. The NOC include minor head injury with one of the following; headache, vomiting, age above 60, drug or alcohol intoxication, anterograde amnesia, trauma above the clavicles, and seizure activity. The aim of this study was to evaluate the significance of inpatient falls and determine if the NOC could be applied to triage these patients. Methods: This study is a retrospective review of inpatient falls from a multi-center health system, which includes an urban tertiary teaching hospital, 3 suburban community hospitals, 1 inpatient psychiatric facility and 1 inpatient rehab. Patient safety data was queried for all inpatient falls, classified as with injury, from May 1, 2015 through April 30, 2016. Encounters were manually reviewed for demographic data, circumstances of fall, laboratory results, components of NOC, CT head orders and results. Outcomes of interest include a head CT with any abnormal findings or an acute intracranial process. Results: Inpatient falls over the 1-year period totaled 332. Of the cases reviewed, 57% received a head CT after sustaining a fall. There were 12 (3.6%) CTs that showed a significant finding, and of those 7 (2.1%) had an acute intracranial process. No patients required surgical intervention or had a fatality related to the fall. Details of each fall case with an acute intracranial process are listed in Table 1. 250 (75.3%) patients met at least 1 component of the NOC, with 161 (64.6% of NOC positive) receiving a head CT. The NOC was positive in 6 of the 7 cases, with the missing case having a significant coagulopathy. Test characteristics of the NOC with and without the addition of coagulopathy for acute intracranial process are listed in Table 2. Conclusions: The NOC has been demonstrated as an effective tool in the emergency room; however, based on our findings its utility to evaluate potential intracranial injury in patients with in-hospital falls is limited. Adding additional criteria to the NOC can improve its test characteristics, but was unable to achieve both high specificity and sensitivity. Further investigation is required to develop a method to appropriately triage patients with in-hospital falls for significant neurological injury

Disparities in Use of Virtual Primary Care During the Early COVID-19 Pandemic

Background: The COVID-19 pandemic increased the use of virtual health care. However, certain factors may disparately affect some patients\u27 utilization of virtual care. Associations between age, racial categories (White or Black), and socioeconomic disadvantage were evaluated during the early COVID-19 pandemic. Methods: This cross-sectional retrospective study included adult patients with virtual or in-person primary care encounters at a large, midwestern hospital system with widespread urban and suburban offices between March 1, 2020, and June 30, 2020. Virtual visits included synchronous video and telephone visits and asynchronous patient portal E-visits. Chi-squared tests and multivariable logistic analysis assessed the associations between ages and racial categories, and area deprivation index with the use of virtual versus in-person primary care. Results: Of 72,153 patient encounters, 43.0% were virtual visits, 54.6% were White patients, and 45.4% were Black. Across equivalent age ranges, black patients were slightly less likely to utilize virtual care than similarly aged White patients, but not consistently across virtual modalities. Women were more likely to use virtual care across all modalities, and individuals \u3e65 years were more likely to use telephone visits and less likely to use video and E-visits, regardless of race. Patients residing in areas with the greatest socioeconomic advantage were more likely to utilize video and E-visits. Conclusions: Differential patterns of utilization emerged across racial categories and age ranges, suggesting that racial disparities are exacerbated depending upon patient age and mode of utilization