Aim Statement Research Articles

A Systematic Approach to Ventilator Management for the Pediatric Patient During Air Medical Transport

ObjectiveA checklist was developed to improve the ventilator management of pediatric patients for air medical transport with the aim of reducing the percentage of patients outside recommended parameters (no bag valve mask use, peripheral capillary oxygen saturation level > 90%, and end-tidal carbon dioxide level > 35 and < 50 mm Hg) from 41.3% to 20% within 7 months. MethodsThe checklist was developed based on recommended guidelines. After checklist orientation, its effectiveness was analyzed via chart review for inclusion criteria (> 5 kg and < 18 years) from July 2018 to January 2019. Parameters identified in the aim statement were used to evaluate effectiveness. After transport, a Likert survey concerning the value of the checklist was distributed. ResultsSignificant improvements in pediatric ventilator management were noted when teams used the checklist. The rate outside of aim parameters was reduced significantly from 41.3% (n = 92, June 2012-May 2018 preintervention) to 10% (n = 20, July 2018-January 2019 postintervention) after the improvement action was implemented (χ2 = 7.01, P = .008). The 5-point Likert survey results (n = 38, 4.68 ± .57) supported teams’ improved comfort after checklist implementation. ConclusionThe checklist improved ventilator management proficiency of pediatric patients and the comfort level of air medical teams providing care.

Quality Improvement Basics: A Crash Course for Pediatric Cardiac Care.

Lack of knowledge of quality improvement (QI) methodology and change management principles can explain many of the difficulties encountered when trying to develop effective QI initiatives in health care. An interactive QI workshop at the 14th Annual Meeting of the Pediatric Cardiac Intensive Care Society provided an overview of the role of QI in health care, basic QI frameworks and tools, and leadership and organizational culture pitfalls. The top five QI projects submitted to the meeting were later presented to an expert QI panel in a separate session to illustrate examples of QI principles. Workshop presenters introduced two major QI methodologies used to design QI projects. Important first steps include identifying a problem, forming a multidisciplinary team, and developing an aim statement. Key driver diagrams were highlighted as an important tool to develop a project's framework. Several diagnostic tools used to understand the problem were discussed, including the "5 Why's," cause-and-effect charts, and process flowcharts. The importance of outcome, process, and balancing measures was emphasized. Identification of interventions, the value of plan-do-study-act cycles to fuel continuous QI, and use of statistical process control, including run charts or control charts, were reviewed. The importance of stakeholder engagement, transparency, and sustainability was discussed. Later, the top five QI projects presented highlighted multiple "QI done well" practices discussed during the preconference QI workshop. Understanding QI methodology and appropriately applying basic QI tools are pivotal steps to realizing meaningful and sustained improvement.

Understanding quality improvement collaboratives through an implementation science lens

Quality improvement collaboratives (QICs) have long been used to facilitate group learning and implementation of evidence-based interventions (EBIs) in healthcare. However, few studies systematically describe implementation strategies linked to QIC success. To address this gap, we evaluated a QIC on colorectal cancer (CRC) screening in Federally Qualified Health Centers (FQHCs) by aligning standardized implementation strategies with collaborative activities and measuring implementation and effectiveness outcomes. In 2018, the American Cancer Society and North Carolina Community Health Center Association provided funding, in-person/virtual training, facilitation, and audit and feedback with the goal of building FQHC capacity to enact selected implementation strategies. The QIC evaluation plan included a pre-test/post-test single group design and mixed methods data collection. We assessed: 1) adoption, 2) engagement, 3) implementation of QI tools and CRC screening EBIs, and 4) changes in CRC screening rates. A post-collaborative focus group captured participants' perceptions of implementation strategies. Twenty-three percent of North Carolina FQHCs (9/40) participated in the collaborative. Health Center engagement was high although individual participation decreased over time. Teams completed all four QIC tools: aim statements, process maps, gap and root cause analysis, and Plan-Do-Study-Act cycles. FQHCs increased their uptake of evidence-based CRC screening interventions and rates increased 8.0% between 2017 and 2018. Focus group findings provided insights into participants' opinions regarding the feasibility and appropriateness of the implementation strategies and how they influenced outcomes. Results support the collaborative's positive impact on FQHC capacity to implement QI tools and EBIs to improve CRC screening rates.

Implementation of the quality training program in Spain.

11 Background: The ECO Foundation is a collaboration of experts representing the major Spanish hospitals in the pursuit of excellence in cancer treatment. Since 2015, ECO has been collaborating with ASCO (American Society of Clinical Oncology) in quality initiatives in cancer care, like the QOPI (Quality Oncology Practice Initiative) program and the QOPI Certification Program (QCP). The Quality Training Program (QTP) is a 6-month course with 3 in-person learning sessions that prepares oncology teams to design, implement and lead successful quality improvement activities in their practices. In 2018, ECO reached a new agreement with ASCO to implement this program in Spain. Methods: The QTP was developed in Spain by ECO in collaboration with ASCO, following the same methodology and contents of ASCO’s program. The first session was carried out in October 2018, with 12 Spanish teams participating with diverse quality improvement projects. The program counted with ASCO and ECO faculty, constituted by experts in the quality and oncology field. Results: Each QTP Spanish team counted with 2-3 representatives from their hospitals and developed an improvement project, following the methodology of the course, including a problem statement, process map, cause and effect diagram, diagnostic data, aim statement, measures, baseline data, priority/pay-off matrix of possible changes/interventions, change data, next steps/plan for sustainability, among others. The projects were mainly focused on the waiting time reduction in the Emergency Area and from the patient’s visit to the oncologist until treatment administration, burnout reduction on oncology professionals, improvement of the identification and management of complications for cancer patients receiving immunotherapy, improvement of the uniformity in the medical records registry, among others. QTP participants presented their projects’ results on the third and last session of the program in April 2019 with positive outcomes. Conclusions: The QTP’s quality improvement approach allows Spanish teams and the ECO Foundation to enhance the goal of a quality-oriented health care system. ECO will continue pursuing excellence and quality with further initiatives like the QOPI program, the QCP and the QTP.

ASCO Quality Training Program: Five-year review.

7 Background: ASCO introduced a Quality Training Program (QTP) in 2013 with an aim: train oncology professionals to design, implement and lead successful quality improvement (QI) activities and assume leadership positions to champion culture change in their practices. Methods: The QTP is a formal 6-month program taught by QI faculty and mentored by QI coaches over five days of in-person learning across three sessions, and hands-on learning at the participants’ practices. Sessions include seminars, case examples, and small group exercises. Participants attend in multi-disciplinary teams and focus on a problem they wish to solve in their practice. Scheduled conference calls with QI coaches were held between sessions. Participants complete pre and post QTP surveys (10 point Likert scale; 1 - no knowledge/competence to 10 - complete knowledge/competence) and provide direct written feedback. Results: Since its inception, QTP has had 15 courses (10 domestic and 5 international) with 120 teams and 544 total participants. QTP is led by an 8-member steering group with 16 faculty and coaches. All post-survey items had an increase in knowledge and competence. Each item’s score was calculated as the mean difference between ‘before’ and ‘after’ score. Participants stated increase of 46% to 84%: overall mean increase for knowledge 38% and competence 37%. The greatest increase were: methodology and practical tools to make changes in practice (writing an aim statement, implementing rapid improvement, process analysis tools, and flowcharting the process). Most common suggestion for improvement was allowing more time for the project. Participants are encouraged to write articles and present work in poster and plenary sessions. QTP have led to 7 manuscripts and 21 abstract presentations to national meetings. Six QTP alumni currently are now QI coaches and faculty. Conclusions: The QTP is a successful QI course for oncology professionals who need to measure performance, investigate quality and safety issues, and implement change. It is the only oncology-focused QI training, as all faculty and coaches are providers and QI specialists with oncology experience, making this a unique opportunity. The success will provide further momentum to offer QTP domestically and around the world.

A Systematic Approach to Ventilator Management for the Pediatric Patient during Air Medical Transport

A checklist was developed to improve the ventilator management of pediatric patients for AeroCare. Reduce the percentage of patients outside recommended parameters (no bag-valve mask use, SpO2 level > 90%, and EtCO2 level >35 and <50 mmHg) from 41.3% to 20% within seven months. The checklist was developed based on recommended guidelines. After checklist orientation, its effectiveness was analyzed via chart review for patients meeting inclusion criteria (> 5 kg and < 18 years) from July 2018 to January 2019. Parameters identified in the aim statement were used to evaluate effectiveness. Post-transport, a Likert survey concerning the value of the checklist was distributed. Significant improvements in pediatric ventilator management were noted when teams used the checklist. The rate outside of aim parameters was reduced significantly from 41.3% (N = 92, June 2012 to May 2018 pre-intervention) to 10% (N = 20, July 2018 to January 2019 post-intervention) after the improvement action was implemented (X2= 7.01, p = .008). The 5-point Likert survey results (N = 38, 4.68 +/- .57) supported teams' improved comfort post-checklist implementation. The checklist improved ventilator management proficiency of pediatric patients and the comfort level of AeroCare teams providing the care.

101. RESIDENT-LED QI INITIATIVE TO IMPROVE ASSESSMENT AND CARE OF PATIENTS WITH EARLY CHILDHOOD CARIES

Background Early childhood caries (ECC), defined as one or more decayed, missing, or filled teeth in children under 6 years, is the most common, chronic, preventable condition in childhood. ECC affects 28% of US children 2-5 years of age, particularly children of lower socioeconomic status. The American Academy of Pediatric Dentistry (AAPD) and the AAP recommend that children establish a dental home by 12 months, but lack of standardized ECC assessments and dental referral processes are often barriers to optimal care. Aim Statement In this 12- month long resident-led QI project we aimed to improve the ECC risk assessment rate for children 6 months to 6 years to 70%, and to improve the dental referral rate to 90%. Interventions The Model of Improvement was used for this QI project from December 2017 to December 2018 at a community clinic affiliated with an academic center. An electronic Oral Risk Assessment Tool was created based on AAP guidelines. Residents performed 6 plan-do-study-act (PDSA) cycles utilizing 7 interventions derived from tertiary key drivers. Measures Process, outcome and balancing measures were collected via electronic medical record review (resident documentation of EEC screening, dental referrals and developmental screening respectively). Statistical control charts were utilized to display and analyze the data. API rules were applied to detect special cause variation. Results 281 patients were screened. Oral health risk assessment improved from 37.84% to 77.74%. Initially, 72.22% of screened patients were at high risk for caries (with >1 risk factor for ECC on risk assessment tool). Over time, this rate significantly decreased to 52.46% largely due to family education. On average, 47.66% of screened patients had a dental home. Residents reached outcome goal of 90% referral rate for those patients without a dental home. Developmental screening rate, as a balancing measure, remained at 100% compliance. Conclusions and Next Steps Implementation of this QI project showed our patient population was at high-risk for ECC, which had previously been unknown, and decreased with our interventions. Creation of an electronic screening tool facilitated screening. Family education and providing a referral list of community dentists were the most successful interventions. Next steps include creating an electronic dental referral system and partnering with community dentists to enhance ECC-related family and patient education.

97. RESIDENT NOON CONFERENCE FEEDBACK IN THE DIGITAL AGE: A QI PROJECT

Background Noon conference lectures are a valuable education tool for residency programs, but feedback is difficult to obtain with many methods unsuccessful. Our program used paper and audience polling systems without meaningful responses as the feedback consisted of a numerical rating without comments. Given the availability of smartphones, Quick Response (QR) codes may provide a sustainable method for feedback. Aim Statement By December 2018, we will increase feedback participation for noon conference lectures to 75% of residents in attendance utilizing QR codes and Google Forms. Interventions PDSA cycles were completed monthly to track changes in resident response rate. In cycle 1, chief residents asked residents to use the QR code to complete feedback. In cycle 2, feedback results were discussed during the monthly housestaff meeting. In cycle 3, faculty presenters displayed the QR code and asked residents to participate. In cycle 4, QR codes were placed in the conference hall. In cycle 5, QR codes were displayed Friday before conference. In cycle 6, faculty were provided education on the QR code process. Measures Following the model for improvement, we reviewed prior attempts to obtain resident feedback and compiled baseline data. Surveys consisting of a 5 point rating scale and comment section were linked to a QR code. The primary outcome was the percent of residents in attendance providing feedback via the QR code. Results Over six months, we were unable to meet the goal of a 75% response rate. However, monthly median response rates increased from the baseline 27.9% to 34.2% at the end of cycle 6 indicating a 22.5% change from baseline in participation. The run chart indicates several runs of data, possibly indicating multiple data sets such as different response rates by residency class. Conclusions and Next Steps Though we have not reached our goal, we have been able to get meaningful feedback from the residents for faculty. Using this feedback, we can guide topic selection for resident lectures and provide feedback on lecture styles to create a more engaging learning environment. Additional cycles are planned working toward the 75% goal, evaluating response rates by class and day of the week.

103. IMPROVING SCREENING LAB COMPLIANCE IN AN URBAN PEDIATRIC PRACTICE

Background Screening laboratory evaluations are important components of pediatric primary care. Current AAP guidelines recommend hemoglobin and lead screening at 12 months as well as lipid screening between 9-11 years. Health disparities, including variable access to transportation, contribute to failure to complete recommended screening labs at an underserved urban pediatric clinic. Following urban clinic relocation from site 1 to site 2 and subsequent loss of on-site phlebotomy, the average lab completion rate declined significantly. Aim Statement Our primary aim is to increase the rate of screening lab completions in our urban pediatric population to 75% by December 2018. Interventions A multidisciplinary team completed a Quality Improvement study to evaluate barriers to completing screening labs. Standardized phone calls to families with incomplete labs were made and fishbone diagrams were created to categorize barriers. A process map was created to understand the steps required to complete screening labs. Interventions included: reminder phone calls, standardized instructions placed into After Visit Summary (directions to the lab location, lab hours and public transportation routes to the lab), initiation of access to onsite phlebotomy, and training of on site clinic staff in phlebotomy. Measures Outcome measures were the percent of patients with completed screening labs. Process measures included percentage of patients without complete labs who received follow-up phone calls. Balancing measures were allocation and cost of staff resources. Plan Do Study Act (PDSA) methodology was used to implement and test interventions. Statistical process control charts were used to analyze the impact of interventions. Results 473 charts were reviewed. Average screening lab completion at Site 1 was 79% with decline to baseline of 21% with move to clinic Site 2. Lab completion rates increased to mean of 42% with initial interventions in action period. Lab completion increased to 90% with special cause improvement after on site staff phlebotomy training. Cost analysis data pending. Conclusions and Next Steps Significant increase was noted in lab completion upon the addition of on-site lab phlebotomy at site 2. Initial interventions did not lead to increased compliance rates further highlighting the importance of accessibility in an urban population. Urban underserved clinics may consider addition of on-site phlebotomy to continue to close the gaps in health disparity.

98. IMPROVING BRONCHIOLITIS MANAGEMENT WITH A CARE PATH

Background Bronchiolitis is the number one cause of hospitalization in children under 2 years of age. AAP guidelines emphasize that only supportive care is needed for bronchiolitis. Data obtained from our institution showed poor adherence to AAP guidelines. This project was undertaken with the goal of improving compliance with these guidelines. Aim Statement Our aim was to reduce length of stay (LOS) for admitted low risk patients with bronchiolitis, age 1-24 months, from 67 hours to Interventions A care path and respiratory score were adapted for our institution. Every patient admitted for bronchiolitis was assessed and given a score using respiratory rate, auscultation, and use of accessory muscles. All patients was ordered nasal suction, saline and reassessed. Persistently high scores resulted in escalation of care. The respiratory score and order set were built into the EMR. The care path was made hospital policy. Physicians, respiratory and nursing received education. Measures Data from patients age 1-24 months hospitalized with bronchiolitis from Nov - Dec 2017 were obtained. Excluded were those born Results Charts of patients with bronchiolitis from Jan to Dec 2018 were reviewed. Data were collected regarding LOS, PICU use, and use of chest x ray, albuterol, steroids, epinephrine and antibiotics. We saw an increase in cases in Sept-Dec 2018 with no increase in PICU use. Nov and Dec 2018 average LOS was Conclusions and Next Steps Conclusions and Next Steps With additional education and reinforcement, we hope to make the trend toward improved care for bronchiolitis the standard in our institution. Early observations after implementation of the care path indicate a reduced length of stay, but further data points are needed to know if this change will be sustained.

94. REDUCING UNNECESSARY TESTING OF VIRAL RESPIRATORY PATHOGENS IN PEDIATRIC PATIENTS

Background Although advancements in respiratory viral testing allow for more timely detection of viruses, these tests are expensive and lacking clear evidence of added clinical utility. The Respiratory Pathogen Panel (RPP) used in our institution checks primarily for non-treatable viruses. It accounted for an estimated 2 million dollars in charges from 2015-2017 and was often ordered without documentation of how the test would change clinical management. This raised concern about the clinical utility and added cost of this test for our patients. Aim Statement We aimed to reduce the number of RPP tests ordered on pediatric patients in the pediatric emergency department (ED), inpatient ward and pediatric intensive care unit (PICU) by 50% over 1 year. Interventions Through retrospective chart review, we identified the common clinical divisions and indications in which the RPP was being ordered. We then met with these high utilizers as well as other key stakeholders to develop provider consensus on appropriate utilization of the RPP. Using clinical consensus, along with a focused literature review, we drafted a best practice advisory (BPA), which notably, has been approved but not yet activated in our electronic health record. Measures We used problem solving methodology and a test of change to decrease RPP test utilization. We tracked test utilization in the pediatric ED, PICU and inpatient ward. Results With development of clinical consensus, the number of RPP tests ordered decreased significantly from a median of 19 tests/week in the 2016-2017 respiratory season to a median of 10 tests/week in the 2017-2018 respiratory season in target units. This resulted in an estimated reduction of charges by 54% (from approximately $811,200 to $436,800). Conclusions and Next Steps Establishing a consensus for appropriate use of respiratory viral testing can significantly reduce test utilization and healthcare cost. We anticipate the BPA will sustain resident efforts to date and further reduce unnecessary testing. We predict creating consensus for other tests may be an effective means of ensuring appropriate utilization and reducing costs.

107. PATHWAYS INITIATIVE TO IMPROVE TRANSITION CARE IN A MED-PEDS RESIDENCY PROGRAM

Background Approximately 750,000 adolescents with special health care needs graduate to adulthood annually, often with their health suffering. Less than half receive the services needed for a successful transition. In Illinois the Division of Specialized Care for Children Family Survey revealed that only 18.2% of youth ages 14-21 received transition services. A recent review demonstrated that almost two thirds of HCT evaluation studies had statistically significant positive outcomes. Another study demonstrated that providing HCT services resulted in a 28% reduction in per member per month total cost driven by reductions in hospitalization and ED visits. Aim Statement 1. Increase HCT services for youth and young adults with special health care needs (YASHCN) in a Med-Peds residency practice (10% per year). 2. Increase HCT consultations for YASHCN (10% per year). 3. Improve HCT knowledge, attitudes and practices among Med-Peds residents. (improve annually). 4. Provide Med-Peds residents with a longitudinal QI project aligned with ACGME requirements. Interventions PATHways is a residency-based HCT consultative service founded to improve health for YASHCN and provide HCT education to residents. PATHways’ QI initiatives are modeled after Gottransition's Six Core Elements. A HCT policy was disseminated. EMR tools were developed to assess HCT skills and create portable health summaries. A registry of over 200 YASHCN aged 14-26 in the practice was created. Formal HCT education was provided to residents through HCT consultations. Measures 1. Baseline and annual follow up HCT knowledge, attitude, and practices survey of residents 2. Baseline and annual follow up audits of patients in the HCT registry addressing key elements (readiness assessment, HCT planning, creation of portable health summaries) 3. Tracking of consultations: Requesting services, diagnoses, HCT services provided. Results 33 consultations were provided over 18 months and were received from 9 different services with Pediatrics comprising 70%. Autonomy planning and completion of portable healthcare summaries comprised the majority of consults (80%). Consultations also aided in guardianship (43%), insurance and income support planning (67%), and identifying adult providers (20%). Residents surveys demonstrated increased HCT knowledge. Residents correctly identified the ages to introduce HCT, begin HCT planning, and prepare for transfer (scores increased by 8%, 21%, and 8%, respectively). They were able to identify specific tools for HCT including the clinic's policy and registry. After one year, 42% of residents stated that they addressed HCT readiness often in their practice, increased from 18%, and no residents reported not ever addressing HCT, improved from 38%. Residents reported providing more frequent guidance on education, insurance planning, registering for adult services, guardianship assessment, and identifying adult providers. Residents reported feeling more empowered and engaged in caring for YASCHN. Baseline and follow up chart audits demonstrated that readiness assessment improved from 10 to 50%, transition planning improved from 20 to 60% and creation of portable health summaries improved from 5 to 45%. Conclusions and Next Steps The PATHways initiative is a feasible way to improve HCT for YASHCN and resident HCT knowledge, attitudes and practices. Next Steps: 1. Utilize the EMR's new feature, Slicer Dicer for transition registry management and chart audits. 2. Mailers and EMR messages will be sent to all patients in the transition registry directing them to schedule a HCT appointment. 3. Continue to raise awareness about the PATHways consultation services.

5. CREATION AND IMPLEMENTATION OF A STANDARDIZED TOOL TO IMPROVE INPATIENT CONSULT COMMUNICATION

Background Communication failures are the most common root cause of patient safety events. Consults provide a significant opportunity for miscommunications to occur; however, trainees receive little education on how to effectively convey consult requests. Based on literature review and needs assessment of pediatric residents and fellows at Stanford, we identified essential consult elements (ECE) for optimal consult communication. 54 consult requests were audited, and our baseline data showed that only 9% included all ECE. At our institution, 98% of residents (n=56) and 95% of fellows (n=41) reported miscommunication around consults, 85% of which led to perceived patient safety errors. Only 13% of residents reported receiving teaching from fellows during the consultation. Aim Statement 1) Develop a standardized consult communication tool that includes all ECE 2) Increase consult requests containing all ECE by pediatric residents from 9% to 40% within a 6-month period. Interventions A consult communication tool containing ECE was developed using modified SBAR (Situation, Background, Assessment, Recommendations) and taught to pediatric residents from July-Aug 2018 through a series of workshops. Multimedia interventions (flyers, screen savers, name badge cards) were disseminated throughout the hospital. During the initial PDSA cycle, residents and fellows were queried to inform subsequent cycle changes, such as targeting faculty engagement and monthly reminder emails. Measures The primary outcome measure was the percentage of inpatient consult requests containing all ECE by pediatric residents. The process measure was adherence to the modified SBAR tool. Secondary outcomes included clarity of consult question, perceived teaching and learning, and miscommunication. Resident and fellow satisfaction was used as a balancing measure. Results Post intervention from Sep-Dec 2018, 51 consults were audited and consults including ECE increased from 9% to 49%. SBAR was used in 76% of consultations. With SBAR, 96% of consult questions were clear/very clear and 100% of fellows reported being satisfied/very satisfied with communication. Conclusions and Next Steps Our modified SBAR tool resulted in increased inclusion of essential elements for consult communication. It led to greater clarity of consult question and satisfaction by pediatric fellows. Data regarding its effect on teaching, learning, and patient safety will be available in March 2019.

105. ADVERSE CHILDHOOD EXPERIENCES SCREENING IN RESIDENT CONTINUITY CLINIC

Background Adverse Childhood Experiences (ACEs) are traumatic events that occur prior to age 18. Exposure to ACEs has been associated with negative health outcomes including developmental delay and mental health conditions. ACEs are common and there are ∼17,000 children in our county with exposure to 2+ ACEs. Studies show early resource utilization and promoting resilience can combat the effects of ACEs, however many individuals are not using resources. Aim Statement his project is aimed at improving screening and recognition of ACEs to allow for referrals to resources in order to decrease effects from ACEs. Our goal is to screen 75% of children ages 0-5 for ACEs during well visits. For those who screen positive (score of 4+), our goal is to refer to resources 75% of the time. The project also focuses on improving provider knowledge of ACEs with a goal of 75% of residents reporting feeling at least “somewhat comfortable” with ACEs screening. This project takes place at Myers Park Pediatrics in the Resident Continuity Clinic and involves children ages 0-5 years. The project was initiated in March 2018 and is ongoing. Interventions Visual prompts were placed on workstations to help registration staff and providers remember which visits the screening was scheduled to take place. Scoring instructions were placed on the form. After initial data showed many screens were left incomplete, scoring instructions were taken off the form to encourage more families to complete the form without fear of a SW consult which was originally listed on the form. Provider education including resilience screening and lectures were provided to increase knowledge about ACEs and allow providers to understand the importance of screening. A cover sheet was also placed on the screening form and was edited to provide families more information on why screening was being performed. Measures Outcome measures included % of children ages 0-5 that are screened for ACEs and % of children ages 0-5 with positive screens that are referred with the goal for both being 75%. Process measures included % of residents trained in ACEs screening, % of front desk staff trained in distributing ACEs forms, % of forms distributed to families, and % of forms completed by families. Balancing measures included 75% of front desk staff will report no change in work flow due to handing out screening and 75% of residents will report that ACEs screening is helping them learn about ACEs and how to manage them. Results The average % of screening for all patients in the targeted population was 57%. At times the percentage of screens was above the goal, however was not sustained. Results demonstrated random variation despite multiple interventions. Only 4 patients had ACEs scores of 4+, however all were referred to resources which was above our goal of 75%. Only 10% of residents initially reported feeling at least “somewhat comfortable” with ACEs screening, however after initiation of the project and further education, 85% of residents reported feeling at least “somewhat comfortable”, with a goal of 75%. Eighty-six percent of residents reported that they learned from ACEs screening. When assessing balancing measure, 88% of registration staff reported no change in overall work flow. Conclusions and Next Steps ACEs are common and can have many negative health outcomes. Early intervention with resources can promote resilience and prevent negative outcomes. We have been successful in implementing screening in a local clinic, but have not met sustainability. We have been able to educate providers and ensure that there is no negative impact on clinic work flow. We continue to make changes to improve screening and identification of those affected by ACEs to refer them to resources. We have also been chosen to participate in a Pediatric Integrated Care Collaborative which will provide improved education for our providers and more resources to our patients related to ACEs.

108. HEPATITIS B VACCINATION IN DUKE UNIVERSITY AND DUKE REGIONAL HOSPITAL NEWBORN NURSERIES

Background Vertical transmission continues to be a mode of Hepatitis B virus (HBV) infection despite implementation of prenatal maternal screening. HBV vaccination induces seroprotection in 98% of term infants. The CDC recommends that all infants should receive the first dose of hepatitis B vaccine at birth or within the first 12- 24 hours of life before they leave the hospital. Nevertheless, HBV vaccination rates prior to discharge were sub-optimal in the Duke newborn nurseries, which consist of the main Duke University Hospital (DUH) nursery and the community-based Duke Regional Hospital (DRH) nursery. Aim Statement We aimed to increase all HBV vaccination rates from a baseline of 94% to 96% at the DUH and from 88% to 90% at the DRH nurseries within 1 year. Interventions Baseline HBV vaccination rates were obtained from the electronic medical record (EMR) by using the 12 months preceding first intervention. The first intervention educated clinicians and nurses on the updated CDC guidelines by displaying posters in work areas. The second intervention aimed to increase project awareness among nursing staff in the nursing newsletter. The third intervention was an interdisciplinary effort among the nursing, physician, and pharmacy teams to coordinate administration of the HBV vaccine with the routine administration of vitamin K injection and erythromycin eye ointment at delivery. Measures After each intervention, a PDSA cycle was completed, assessing vaccination rates over the next three months on average. We assessed the effect on nursing workflow through a survey as a balancing measure. Results At both DUH and DRH nurseries respectively, we saw the rates of HBV vaccination increase slightly from baseline rates of 88% and 94% to 92% and 95% after the first two cycles. The third intervention at DUH resulted in a robust response in vaccination rates (up-trending to 95.8% in the month of November). Rates have been above the means for 7 and 10 consecutive months for DUH and DRH since the project began. Conclusions and Next Steps We have demonstrated a trend in improvements in HBV vaccination rates in the DUH and DRH newborn nurseries over several PDSA cycles. Most notably, the multi-disciplinary intervention of administering HBV with the vitamin K injection and erythromycin eye ointment at DUH had a marked impact. Continued multi-disciplinary efforts to improve HBV vaccination in the newborn nursery at both hospitals will optimize the care of newborn infants in prevention of HBV.

106. IMPROVING THE FREQUENCY AND QUALITY OF FEEDBACK RECEIVED BY RESIDENTS THROUGH EDUCATION, REMINDERS, AND INCENTIVES

Background Feedback is an essential and effective tool for resident learning and improvement. Our residency-wide quality improvement project is focused on feedback, after identifying this as an area for improvement on our annual ACGME survey. The Milestones Guidebook lists the five features of high quality feedback as timeliness, specificity, balance, reflection, and action plans. Our baseline data revealed that, on average, 55% of residents received weekly feedback, and the feedback was rated as 2.9 out of 5 on a Likert scale, with a 3 being moderately helpful. On assessment of quality measures, residents perceived their feedback as 69% timely, 75% specific, 42% balanced, 40% reflective, and 39% actionable. Aim Statement Our goal is to improve the verbal feedback for residents on all rotations by increasing the percentage of residents receiving weekly feedback by 30%, improving the average Likert score by 1, and improving each quality measure by 30%. Interventions We used the model for improvement, with resident-designed monthly PDSA cycles, led by the chief residents. PDSA cycle 1 focused on reminders. Biweekly emails were sent to all residents on setting expectations and asking for feedback, and one email was sent to faculty and fellows about the importance of weekly feedback. PDSA cycle 2 focused on education and incentives. Cards were provided to each resident with tips for receiving high quality feedback and a link to log the feedback, for which points were awarded towards the resident's “House Staff Cup” team. Measures Data are collected via weekly online surveys, which are disseminated through a QR code at grand rounds to provide protected time for survey response. Results We have shown improvement in every outcome measure, though not yet to our goal. The frequency of weekly feedback has improved from 55% to 65% after two PDSA cycles. The average Likert score has improved from 2.9 to 3.23. The five quality measures have improved by an average of 28% from baseline. Conclusions and Next Steps Our largest gains after two PDSA cycles have been in the quality measures, which were likely impacted by improved awareness of what constitutes high quality feedback. The frequency of feedback has improved, but not to our 30% goal. Additional cycles will be designed with input from residents with a goal of overcoming barriers such as time constraints and faculty culture. We hope to see improvements in the evaluation and feedback components on our ACGME survey this year.

102. CARPE DIEM MEDIUM: MAKING THE MOST IMPACT IN AN ACADEMIC HALF DAY

Background There are a variety of challenges to providing meaningful and relevant education to pediatric residents, including adapting to different adult learning styles, availability of lecturers, and balancing protection of educational times and coverage of patient care. In 2015, our program noticed a decline in our board pass rate to 25% for this graduating class, which lowered our three year pass rate for first time takers to 65% for 2013-15. Aim Statement Our educational goal is planned to improve in training exam (ITE) standard scores to national average and improve first-time-taker board pass rates to meet 3 year pass rate of at least 80% by 2019 and 100% by 2021. Interventions We used serial PDSA cycles with change processes during the academic afternoons from 2015 through 2019. In 2015-16, we initiated a standardized 18-month curriculum. In 2016-17, we revised curriculum focusing on American Board of Pediatrics (ABP) content specifications and providing residents with standardized pre-reading materials. In 2017-18, we adjusted the curriculum to 12-months and started to follow residents’ progress and assess knowledge gaps using an online pediatric question bank. This also helped us track residents considered “at risk” for board failure. Measures We trended ITE scores and first-time-taker ABP board pass rates to measure effectiveness in changes to half day processes. Results When tracking ITE scores, our intern class in 2015 had a score 9 points below national average, and in their third year closed gap to 3 points below. As for our intern class from 2016, they averaged a 16 point deficit, improved to a 4 point deficit in 2017, and surpassed national average by 2 points in 2018. In regards to first-time-taker board pass rates, we had rates of 40% (2/5 residents) for 2015, 83% (5/6) for 2016, 83% (5/6) for 2017, and 100% (7/7) for 2018. Our 3 year first-time board pass rate increased to 85% for 2016-18. Conclusions and Next Steps Academic half days do pose some challenges in regards to scheduling coverage and faculty lecturers; however, our utilization has been successful and well received by our residents. We have shown significant improvement in ITE scores and board pass rate with minor changes each year. Our next PDSA cycle now incorporates weekly board review for the third year residents and a longitudinal developmental/behavioral/psychiatric curriculum for first and second year residents.

109. IF YOU CALL IT, WILL THEY COME?: USING QUALITY IMPROVEMENT METHODOLOGY TO IMPROVE RESIDENT CODE TEAM LEADERSHIP SKILLS

Background Management of an acutely ill or decompensating child is pivotal to a pediatric resident's training. Pediatric physicians should be prepared to recognize and respond to pediatric emergencies. Starting in 2014, senior residents in our program were designated as the code team leader on even days. Subsequent data demonstrate that residents rarely led codes on even days. We therefore developed a quality improvement initiative to improve resident code team leadership skills. Aim Statement Our primary aim was to increase the percent of even day codes led by a resident to 50% by May 2018. Interventions A needs assessment survey was conducted to identify barriers to resident code team leadership. A fishbone diagram developed to categorize barriers to target. Plan Do Study Act cycles were conducted to implement and test various interventions including a simulation-based workshop on code team leadership, data sharing about code events, and just-in-time resources addressing common questions. Measures Outcome measures included the percentage of even day codes led by resident. Process measures included resident self-confidence in their code team leaders. Balancing Measures included the percent of even day codes with subsequent negative events. Results Baseline data demonstrated no even day codes led by residents. Special cause variation was seen following interventions of simulation-based education and just-in-time training with 40% of codes led by senior residents. Improvements were sustained throughout the academic year. Conclusions and Next Steps Using quality improvement methodology we were able to successfully increase the number of codes led by senior residents without increased negative outcomes. Future interventions will aim at sustaining improvement into a new academic year.

96. IMPLEMENTING AND MAINTAINING A PEDIATRIC NIGHT EDUCATION CURRICULUM

Background Resident work hour restrictions have led to increasing night float coverage, reducing the ability of residents to attend educational conferences. A night education curriculum could help fill this void. While sample curricula exist, few have evaluated factors leading to successful implementation. Aim Statement To increase resident-led formal teaching while on ward night shifts from zero occurrences per week to at least three times weekly by December 31, 2018. Interventions Resident-completed surveys provided information on educational needs and indicated formal nighttime teaching was exceedingly rare. Key drivers were developed to identify areas for intervention, including: flexibility on timing of teaching and who is present for teaching, resident understanding of survey results, comfort with teaching skills and content, and perception of adequate time to teach. Measures Several plan, do, study and act cycles were instituted as changes were tested. Weekly data were analyzed using a run chart with six consecutive points on either side of the median line representing special cause variation indicating a shift. Results Nighttime teaching initially occurred zero times per week. Introduction of the curriculum with expectations to teach on Monday, Wednesday and Friday at 10 PM with the attending present increased teaching to a median of one session per week. Based on resident feedback and concerns, targeted interventions providing more flexibility in teaching expectations led to a shift of the median to our goal of three times per week which has been sustained for 20 weeks. These changes in teaching expectations included the flexibility on who is present for teaching, the night it occurs, the time it occurs and the duration of teaching. Other interventions such as providing results of the survey and placing a calendar as a reminder did not result in a more reliable process. Conclusions and Next Steps Simply creating night curriculum content does not ensure teaching occurs, especially when overnight workflows and workloads are variable and hectic. Implementing and sustaining a pediatric night education curriculum is possible using quality improvement methodology. Utilizing resident feedback for modifications to the curriculum and allowing more resident-ownership by testing different interventions increased the consistency at which resident-led night teaching was done at our institution.

95. IMPROVING RESIDENT NOTE COMPLETION IN A GENERAL PEDIATRICS CLINIC

Background Timely note completion is an important part of patient care. Our hospital has standard expectations for note completion; however, pediatric residents in our program were often delinquent in their documentation, resulting in incomplete patient data in the electronic health record during return visits, elevated resident stress, and threat of suspension of clinical duties from the professional board. The vast majority of these delinquencies were from our general pediatric clinic, where residents see patients for both acute and well child care. Aim Statement Decrease number of delinquent resident notes by 80% over a 9 month period. Interventions We used problem solving methodology and serial tests of change to improve note timeliness. The primary outcome measure was the number of overall delinquent charts according to a weekly graduate medical education deficiency notification system. Tests of change included: 1-Program Director emails and pages to residents with delinquent notes (defined by the institution as >14 days for ambulatory charts) 2-General Pediatric attending consensus on note completion timeliness (same day for acute care visits, next day for well child visits) 3-Intermittent auditing and real time alerts by administrative staff for residents who failed to comply with the same day/next day clinic note completion timeline. Measures Number of delinquent charts by pediatric residents according to the weekly graduate medical education deficiency notification system. Results Timely note completion improved significantly over the 13 months of the project. Program Director emails/pages to residents with deficient charts resulted in a reduction of a median 26 deficient charts/week to 12 deficient charts/week. Intermittent real time alerts to residents who failed to close charts within 24 hours of an acute care visit or 48 hours of a well child visit further reduced the median from 12 charts per week to 2 charts per week. Conclusions and Next Steps Standard expectations for resident note completion in a general pediatric clinic coupled with real time feedback improved resident adherence to institutional expectations around timely note completion. While program director contact with residents who have delinquent charts demonstrated some improvement, this intervention alone was insufficient.