Interdisciplinary Working Group Research Articles

Hans Jonas and the Ethics of Human Subjects Research.

In the 1960s, human experimentation and public funding of research increased significantly, and with the rise of the modern teaching hospital, the distinction between clinical care and experimentation became more and more blurred. Yet little in the way of meaningful government regulation existed in the United States prior to 1970. In 1966, Paul Freund, the president of the American Academy of Arts and Sciences, appointed an interdisciplinary working group to consult on the issues being raised by human experimentation. Contributions from the group were published in a 1969 issue of Daedalus titled Ethical Aspects of Experimentation with Human Subjects. In the lead essay, Hans Jonas challenged then-conventional understandings of the moral problems posed by research involving humans and argued for an alternative moral framework. To Jonas, it mattered whether the physician was trying to make the patient well rather than trying to find out how to improve the health of future patients.

2017 National Standards for Diabetes Self-Management Education and Support.

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends. The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision. Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes. Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

AN ASSESSMENT OF GERIATRIC TTRAINING AND SUPPORT NEEDS FOR CAREGIVERS AND HEALTH CARE PROFESSIONALS IN RURAL TEXAS

Of the 254 counties in Texas, 69% are rural, and three out of every four counties are designated as whole or partial Primary Care Health Professional Shortage Areas. Rural counties in Texas have a higher proportion of older adults compared to metropolitan counties, and rural older adults with Alzheimer’s Disease and their caregivers face unique challenges of limited access to healthcare and lower earnings, resulting in more health-related problems. As part of a HRSA Geriatrics Workforce Enhancement Program, an academic medical center, two Area Agencies on Aging in North Texas, and an Alzheimer’s Association Chapter partnered to expand access to evidence-based programs into surrounding rural counties for older adults and caregivers of persons with Alzheimer’s Disease. An interdisciplinary workgroup developed focus group questionnaires for older adults, caregivers, and health care providers in rural areas to identify perceived needs, barriers to accessing services, and strategic partnerships. The North Central Texas Council of Governments conducted 11 focus groups in late 2018 and early 2019. Of these, seven consisted of family members caring for persons with memory loss. Four consisted of professionals who treat persons with memory loss. Transcription and thematic analysis identified key themes of training needs (both providers’ and laypersons’), resource needs, providers’ best practices, barriers to quality care, and other support needs. Practice implications of the findings include cross-sector partners and integrating telehealth platforms for program delivery. Collaboration between academic and community partners can expand access to evidence-based programs for rural and other underserved communities and address areas of need.

Preventive actions for the gradual reduction of excessive salt intake and its monitoring in Italy

Abstract Issue The WHO Global Action Plan for the Prevention of NCDs recommends a 30% relative reduction in mean population intake of salt/sodium. To this end, the Italian Ministry of Health (MoH) has strengthened prevention and health promotion through the “Gaining health: making healthy choices easy” Programme and the National Preventive Plan (NPP) 2014-2019, with the collaboration of the Interdisciplinary Working group for Salt Reduction in Italy (GIRCSI). Description of the problem According to the “Gaining Health” Programme, agreements between the MoH and the associations of artisan bakers and food industry companies were signed since 2009 to reduce the salt content in bread and in other food products. The reduction of excessive salt intake is one of the main objective of the NPP 2014-2019 pursued by the Regions through initiatives as local inter-sectors agreements and information activities for the population and training for food sector operators. The Italian Institute of Health conducts national surveys to estimate habitual salt intake in the general adult population by collecting 24h urine. Baseline assessment was in 2008-2012 from random samples of persons aged 35-79 years, resident in all 20 Regions. A new survey is ongoing (2018-2019) involving persons aged 35-74 years, resident in 10 Regions. Surveys are funded by the MoH-CCM; urinary sodium excretion is effected by a central lab at Federico II University of Naples, subjected to strict quality controls. Results The baseline survey showed a mean sodium excretion of 10.6 g/24h (95% confidence interval 10.5-10.8) in 1963 men and 8.2g/24h (8.1-8.4) in 1894 women. Results of the ongoing survey are expected in the coming months. Lessons In Italy preventive actions of salt reduction supported by the MoH have been implemented. Estimation of salt intake in diet by 24h/urine is included. Results of baseline and on-going surveys will allow to estimate the possibility of meeting the WHO salt reduction target by 2025. Key messages In Italy inter-sectors preventive actions of salt reduction are implemented. Results of the baseline and on-going surveys will allow to estimate in Italy the possibility of meeting the WHO salt reduction target by 2025.

Development and preliminary verification of the evaluation system for clinical practice guidelines in China

ObjectiveClinical practice guidelines can improve healthcare processes and patient outcomes; however, the quality of these guidelines varies greatly in China. The aim of this study was to construct a comprehensive instrument for the appraisal of clinical practice guidelines in China (AGREE-CHINA), and to validate its reliability as a tool for helping potential guideline users in assessing guideline quality. MethodsFirst, an interdisciplinary working group was established for developing the methods. They also created a checklist as a tool according to the Appraisal of Guidelines, Research and Evaluation II (AGREE II) standards, considering the particularity of Chinese clinical practice. Next, the first draft of AGREE-China was developed by vote, modification, preliminary trial, and cross-verification. To ensure the objectivity, credibility, and reproducibility of the draft assessment, all of the checklists and standards were cross-reviewed fairly widely. Finally, AGREE-CHINA and AGREE II were used to assess the Chinese guidelines published in the past five years, and the results were compared. ResultsThe presented AGREE-CHINA covered five main checkpoints (science and rigor, effectiveness and safety, economy, usability and feasibility, and conflicts of interest) with each point divided into several more specific checkpoints. Definitions and rationales for each main checkpoint appear in the Appendix. The quality ratings based on the total scores of AGREE-China and AGREE II were consistent (r = 0.508, P = 0.020). Compared with AGREE II, the study showed a higher level of interrater-reliability for AGREE-CHINA overall (ICC = 0.957, P < 0.001). The mean time required for AGREE-CHINA was less than that for AGREE II; this was approximately 30 minutes for every assessment. User satisfaction was generally high. ConclusionsThis paper has presented the first edition of the AGREE-CHINA appraisal tool for clinical guidelines. It is quick and easy to use; it assesses and performs well in comparison to AGREE II. This first version of AGREE-CHINA will require further development and validation.

Unpacking the Black Box: Demystifying Ecological Models Through Interactive Workshops and Hands-On Learning

Environmental management decisions increasingly rely on ecological models to forecast outcomes of management actions. Models are becoming increasingly complex through the integration of processes from multiple disciplines (e.g., linking engineering and ecological models). These models are often viewed as mysterious, baffling black boxes, which can lead to mistrust, misinterpretation and/or misapplication of model results. Numerical models have historically been developed without decision makers, coordinating partners, or stakeholders playing active roles in model development, which further complicates communication. Ultimately, mistrust of models and associated outputs can lead to poor decision-making, increase the risk of ineffective decisions, and lead to litigation over decisions. Improved ecological model development practices are needed to increase transparency, include stakeholders and decision makers throughout the entire modeling process from conceptualization through application, and overcome common communication barriers. Building from participatory modeling and prototyping methods, we have developed a workshop approach for applied ecosystem modeling problems that cultivates a foundational understanding of ecological models through hands-on, interactive model development. In this workshop environment, interdisciplinary and interagency working groups co-develop models in real-time which demystifies technical issues and educates participants on the modeling process. The purpose of this paper is to synthesize a repeatable mediated modeling workshop and identify its utility in overcoming major communication challenges of integrated modeling for complex environmental problems. The workshop approach informs modeling teams of the complexity facing decision-makers, creates a sense of model ownership by participants, builds trust among partners, and ultimately increases “buy-in” of the eventual decision.

A Quality Improvement Initiative to Reduce Opioid Consumption after Cesarean Birth.

One in 300 opioid naïve women become addicted to opiates after cesarean birth. After cesarean, women are often prescribed more opiates at discharge than necessary, resulting in increased opportunity for diversion. To improve use of comfort strategies and nonopioid medications to decrease the amount of opioids required postoperatively and prescribed at discharge, in women who gave birth via cesarean. An interdisciplinary workgroup was convened to assess data on opioid use, prescribing practices at discharge, and nurses' use of alternative comfort strategies from January to March 2018. A comfort bundle was designed to include standardized use of preoperative acetaminophen, postoperative comfort education, simethicone, postoperative gum chewing, and abdominal binders. Nurses and healthcare providers were educated on the initiative. Data were reevaluated and compared with preintervention data assessing for improvement and adherence to the bundle components. There was a 61% reduction in morphine milliequivalents given to women after cesarean birth between the first quarter in 2018 and the fourth quarter in 2018. Comparing March with December, 2018 data, adherence to each bundle component improved. The percentage of women receiving less than 20 tabs of oxycodone at discharge increased from 26.3% to 96.7%. Nurses should evaluate comfort options provided after cesarean birth and educate women about use of nonopioid pain relief strategies. A standardized process to address pain and comfort after cesarean birth may decrease exposure to opioids while maintaining comfort.

A Stratified Approach for Cushing’s Syndrome Diagnosis

Cushing&amp;rsquo;s syndrome is an endocrine disorder broadly renowned as a diagnostic challenge. From the initial clinical presentation up to the identification of the underlying etiology, it is necessary to adhere to a logical and stratified plan of action, directed to the correlation of signs and symptoms to the physiopathology of the syndrome, in order to accurately establish a diagnosis and adequate treatment. From stages as early as the patient&amp;rsquo;s first clinical evaluation, the physician should be specially attentive of a constellation of clinical signs which strongly suggest the diagnosis of Cushing&amp;rsquo;s syndrome, such as the presence of a &amp;ldquo;moon face&amp;rdquo;, a &amp;ldquo;buffalo hump&amp;rdquo;, cutaneous atrophy, proximal muscle weakness and purplish cutaneous striae, among others. Based off these findings, laboratory analyses are necessary for the detection of hypercortisolism. According to these results, and if physiologic causes are ruled out, pathologic hypercortisolism is confirmed. Lastly, a complex array of diagnostic tests must be navigated to identify the primary origin of the disorder. Thus, the diagnosis of Cushing&amp;rsquo;s syndrome requires a logically structured algorithm of action, constructed off its pathophysiologic implications, in order to optimize time, resources and the interdisciplinary workgroup required for its consecution, and offer patients the possibility of a better quality of life. It is also important to highlight the need for a stratified approach in patients with metabolic disturbance given that medical professionals may simply treat the patient for obesity not recognizing the presence of the complicating condition Cushing&amp;rsquo;s syndrome.

Applying science to pressing conservation needs for penguins.

More than half of the world's 18 penguin species are declining. We, the Steering Committee of the International Union for Conservation of Nature Species Survival Commission Penguin Specialist Group, determined that the penguin species in most critical need of conservation action are African penguin (Spheniscus demersus), Galápagos penguin (Spheniscus mendiculus), and Yellow‐eyed penguin (Megadyptes antipodes). Due to small or rapidly declining populations, these species require immediate scientific collaboration and policy intervention. We also used a pairwise‐ranking approach to prioritize research and conservation needs for all penguins. Among the 12 cross‐taxa research areas we identified, we ranked quantifying population trends, estimating demographic rates, forecasting environmental patterns of change, and improving the knowledge of fisheries interactions as the highest priorities. The highest ranked conservation needs were to enhance marine spatial planning, improve stakeholder engagement, and develop disaster‐management and species‐specific action plans. We concurred that, to improve the translation of science into effective conservation for penguins, the scientific community and funding bodies must recognize the importance of and support long‐term research; research on and conservation of penguins must expand its focus to include the nonbreeding season and juvenile stage; marine reserves must be designed at ecologically appropriate spatial and temporal scales; and communication between scientists and decision makers must be improved with the help of individual scientists and interdisciplinary working groups.

Desarrollo de un mapa de riesgos en una unidad de cirugía oral y maxilofacial

Introductionthe main aim of this study was to develop and implement a risk map in the Oral and Maxillofacial Surgery Service of the University Hospital «Virgen de las Nieves» of Granada to minimize the incidence of adverse effects (AE). Materials and methodsLongitudinal, prospective study carried out in the Oral and Maxillofacial Surgery Service of the Hospital Universitario Virgen de las Nieves of Granada, from June 2017 to May 2018, through the methodology of «Analysis and Failure Mode Effect». Management of the different AE was addressed. The following phases were considered as it follows: identification of the problem, identification of AE for within the practice of the oral and maxillofacial surgery that represents a problem in the assistive safety, creation of an interdisciplinary working group, analysis of the current situation in patient safety and risk management using 2analysis tools, SWOT and PITELO, preparation of the patient care process, development of a catalog of AE and preparation of a risk map. ResultsA total of 33 AE were identified. The risk map showed a higher incidence of AE in the Surgical Area (22) compared to the areas of Outpatient Clinic and Hospital Discharge (6). A total of 10 critical AE were identified. ConclusionsThe elaboration of a risk map allowed to determine the process of the oral and maxillofacial surgical patient, and to elaborate a catalog of AE.

Development of an interdisciplinary conceptual conservation of energy theme for use in undergraduate physics, chemistry, and biology courses

An ongoing need exists for the creation of interdisciplinary working groups in the sciences and development of pedagogical approaches to content themes that tie together different scientific disciplines. The work described here addresses this need through the development of a collaborative faculty group and a process of content and pedagogical development around the central interdisciplinary theme of energy conservation and transfer, taught in various lower and upper level courses in physics, biology, and chemistry. Our main goal was to design conceptual, visual models that addressed our energy topic and allowed us to provide related, challenging, active-learning experiences that students could easily recognize and expand upon in subsequent courses as they progressed through our curriculum. We used an assessment-first approach in which we designed models with our student outcomes in mind and then created course approaches around our assessment tools. Early indications suggest that students are challenged by and appreciative of these learning approaches, especially when more advanced models are developed in advanced courses in the Physics of Medicine curriculum.

European Stroke Organisation (ESO)- European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke

BackgroundMechanical thrombectomy (MT) has become the cornerstone of acute ischemic stroke management in patients with large vessel occlusion (LVO). The aim of this guideline document is to assist physicians in...

De Souza interprofessional practice cancer competency framework

As the demand in cancer care continues to increase, health systems require a workforce of highly educated specialists and generalists to provide continuity of care across settings. Led by de Souza Institute in Canada, an interdisciplinary working group was formed to develop a competency framework with relevance across regulated health professionals involved in cancer care. The working group was presented with results from a scoping review of national and international guidelines, standards, and competencies in oncology, as well as data from needs assessments on continuing education opportunities and oncology topics most relevant to clinicians. Fifty-one professionals from, e.g., family medicine, pharmacy, social work, psychology, occupational therapy, and nursing participated in seven focus groups. An additional 32 nurses participated in a nursing-specific needs assessment survey. Using modified Delphi technique, working group members conducted three iterative rounds to review data and built consensus on competency items in relation to three levels of expertise, from early learner/novice practitioner, advancing practitioner, to expert practitioner. A final consensus was reached for the selection of competencies that reflect optimal cancer care mapped into three levels of expertise, as well as knowledge, skills, and attitudes expected of each level. Examples for the competency for early learner/novice practitioner include the following: Have awareness of common ethical issues in cancer care (knowledge); demonstrate ability to discuss, educate, and counsel patients and their support persons(s) regarding preferences (skills); and appreciate the impact of culture, the sensitivity, and diversity of attitudes in relation to cancer (attitude). Expert practitioner examples include: recognition of need for, and ability to advocate for challenges involving equity and access in order to improve health outcomes (skill) and awareness of workplace complexities, such as provider roles, team functioning, and organizational environments affecting patient-practitioner relationships (attitude). The de Souza Interprofessional practice cancer competency framework provides a set of shared competencies and a novice to expert pathway for clinicians across disciplines and supports a more standardized learning and comprehensive approach in organizing professional development towards a coordinated, high quality, and person-centered care.

Bridging the Gap between the Research Ethics Board and the Scholarship of Teaching and Learning

In 2016, Dalhousie University’s Research Ethics Board created an interdisciplinary working group to identify the key ethical challenges of SoTL research, with the overarching aim of recommending best practices and communicating these to researchers in order to support and expand the conduct of ethically sound SoTL research. This essay reflects on the lessons learned through this process and shines a light on the three most contentious arenas that emerged: using class time to conduct SoTL research, integrating Students Ratings of Instruction (SRI) into SoTL, and incorporating student work as a data source.&#x0D; This essay contributes to the emerging conversation around ethical SoTL research in two important ways. First, we argue for more lenient REB protocols that encourage SoTL research by exposing how restrictive interpretations of key issues serve as obstacles for student-centered research. Second, we introduce new tools designed to address these impediments, including the first-ever interactive user guide. The overarching aims of this essay are (a) to help SoTL researchers navigate this complex terrain, and (b) to encourage other Canadian REBs to consider implementing more permissive regimes.

Multimodal Strategy to Improve Comfort and Reduce Opioid Use After Cesarean Births

Opioids are regularly prescribed as a method of pain control after a cesarean. One in 300 opioid-naïve women become addicted after cesareans. Although nurses strive to ensure appropriate postoperative pain control, we should be responsible in our delivery of opioids. Research has shown that after cesarean, women are often prescribed more opiates at discharge than necessary, which results in increased opportunity for diversion. Therefore, it is necessary for health care providers to address prescribing practices as well as comfort strategies used in managing postoperative pain. To improve use of comfort strategies and nonopiate medications to decrease the amount of opioids required postoperatively as well as to decrease the number of opioids prescribed at discharge for women who underwent cesareans. An interdisciplinary workgroup was convened to assess data on opioid use, provider prescribing practices at discharge, and nursing use of alternative pain relief strategies between January and March 2018. A literature review was performed to identify strategies that had reduced opioid consumption postcesarean and to improve comfort. Nursing staff and health care providers were educated on the initiative. A comfort-measures band was added to the electronic medical record system to increase ease of documentation. Several new strategies for improving comfort and reducing opioid use were incorporated into our multimodal approach. Data were reevaluated August 2018 and compared with preintervention data to assess improvement: preoperative administration of acetominophen (0% vs. 33.3%), education on postoperative comfort strategies (0% vs. 100%), regular use of simethicone (45% vs. 100%), postoperative gum chewing (0% vs. 25%), abdominal binder use (50.7% vs. 58.3%), and lower prescribed opioid dose at discharge (28% ≤ 20 tablets at discharge vs. 100% ≤ 20 tablets at discharge). Although we noted modest improvement in some areas, we believe the new documentation process may have hampered our improvements, because many nurses reported being unaware of where to document their efforts. Nurses have an important role in intervening and educating patients about the use of nonopioid pain-relief strategies. This, in turn, may affect patients’ opiate consumption, both inpatient and after returning home.

Teleprescribing Controlled Substances: Flowchart Analysis of the Ryan Haight Act and State Telemedicine Laws

Legal liability concerns rank among the top organizational barriers to telemedicine adoption. Such concerns extend to medication-assisted treatment for opioid use disorders and to clinical use of controlled substances in general. These concerns stem from the complex web of federal and state regulations that govern teleprescribing of controlled substances. Existing health law literature on this topic has in large measure summarized regulations and exceptions under the Ryan Haight Act Online Pharmacy Consumer Protection Act (Ryan Haight Act) or categorized state telemedicine laws by nature and breadth of requirement. However, flowcharts can aid in the cognition, understanding, and evaluation of complex legal knowledge. This study analyzed the Ryan Haight Act, state administrative code, and published telemedicine guidelines using a multimethod qualitative approach. Legal analysis identified the structure and key language of federal statute through examination of sentence structure, logical connectors, punctuation, and key terms and language. Subsequently, Ryan Haight Act and state regulatory compliance flowcharts were developed using an adapted version of the six-stage process described by the American Society for Quality (ASQ). The creation of flowcharts proceeded in an iterative manner, and an interdisciplinary workgroup of subject matter experts reviewed the results for logic, clarity, cohesion, completion, and accuracy. Regulatory compliance flowcharts for teleprescribing of controlled substances may provide practitioners, educators, and advocates a tool for telemedicine risk management, competency-based education, and policy development.

Increasing antepartum Tdap vaccine administration: A quality improvement initiative

The Centers for Disease Control and Prevention (CDC) recommends antepartum Tdap vaccination for women with each pregnancy to protect themselves and their vulnerable infants through transplacental transfer of maternal antibodies. Our aim was to increase the rate of antepartum Tdap vaccine administration by 20%. Obstetricians were surveyed to identify their present approaches and barriers to antepartum Tdap vaccine administration to help guide the development of our intervention. Limited staff training, lack of vaccine on site, and cost were the most commonly identified barriers. Using these survey responses, existing literature, and brainstorming conversations with colleagues, an interdisciplinary workgroup then created a fishbone analysis and developed a 5-step intervention to address these barriers: (1) educate providers and patients on Tdap and pertussis; (2) increase Tdap availability to all pregnant women; (3) remind staff of the established Tdap standing order to facilitate administration; (4) encourage obstetricians to offer Tdap; (5) transfer documentation of Tdap administration from office to hospital. To monitor changes in the process over 15 months of pre- and post-intervention, data were collected from monthly chart audits and a two-phase control chart was created. The main outcome measure was proportion of eligible women who received Tdap during current pregnancy. In the pre-intervention period, 362 of 636 eligible women (56.9%) received Tdap during their current pregnancy; in the post-intervention period, 457 of 708 eligible women (64.5%) received Tdap during their current pregnancy. This absolute difference of 7.6% (64.5% vs. 56.9%, p < 0.01) represents a 13.4% relative increase (64.5%/56.9%) in the proportion of clinically eligible pregnant women who received Tdap. This represents a clinically and statistically significant increase in the rate of antepartum Tdap immunization. More research is needed to further understand obstetric barriers and maternal refusal of antepartum Tdap administration.

Legal Remedies to Address Stigma-Based Health Inequalities in the United States: Challenges and Opportunities.

Stigma is conceptualized as a fundamental cause of population health inequalities. Antidiscrimination law is one important lever that can influence stigma-based health inequities, and yet several challenges currently limit the law's potential to address them. To determine whether antidiscrimination law adequately addresses stigma, we compared antidiscrimination law for its applicability to the domains and statuses where stigma is experienced according to the social science literature. To further examine whether law is a sufficient remedy for stigma, we reviewed law literature and government sources for the adequacy of antidiscrimination law enforcement. We also reviewed the law literature for critiques of antidiscrimination law, which revealed conceptual limits of antidiscrimination law that we applied to the context of stigma. In this article, we explored the importance of antidiscrimination law in addressing the population-level health consequences of stigma and found two key challenges-conceptualization and enforcement-that currently limit its potential. We identified several practical solutions to make antidiscrimination law a more available tool to tackle the health inequities caused by stigma, including (1) the development of a new surveillance system for antidiscrimination laws and their enforcement, (2) an interdisciplinary working group to study the impact of antidiscrimination laws on health, and (3) a central agency tasked with monitoring enforcement of antidiscrimination laws. Antidiscrimination law requires better tailoring based on the evidence of who is affected by stigma, as well as where and how stigma occurs, or it will be a poor tool for remedying stigma, regardless of its level of enforcement. Further interdisciplinary research is needed to identify the ways in which law can be crafted into a better tool for redressing the health harms of stigma and to delimit clearer boundaries for when law is and is not the appropriate remedy for these stigma-induced inequities.

Interdisciplinary Safety Evaluation and Quantitative Safety Monitoring: Introduction to a Series of Papers.

The American Statistical Association and DIA have created an interdisciplinary working group of drug safety experts from academia, industry and regulatory backgrounds to explore the future direction for safety monitoring. This introduction to the series explains the background and rationale for this special section.

Minding the gap in pediatric headache care: Can a focus on quality measures improve outcomes?

The American Academy of Neurology Headache Quality Measures seek to improve care delivery and outcomes by addressing gaps in care. Our practice identified underperformance in 3 of the 7 measures that apply to children and adolescents. We expected that improved performance on these measures would lead to a reduction in emergency department (ED) visits and improvement in the average disability grade of established patients. An interdisciplinary workgroup used the Institute for Healthcare Improvement's Model for Improvement. Quality improvement (QI) interventions focused on the use of Pediatric Migraine Disability Assessment (PedMIDAS), headache action plans (HAPs), nurse triage, and infusion center order sets. Provider use of PedMIDAS increased from 15% to 55% (p <0 .0001) of patient visits during the comparison period. Generation of HAP letters increased from 10% to 15% (p < 0.0003), but these gains were not sustained. ED visits for headache decreased by 32% (p < 0.0001). The average migraine disability grade remained unchanged. QI efforts using team-based strategies and electronic medical record (EMR) integration can improve performance on headache quality measures, although it may be difficult to demonstrate improved patient outcomes. The project's time frame and disability assessment strategy were likely insufficient to detect a change in disability. Optimization of nurse triage and EMR workflows enabled more patients with status migrainosus to receive their treatment in the infusion center rather than the ED with a favorable revenue benefit for the hospital.