Download Category: Resident - Lancaster General Health

7th Annual Health Sciences Poster Session
May 13th, 2014
#1
Residents' Personality and Perception of Workload
Nicholas Buckwalter MD, Adam Lake MD, Margaret Nepps PsyD, Michael Horst PhD
Lancaster General Family Medicine Residency
[email protected]; [email protected]
A common superstition among physicians is that of the “black cloud.” Physicians
who are “black clouds” are believed to always have call nights with heavy workloads
and negative outcomes, while “white clouds” have the opposite. This study looked
for correlations between residents’ perceptions of their own cloud status and their
actual experiences on call. It also examined correlations between residents’
perceived cloud status and personality and burnout.
Data was reviewed from the electronic medical record for code blues, hospital
admissions, OB triage visits, and deliveries for the year 2013. These events were
counted toward the workload for all residents on the service responsible for the
event at the time of occurrence. At the start of the study, personality was assessed
using the NEO-FFI scale and Rotter I-E scale, and burnout with the Maslach Burnout
Inventory. A survey of residents’ perceived cloud status was also administered, and
it and the burnout scale were repeated 6 months later to see how static or dynamic
these constructs may be.
Data will be analyzed using appropriate statistical methods to determine
associations of perceived cloud status with actual experience while working, as well
as with personality and burnout. Conclusions will be drawn from the data and
questions for further research will be identified.
#2
Most Common Diagnoses in a Family Medicine Resident and Faculty Practice
Caitlyn Burford MD, Andrew Coco MD, Michael Horst PhD
Lancaster General Family Medicine Residency
[email protected]
The purpose of this project is to compare the visit rates of the 14 most common
chronic diagnoses seen by residents and residency faculty in three family medicine
ambulatory sites operated by the Lancaster General Hospital and compare these
rates to a nationally representative survey of ambulatory family medicine visits.
The objectives were achieved by examining ICD-9 codes. In order to reduce the
over 14,000 ICD-9 codes to more meaningful and manageable clinical groupings, a
diagnostic application, developed by the Agency for Healthcare Quality and
Research, entitled Clinical Classification Software was applied to the visit data. This
reduced the diagnostic groupings to 246 categories. Residents and faculty
physicians at LGH have similar visit rates for chronic adult diagnoses. Hypertension
is the most common chronic visit diagnosis nationwide, occurring in about 14% of
visits. LGH residents and faculty see more visits with depression and obesity than
other family physicians nationally. Residents and faculty at LGH see similar
diagnoses in their practices, which indicates that residents are seeing the
appropriate diagnoses to prepare them to be attending physicians.
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#3
Characteristics of Patients with Unsuppressed Viral Loads at a Community
Outpatient Clinic
Tamayi Bwititi MD and Jeffrey Kirchner DO, FAAFP
Lancaster General Family Medicine Residency
[email protected]
Suppression of HIV-1 RNA is the goal of antiviral therapy (ART) and is associated
with improved clinical outcomes while decreasing transmission rates. According to
the Department of Health and Human Services, virological failure is the inability to
maintain or achieve virological suppression <200 copies/mL. Past studies have
shown adherence to be a key factor in patients with virologic failure. The objective
of this study is to identify characteristics among patients at our clinic with
unsuppressed viral loads. During the calendar year of 2013, a list was compiled of
all patient’s with viral load <200 copies/mL. Chart reviews of this patient population
were done to explore factors such as mental illness history, substance abuse history,
co-morbidities, complexity of medical regimens, drug resistance, maintenance of
regular follow up, adherence, demographics, distance to clinic, social support and
socioeconomic status. Using appropriate statistical methods this data will be
analyzed to determine which factors are more prominent in our patient population.
This will lead to future research work that will compare and contrast the same
factors from the unsuppressed viral load group to the suppressed viral load group
and see if there is any significance or correlation supporting the findings of this
study. In, addition, future interventions can be formulated to improve care among
patients that have unsuppressed viral loads.
#4
Primary Care Approach to Sexual Assault
Saira George, MD
Lancaster General Family Medicine Residency
[email protected]
1 in 3 women will experience sexual assault in their lifetime. Sexual assault is
underreported. While 20 to 30% reported sexual assault in community surveys,
only around half of those presented for medical care. Family physicians must be
equipped to see to the immediate needs of a victim, especially, as sexual assault is
already underreported, the victim/survivor may not seek care elsewhere. The
purpose of this project was to see if a protocol could be established to triage, assess
and treat sexual assault victims within Walter L. Aument Family Health Center.
Through literature searches and interviews with community members involved in
such cases, a protocol has been proposed. Limitations include lack of training, lack
of organizational relationships, lack of equipment, however, these are areas that
can be improved upon with some effort, such as initiating open dialogue between
organizations involved.
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#5
The Effect of a Multi-Component Intervention on Shingles Vaccination Rates
Soo Chong Kim, MD
Lancaster General Family Medicine Residency
[email protected]
The purpose of this study was to determine if a multi-component approach
targeting known barriers to the shingles vaccine would improve immunization rates.
The barriers addressed were lack of information about costs and insurance
coverage, physicians and nursing staff knowledge about vaccine importance and
availability, physicians’ need to remember to recommend the vaccine, and patient
awareness of their risk of developing shingles and the availability of a vaccine. An
EPIC electronic medical record query was performed for patients aged 60+ who had
a visit to the Walter L. Aument Family Health Center before and after the
interventions began. Interventions included education to staff and providers,
patient education materials, point of care reminders for providers, and EMR tools to
communicate key cost and vaccine access information to patients. Findings
demonstrated that serial introduction of interventions correlated with an increase
from 6.8 %to 12% in 50-59 year-old patients (p=0.003) and an increase from 26 to
32.5% in 60+ year-old patients (p= 0.011).
#6
Association of Self-Reported Dental Hygiene and Preterm Birth
Michael Loeven MD, Michael Horst Ph.D, Daniel Weber MD
Lancaster General Family Medicine Residency
[email protected]
Periodontal disease has long been recognized as a risk factor for preterm birth;
however, large metanalyses have shown no significant improvement in preterm
birth rates with treatment. The effect of basic dental hygiene practices on preterm
delivery has not been examined or published. The goal of this study was to examine
self-reported oral hygiene practices in 1000 consecutive post-partum mothers in a
community hospital to determine if there is any association with the rate of
preterm delivery. 0-1 times daily brushing displayed an odds ratio of 2.30 for
preterm birth when compared with twice daily brushing. One out of four pregnant
women brush only once daily. There were no significant differences in tooth
brushing rates and their effect on preterm birth when adjusted for health insurance
status. This is the first study to demonstrate a significant difference in preterm birth
rates based on dental hygiene practices.
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#7
Improving Completion of Procedures in a Family Medicine Clinic
Geoffrey Ostrander, MD
Lancaster General Family Medicine Residency
[email protected]
There is data to suggest that primary care physicians are not performing in-office
procedures due to lack of training and comfort with these techniques. This
intervention was aimed at producing procedure cards outlining the supplies and
general procedure techniques to be used by providers and nurses to facilitate
comfort with performing in-office procedures. A pre and post survey was
completed judging perceptions of providers and nurses after making these cards
available. There seemed to be a trend towards improvement in facilitating same
day procedures, however no significant results were obtained. Stronger results
could be obtained with a longer intervention period as well as staff training about
utilizing these tools effectively.
#8
Percentage Of Patient Reported Concerns Addressed During An Outpatient
Primary Care Office Visit
Valerie Owings, MD and Jonathan Stewart, MD
Lancaster General Family Medicine Residency
[email protected]
The purpose of this study was to establish a baseline of how well Walter Aument
Family Health Center providers are at addressing patient concerns in an objective
manor in order to identify a potential opportunity for improvement in patient care.
114 adult patients at Walter Aument Family Health Center completed a survey
listing their concerns prior to their office visit. After the visit, the participants then
selected whether those concerns were addressed by the provider. There was no
statistically significant difference in the number of concerns reported or addressed
among age groups or sexes. Overall, the average percentage of concerns addressed
was >97% with very few patients reporting that all of their concerns were not
addressed. Results of this study indicate that Walter Aument providers are doing
well at addressing almost all of patient reported concerns.
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#9
The Female Athlete Triad
Jennifer Payne, MD and Jeffrey Kirchner, DO
Lancaster General Family Medicine Residency
[email protected]
Abstract not available.
#10
The Impact of Mandated Coach Referral on the Number of Athletes Evaluated for
Concussion in the Training Room
Shawn F. Phillips, MD, Patrick Moreno, MD, John C. Wood, MD, Lecia Orr, ATC
Lancaster General Family Medicine Residency
[email protected]
Purpose: To examine effects of a new Pennsylvania law holding coaches
accountable for referring athletes with suspected concussion for evaluation.
Methods: In 2011 a Concussion Management System was implemented in an urban
high school to educate coaches, parents, trainers and athletes on the symptoms of
concussion. In 2012 Pennsylvania state law made it mandatory to pull any athlete
with concern for concussion out of competition for further evaluation. The number
of students evaluated for concussion was compared from before and after the 2012
law. The number of days until return to play was also examined.
Results: 27/322(0.084) athletes were seen for symptoms of concussion in 2013.
31/254(0.088) athletes were seen for symptoms of concussion by the team
physician in 2013. This is compared to 16/325 (0.049) in 2011. The mean interval
between injury and return to play was 7.1 days(range 2-16: SD= 4.1) in 2013 and
7.8 days(range 1 to 31 SD 6.2) in 2012 as compared to 20.8 days(range 14 to 36 SD
7.4, p=0.010) in 2011.
Conclusions and Implications: Data from 3 years from one urban high school
indicate a trend toward increased number of referrals for symptoms of concussion
after the implementation of a mandatory referral law in the state of Pennsylvania.
This appears to correlate with an increased number of concussions diagnosed in
2012 as compared to a similar period in 2011. This increase remained consistent in
2013. At the same time the interval between injury and return to play is
significantly less. This is likely a result of more mild, previously undiagnosed
concussions now being recognized by coaches, parents or trainers. One certainly
cannot infer from this data that the outcome or natural course of concussion is
changed as a result of this concussion management system. More research will be
needed to confirm these early results.
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#11
Assessment of the Effects of Clinic Based Condom Distribution on Condom Use in
a High Risk Patient Population
Benjamin R. Snell, MD, MA; Peggy Nepps, PsyD; Michael Horst, PhD, MS; Caroline
Robb, MA; Jordan Rast
Lancaster General Family Medicine Residency
[email protected]
Our research explores two related questions regarding clinic based condom
distribution. Can clinic based condom distribution increase the rates of overall
reported condom usage, as well as decrease the incidence of Chlamydia infection in
high risk female patients in the same clinic? To address these questions, the study
consisted of two arms.
1. Condom Arm: This arm assessed the effect of condom distribution in a high
risk, urban clinic population served by a family medicine residency program. It
used a survey to compare reported condom use prior to clinic based condom
distribution and afterwards. Female and male condoms were distributed
withou8t charge and placed in baskets in all exam rooms in the clinic. The
studied population involved patients ages 15 and older that came to the clinic
during the three months prior to the initiation of clinic based condom
distribution or the three months following implementation. The goal was to
collect at least 200 surveys prior to the start of condom distribution and at
least 200 surveys afterward.
2. Chlamydia Arm: This arm assessed the rate of Chlamydia diagnosis and
screening rates in a high risk cohort within the same clinic population. This
established a baseline of screening and infection rates prior to condom
distribution that could be measured again for future study on the longer term
effects of the condom distribution. The population was a cohort of the 980
female patients ages 18-25 who had clinic visits between January 2011 and
December 2012. Data was drawn from an existing database.
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#12
Optimizing a Pharmacist-driven Erythropoietin Stimulating Agent Protocol
Paul Furler, PharmD, Nga Pham, PharmD, Jill Rebuck, PharmD, BCPS, FCCP, FCCM,
Kimberlee Young, RPh
Department of Pharmacy, Lancaster General Health
[email protected]
The purpose of the study is to demonstrate that we can better manage patients’
anemia by expanding our existing pharmacist-driven erythropoietin stimulating
agent (ESA) protocol, as determined by improvements in in-range hemoglobin rates
and increased monitoring of iron stores. Participants are adult patients who were
referred by their physicians to receive an ESA as an outpatient managed by a
pharmacist-driven protocol. Patients are included in the data analysis if they have
received more than two doses. Participants received usual care as outlined in the
protocol. Their hemoglobin levels and orders for iron studies were collected pre
and post intervention. The intervention consisted of an expansion to the protocol,
targeting evidence-based modifications hypothesized to improve clinical
outcomes—including adjustment to therapeutic goals for the management of
anemia in patients with chronic kidney disease (CKD), enhanced proactive dosing
adjustments for patients with myelodysplastic syndrome (MDS), and pharmacist lab
order entry for iron studies at recommended intervals per Guidelines. At Week 8
post-intervention, there was no statistical difference detected in the average
hemoglobin between the pilot protocol and the expanded protocol. However,
adherence to guidelines for iron studies’ monitoring improved by two-fold for CKD
and MDS patients (p=0.047, OR=2.02 and p=0.093, OR=1.9 respectively). This
finding may help identify patients whose ESA doses are suboptimal or erratic due to
inadequate iron stores.
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#13
Evaluation of Medication Adherence in a Superutilizer Population
Sheetal Patil, PharmD; Amber Jerauld, PharmD; BCPS, Mike Horst, PhD; Jill Rebuck,
PharmD, BCPS, FCCM, FCCP; Jeffrey R Martin, MD, FAAFP; John C Wood, MD, FAAFP;
Kim Bahata, MBA, BSN, RN, CPHQ
Department of Pharmacy, Lancaster General Health
[email protected]
Purpose: To demonstrate an improvement in medication adherence scores using a
validated tool, the Morisky Medication Adherence Scale - 8 (MMAS-8) for Care
Connections (CC) Clinic patients.
Methods: 51 individuals during the study period were included. The MMAS-8
contains 8 questions regarding medication adherence and this scale was
administered periodically throughout the patient’s time at Care Connections (i.e.
baseline, 30, 60, 90 days). Demographic, medication factors, and other variables
were also collected.
Results: CC patients had a statistically significant improvement in medication
adherence scores, the greatest being between visit 1 and visit 2. The average scores
improved from an adherence level of low to medium. Correlation with demographic
variables showed marital status of “single” was found to have statistically significant
lower medication adherence scores compared with the “other” (widowed, divorced,
legally separated, life partner, other) group.
Conclusion: The high intensity team based care and home visits completed by CC
may improve medication adherence and appears to occur within first 60 days of CC
enrollment.
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#14
Assessment of Guideline Adherence for Infantile Gastroesophageal Reflux (GER)
Management in the Hospital Setting: A National Survey of Pediatric Pharmacists
Heather Rodman, PharmD; Lauren Solski, PharmD; Jill Rebuck, PharmD, BCPS, FCCP,
FCCM; Colin Bridgeman, MD
Department of Pharmacy, Lancaster General Health
[email protected]
Purpose: The primary objective for the study was to survey pediatric reflux
guideline adherence regarding GER management for infants in a hospital setting
from the perspective of pharmacists with pediatric experience.
Methods: The study was an IRB-approved, observational, online national survey
which included eligible pharmacists identified through pediatric-focused pharmacy
organizations.
Results & Conclusion: Based on the survey results, infants still receive empiric acid
suppression trials for GER in the hospital, which goes against the current guideline
recommendation. Most pediatric pharmacists stated they were at least “somewhat
comfortable” with the differentiation between GER and GERD, yet > 40% were
uncertain or believed that acid suppression therapy trials are acceptable for
infantile GER plus intermittent irritability. Nonetheless, pediatric pharmacists make
multiple interventions regarding GER and GERD in the hospital setting. In addition,
most hospitals represented did not have a guideline or policy to address infantile
GER versus GERD, which provides an opportunity for hospitals to optimize the
appropriate use of infant acid suppression pharmacotherapy.
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#15
Primary Care Diagnoses Associated with Emergency Department and Inpatient
Superutilizer Categories
Michael Horst, PhD; Andrew Coco, MD; Donna Cohen, MD; Jeffrey Martin, MD; John
Wood, MD
Lancaster General Research Institute
[email protected]
Background: Superutilizers, individuals with high rates of inpatient (IP) or
emergency department (ED) utilization, consume significant healthcare resources
which are important to control in managing population health costs and outcomes.
Objective: To determine if there are differences in primary care diagnosis across
superutilizers stratified by a typology model developed at the Camden Coalition.
Methods: Retrospective cross-sectional study. All primary care patients during
calendar years 2011-2013. N = 223,282 unique individuals – includes all primary
care, ED and IP visits. We identified common primary care diagnoses coded from
the Healthcare Cost and Utilization Project (HCUP) Clinical Classification Software
(CCS). Age, gender and CCS diagnosis adjusted multinomial logistic regression with
cluster correction for practice; referent category are normal utilizers.
Results/Conclusions: ED superutilizers are more likely to be younger, female and
having medical assistance. IP or combined IP/ED superutilizers are more likely to
have Medicare. There are differences in primary care diagnoses across the 3
superutilizer types and there is variability in superutilizer rates and types by practice.
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#16
Breast Conservation Surgery 2007-2012: An in Depth Review of Relumpectomy
Surgeries
Daleela G. Dodge, MD; Hannah E. Groff, BS; Michael A. Horst, PhD.
Lancaster General Research Institute & Ann B. Barshinger Cancer Institute
[email protected]
Breast conservation surgery provides a safe and effective way to conserve a
woman’s breast and successfully remove the cancerous breast tissue. However,
many patients will experience difficulties with tumor margins and re-excision
surgeries. Our purpose is to determine the rate of breast cancer relumpectomies at
Lancaster General Hospital (LGH) in the past eight years and determine potential
risk factors associated with receiving a relumpectomy surgery in order to reduce
the number of unnecessary re-excision surgeries. Data from 726 female patients
diagnosed with Stage I, II, III breast cancer undergoing a lumpectomy between
2007-2012 treated at LGH was collected from the LGH Tumor Registry and manually
abstracted for several different variables. A multivariate binary logistic regression
model was used to identify factors significantly associated with re-excision surgery
including the presence of DCIS, lower tumor margins, lower specimen weight, and
pre-operative tumor localization. Between 2007-2012, there was a 30% overall
relumpectomy rate at LGH. Of the 219 patients receiving a relumpectomy surgery,
178 (81.3%) did not have cancer in their re-excision specimen. This data provides
the support and background to promote local adoption of the new 2014 consensus
guidelines on lumpectomy margins.
Funding provided by the Louise von Hess Medical Research Institute at Lancaster
General.
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#17
Magnet Hospitals are a Magnet for Higher Survival Rates at Adult Trauma Centers
Tracy Evans, MD, FACS; Katelyn Rittenhouse, BS; Michael Horst, PhD; Turner Osler,
MD, MS; Amelia Rogers, BS; Jo Ann Miller, RN, BSN; Christina Martin, MSN, RN;
Claire Mooney, MBA, BSN, RN; Frederick Rogers, MD, MS, FACS
Trauma Service, Lancaster General Health
[email protected]
BACKGROUND: Little is known about nursing care’s impact on trauma outcomes.
The Magnet Recognition Program recognizes hospitals for quality patient care and
nursing excellence based on objective standards. We hypothesized that Magnetdesignated trauma centers would have improved survival over their non-Magnet
counterparts.
METHODS: All 2009-2011 admissions to Pennsylvania’s Level I & II trauma centers
were extracted from the Pennsylvania Trauma Systems Foundation State Registry.
A multivariate logistic regression model of mortality was used to assess the impact
of Magnet designation on the outcome of trauma patients.
RESULTS: A total of 73,830 patients from the PTOS database were included in this
study. When adjusting for age, gender, injury severity, status at hospital admission,
and mechanism of injury, patients admitted to a Magnet Hospital were found to
have significantly decreased odds of mortality when compared to their Non-Magnet
counterparts. Overall the regression model has outstanding discrimination with an
ROC of 0.93.
CONCLUSION: Admission to a Magnet designated hospital is associated with a 20%
reduction in mortality, supporting our hypothesis that the Magnet program’s
attention to nursing competence has important consequences for trauma patients.
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#18
The ACT Alert: A Novel ED Protocol to Improve Care of Anticoagulated Geriatric
Trauma Patients
Rittenhouse KJ, BS; Miller JA, BSN, RN; Chandler R, RHIA, CTR, CSTR; Rogers FB, MD,
MS, FACS
Trauma Service, Lancaster General Health
[email protected]
BACKGROUND: In busy EDs, elderly patients on anticoagulation (AC) sustaining
minor injuries who are triaged to a lower priority for evaluation are at risk for
potentially serious consequences. In March 2012, the ACT Alert (AntiCoagulation
and Trauma), a novel protocol to expedite diagnostic workup of minor head injured,
geriatric patients on AC, was implemented. We sought to determine if a novel ED
protocol prioritizes workup and improves outcomes of our minor head injured
geriatric population on AC.
METHODS: All geriatric (age≥65) trauma patients on AC, GCS≥13, and head trauma
(AIS Head≥1) were queried from 2009-2013. Patients treated by the Trauma Service
prior to ACT Alert implementation (2009-Feb.2012) were compared to patients
treated by the Trauma Service post ACT Alert implementation (Mar.2012-2013).
RESULTS: 276 Pre-ACT Alert patients were compared to 204 Post-ACT Alert patients.
In the Post-ACT Alert period, the average number of trauma activations satisfying
ACT Alert triage parameters each month significantly increased (Pre:7.3 vs. Post:9.3;
p=0.013). Although no significant differences in mortality and discharge to hospice
were observed, significant reductions in mean hospital LOS and mean ICU LOS were
observed. Additionally, a significant reduction in undertriaged patients was found in
the Post-ACT Alert period.
CONCLUSION: The ACT Alert protocol has improved the Trauma Service’s triage and
patient throughput.
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#19
Beta-Blocker Use Pre and Post Traumatic Brain Injury
Mathew Edavettal, MD, PhD; Katelyn Rittenhouse, BS; Jo Ann Miller, BSN, RN,
CCRN; Amelia Rogers, BS; Frederick B. Rogers, MD, MS, FACS
Trauma Service, Lancaster General Health
[email protected]
BACKGROUND: A growing body of literature indicates that beta-blocker
administration following traumatic brain injury (TBI) is cerebroprotective and limits
secondary injury. This study sought to determine how pre-injury and post-injury
beta-blocker usage affects mortality in our moderate and severe TBI population.
METHODS: All moderate to severe traumatic brain injury patients (age≥45)
admitted to Lancaster General Hospital between May 2011 and December 2013
were queried. A multivariate logistic regression model of mortality was used to
assess the impact of pre-injury and post-injury beta-blockers on TBI patients.
RESULTS: Beta-blockers pre-injury was not associated with mortality (AOR:1.11;
95%CI:0.31-3.98;p=0.870); however, beta-blocker administration post-injury was
found to be associated with significantly reduced odds of mortality (AOR:0.14;
95%CI:0.04-0.44; p=0.001). However, the protective benefits of beta-blockers postinjury were only significant in patients with evidence of myocardial injury (elevated
cardiac troponins).
CONCLUSION: Beta-blocker administration post-injury decreases odds of mortality
in moderate and severe TBI patients. Elevated cardiac troponins may be a useful
indicator for beta-blocker administration post-TBI.
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#20
Time to INR Reversal in Anticoagulated TBI Patients
Hans Andrews, BS; Katelyn Rittenhouse, BS; Roxanne Chandler, RHIA, CTR, CSTR;
Frederick B. Rogers, MD, MS, FACS
Trauma Service, Lancaster General Health
[email protected]
BACKGROUND: As there is currently no consensus on the on impact of rapid
international normalized ratio (INR) on traumatic brain injury (TBI) outcome, we
sought to determine the impact of time to INR reversal in our traumatic head bleed
population.
METHODS: Patients admitted to Lancaster General Hospital’s trauma service from
2010-January 2014 with a head bleed, an elevated INR (INR>2.0), and INR reversed
(INR<1.5) in hospital were included in this study. Multivariate logistic regression was
used to analyze three outcomes: mortality, unstable at discharge (in-hospital death
or discharge to hospice), and head bleed progression.
RESULTS: INR reversal<5hrs was not associated with mortality, unstable at
discharge, or head bleed progression. INR reversal<10hrs was not found to be a
significant predictor of mortality or unstable at discharge. However, it was found to
be correlated with reduced odds of bleed progression (AOR:0.36; 95%CI: 0.13-0.97;
p=0.043).
CONCLUSION: Although time to INR reversal was not found to be correlated with
decreased odds of mortality or unstable status at discharge, INR reversal<10hrs was
found to be significantly correlated with a reduced odds of head bleed progression.
This finding indicates that a shorter time to INR reversal may be beneficial to
anticoagulated, head injured patients.
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#21
Application of the PECARN Head Trauma Prediction Rules to Pediatric Trauma
Activations in Central Pennsylvania
1
2
3
Jonathan Hilton, B.S. , Katelyn Rittenhouse, B.S. , Christina Herting, D.O. , Robert P.
3
2
2
Olympia, M.D. , John C. Lee, M.D. , Frederick B. Rogers, M.D.
1
2
Penn State College of Medicine, Hershey PA, Lancaster General Hospital ,
3
Lancaster PA, Penn State Hershey Children’s Hospital, Hershey PA
[email protected]
BACKGROUND: Radiation induced malignancy associated with diagnostic imaging in
pediatric patients is a major concern. The objective of this study was to validate and
assess compliance with the Pediatric Emergency Applied Research Network’s
(PECARN) clinical decision rules to identify children at low risk for clinically
important brain injury (ciTBI), published in 2009.
METHODS: A retrospective chart review of pediatric trauma activations presenting
to Penn State Hershey Medical Center and Lancaster General Hospital between
2009 and 2013 was conducted. The sensitivity, specificity, and negative predictive
value of the PECARN’s pediatric head CT rules were calculated for age<2 and age218.
RESULTS: A total of 819 patients were included in this study. The PECARN pediatric
head CT rules were found to have a sensitivity of 94.4%, specificity of 27.6%, and a
negative predictive value of 99.5% in patients age<2. In patients age 2-18, the
PECARN rules were found to have a sensitivity of 100%, specificity of 28.1%, and a
negative predictive value of 100%. Complete compliance with the PECARN rules
would have reduced the number of pediatric head CT scans given by 87.
CONCLUSION: Application of the evidence-based PECARN clinical decision rules
effectively identified children at low risk for ciTBI for whom a head CT scan may be
avoided.
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#22
Compliance with PECARN Head Trauma Prediction Rules for Pediatric Trauma
Activations at Two Central Pennsylvania Hospitals
1
2
3
Jonathan Hilton, B.S. , Katelyn Rittenhouse, B.S. , Christina Herting, D.O. , Robert P.
3
2
2
Olympia, M.D. , John C. Lee, M.D. , Frederick B. Rogers, M.D.
1
2
Penn State College of Medicine, Hershey PA, Lancaster General Hospital,
3
Lancaster PA, Penn State Hershey Children’s Hospital, Hershey PA
[email protected]
BACKGROUND: Though validated and published in 2009, compliance with the
Pediatric Emergency Care Applied Research Network’s (PECARN) clinical decision
algorithms to identify children at very low risk of clinically important traumatic
brain injury (ciTBI) has not been significantly evaluated to date.
METHODS: Compliance with the PECARN head CT guidelines was compared
between a Level I pediatric trauma center (HMC) and a Level II adult trauma center
(LGH) between 2009 and 2013.
RESULTS: HMC complied with PECARN guidelines in 87.6% of pediatric patients; LGH
complied with PECARN guidelines in 84.3% of pediatric patients (p=0.190). Of
patients indicated for CT scan or Observation, LGH scanned more patients (HMC:
86.5% vs. LGH: 94.9%; p<0.001).
CONCLUSION: Compliance with PECARN head CT guidelines was comparable at
HMC and LGH. Future inclusion of an algorithm in the electronic medical record
may be a useful tool to improve physician compliance with the PECARN guidelines
at both sites. This would also allow for a more accurate record of physician gestalt
and parental insistence when determining whether or not to CT scan a patient.
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#23
Thromboelastography (TEG): Improving Coagulation Treatment in Trauma
Miller JA, BSN, RN; Rittenhouse KJ, BS; Edavettal M, MD, PhD; Nubi AO, MD; Rogers
FB, MD, MS, FACS
Trauma Service, Lancaster General Health
[email protected]
BACKGROUND: Coagulation of blood is a very intricate and complex process. This
process is of significant concern in trauma, as it is integral to hemostasis. Disorders
of coagulation can lead to increased risk of bleeding (hemorrhage) as well as
obstructive clotting (thrombosis). As our knowledge of coagulation improves, novel
technologies have been developed to assist in the measurement of the
elastoviscosity of blood, such as thromboelastography (TEG). In March 2014, the
Trauma Service at Lancaster General Hospital began to use TEG to monitor and
treat coagulation in trauma patients.
INTENDED STUDIES: As TEG is a new technology to which very few institutions have
access, this instrument presents a multitude of research opportunities. Several TEG
research projects that the Trauma Service is intending to conduct in the near future
include evaluating TEG as an instrument to monitor prophylactic anticoagulation,
using TEG to monitor and treat hyperfibrinolysis, and using TEG to monitor and
treat patients with hepatic insufficiency in the perioperative period.
#24
Compassion Fatigue and Compassion Satisfaction in a Surgical Population
Daniel Wu, DO, FACOS, FACS; Katelyn Rittenhouse, BS; Claire Mooney, MBA, MSN;
Mathew Edavettal, MD, PhD; Frederick Rogers, MD, MS, FACS
Trauma Service, Lancaster General Health
[email protected]
BACKGROUND: It is well-known that a career in surgery poses significant challenges,
such as procedural precision and management of acute problems. Balancing a
demanding professional career with personal obligations and social life can be a
significant stressor. However, professional quality of life has not been significantly
examined in surgical specialties to date.
OBJECTIVE: To examine professional quality of life (compassion satisfaction and
compassion fatigue) in a population of surgeons. Specifically, the professional
quality of life of surgeons who provide trauma care will be compared to surgeons
who do not.
METHODS: The validated Professional Quality of Life (PROQOL) survey will be
administered to members of the American College of Surgeons through Lancaster
General’s encrypted REDCap database. The expected date of survey administration
is the summer of 2014.
INTENDED OUTCOME: The results of this study will be used to characterize the
professional quality of life of multiple surgical populations. These findings will be
useful in the development of targeted interventions to improve the professional
quality of life of surgeons, which will likely improve patient care.
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#25
The Effects of Compassion Fatigue and Compassion Satisfaction on MAGNET
Oncology and Intensive Care Nurses
Claire Mooney, MBA, MSN, RN, CCRN; Katrina Fetter, BSN, RN, ONC; Katelyn
Rittenhouse, BS
Department of Nursing, Lancaster General Health
[email protected]
BACKGROUND: Many nurses enter the medical field intending to provide
compassionate care for their patients. Unfortunately, empathic and considerate
nurses can become victims of constant stress to satisfy the overwhelming needs of
patients and their families. Over time, they can lose empathy and begin to dread
working with their patients; this condition is identified as compassion fatigue, also
known as secondary traumatic stress.
OBJECTIVE: To determine the level of compassion satisfaction and compassion
fatigue in a population of nurses working in oncology and intensive care at
MAGNET-designated institutions.
METHODS: This is a cross-sectional study to be conducted between April and May
of 2014 of compassion fatigue in MAGNET nurses from member hospitals of the
Philadelphia MAGNET Consortium that have at least 6 months experience in the
following specialties: Oncology and/or Intensive Care.
INTENDED OUTCOME: The results from this study will be used in the development
of targeted interventions to combat compassion fatigue and promote compassion
satisfaction. We believe that will be beneficial to both our nurses and our patients,
because improving professional quality of life will both improve the way nurses feel
about their jobs as well as improve their performance at work. Combating
compassion fatigue needs to be a team effort with interventions at the individual,
supervisor, and organizational level.
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#26
Variation in Intravenous Amiodarone Use – Reducing Adverse Outcomes with an
Inpatient Safety Initiative
Jennifer C. Slaymaker, RN, BSN; Carin Schmidt, RN, BSN; Lisa King, RN, BSN; Michael
Horst, PhD
Lancaster General Heart and Vascular Institute
[email protected]
Introduction:
Intravenous amiodarone (IV amio) is an important antiarrhythmic prescription for
pts with heart rhythm disorders. Yet the rate of phlebitis and infiltration is known to
be a safety concern. We sought to identify the variations in practice patterns of IV
amio use and pt outcomes between cardiology groups at our institution.
Methods:
A 6 month retrospective review was conducted on pts who received IV amio as
captured by our IV team. Volume of prescriptions was compared to total volume of
discharges and consults per group; incidence and odds of infiltrate were calculated.
Analysis was repeated for a 3 month follow up period.
Results:
A total of 67 pts received IV amio out of 4215 pts. There were 54 infiltrates for a
rate ranging from 47.4%-75% across the 3 cardiology groups. Between the groups,
there was significant difference in the odds of IV amio use and odds of infiltrate.
(Figure 1). Based on this data, a communication was sent to all providers; care
protocols were adjusted to include the use of central lines (PICCs) for IV amio
administration. Evaluation post intervention revealed no significant change in odds
of IV amio use, but infiltrate rate range decreased to 16.7%-53.9% as well as the
overall odds of infiltrate (Odds ratio 0.4, 95%CI 0.2-0.9, p = 0.035).
Conclusions:
IV amio use can be associated with adverse outcomes of infiltrate and phlebitis. We
identified significant practice variations between cardiology groups at our
institution. Education and modification of care guidelines resulted in reduction of
infiltrate odds. Ongoing evaluation and safety protocols for IV amio use continue to
be a multidisciplinary priority for our cardiology team.
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#27
Growing Healthcare Team Relationship: EMD Nurse and Chaplain
Tim Patterson, mDiv, Chaplain Associate; Vicki Fitzgibbons, BSN, RN
Chaplaincy Care & Education Department (CC&E); Lancaster General Health
Emergency Medical Department (EMD)
[email protected]; [email protected]
Background: In the EMD, to yield the best possible outcome for patient and family,
Nurse and Chaplain must work collaboratively. Jointly, reflecting on a case worked
by study authors, it was recognized barriers existed to this collaborative effort Communication; Role Confusion; Scope of Practice – and opportunities were
identified.
Purpose: This poster provides an overview of the defining of collaborative barriers,
the development and implementation of an approach for removing barriers, and
the measurement of outcomes. The ultimate goal was joint growth in
interdisciplinary team relationship.
Participants: EMD Nursing Staff and CC&E– Staff Chaplains, Chaplain Associates,
Chaplain Residents and Chaplain Interns.
Overview: The project was initiated with development and presentation of a CC&E
teaching tool for the EMD Nursing Staff, and a survey of identified barriers was
conducted polling both the EMD Nursing Staff and CC&E. This led to a revision of
the chaplain orientation process to the EMD and improvement to the method of
communication – Chaplain with EMD Nurse – the where, and the how.
A follow up survey was conducted measuring outcomes. Both initial and follow up
surveys incorporated objective and subjective free scripting, EMD Nurse survey also
incorporated scaling, to measure overall experience of relationship between EMD
Nurse and Chaplain.
Findings: Nursing staff reported a 4.7% positive increase in scaling as Very Good or
Excellent in their overall experience with the chaplain.
Chaplains, in free scripted responses, reported a 28% reduction in communication
barriers with EMD Nurses.
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#28
Hospital Staff Responsiveness: An Evaluation of Barriers, Expectations and an
Administrative Program Designed to Improve Performance
Brad Miller, MPH; Susan Sterkenberg, M.Ed, Site Supervisor, Lancaster General
Health; Kate Nolt, MPH, Faculty Advisor, West Chester University
[email protected]
Background: Patient experience is a key contributor to determining the
reimbursement model under the Affordable Care Act. This investigation focused on
determining the effects of various factors on the patient’s expectations related to
staff responsiveness as well as gaining an understanding of the staff’s varying
definitions of promptness and the barriers that delay a timely response. Methods:
HCAHPS surveys were collected and analyzed from LGH to gain insight on potential
differences in satisfaction scores among various demographics such as
hospitalization history, personal rating of overall health, private versus semi-private
room arrangements and age. LGH staff were surveyed to determine barriers and
expectations regarding a prompt call bell response time. Seventy-four patients
were interviewed during their stay at LGH with questions surrounding the use of
the call bell. Results: Patients tended to respond more favorably towards the staff
during their first encounter to the organization as an inpatient. Patients appeared
more lenient in their expectations of a call bell response time as those surveyed
suggested 4-6 minutes as the most common response, compare to staff’s response
of 1-3 minutes. Conclusion: This study suggests that patients are more lenient in
their expectations of a timely response to their call bell request than the nurses.
This contradicts the results of the HCAHPS survey which prompted this investigation.
Given the limitations of this study, it might best serve as a pilot study for more
formal research as well as an investigation in to the varying perceptions of elapsed
time after a request for assistance. Finally, the research suggests that first time
inpatients to the organization are more satisfied with the responsiveness of the
staff, so a targeted approach to those returning guests might be a valuable
undertaking.
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#29
The Effects of Light on Sleep-Wake Cycles
Chelsea Garber, RN
Student, Eastern Mennonite University at Lancaster, RN to BS in Nursing Program
Medical-Surgical Neuroscience Unit
[email protected]
This poster summarizes seven studies about the effect of light on sleep-wake cycles.
Each study reviews the influence of types of lighting on circadian rhythm among
different patient populations. Evidence supports the use of bright light during the
morning and all-day to improve patient outcomes and patient experience of sleep.
Ambient light and cycled lighting were also beneficial. Light manipulation by
nursing promotes a healing environment. Lighting types and structure can be
incorporated into evidence-based designs for healthcare facilities. This project was
designed for and supported by Eastern Mennonite University at Lancaster’s RN to
BS in Nursing Program.
#30
Liberal Arts and Education Attitudinal Survey at a Health Sciences College
Rebecca Smith, Lena Frennborn, Andrew Brader, Kristen Buchanan, Jonathan
Crothers, Erich Goldstein, Meghan MacNamara, Peggy Rosario, and Stefanie
Schwalm
Pennsylvania College of Health Sciences
[email protected]
Although healthcare professions emphasize technical skills, employers value
graduates who also have a broad, liberal education. This research describes student
appreciation of liberal arts at a health sciences college. The researchers
administered the Appreciation of Liberal Arts Scale- Revised (ALAS-R) to 616
students using a census of programs with fewer than 30 students and a random
sample of students in larger programs. The response rate was 54%; the mean ALASR score was 3.66. Bachelor’s students scored significantly higher on the ALAS-R
compared with associate degree students, with means of 3.96 versus 3.57 (P =
0.000). More than half of the sample was 24 years or older and their ALAS-R mean
was significantly higher than students younger than 24, with means of 3.80 versus
3.51 (P = 0.000). Because older students and students seeking higher degrees had a
greater appreciation of liberal arts, life experience may contribute to that
appreciation.
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#31
Implementation of a Decision Support Tool to Improve the Care of Clients with
Diabetes Mellitus Type 2
Dolores A. Minchhoff, DNP, MS, CRNP
Pennsylvania College of Health Sciences
[email protected]
The purpose of this project was to improve outcomes for clients with diabetes
mellitus type 2 (DM 2) through the use of a decision support tool created using ADA
guidelines. Pre and post intervention data were collected from 21 medical records
of clients 18 years and older, with uncontrolled DM 2. There was a significant
improvement in A1C levels (p<0.05) and BP control, increased use of antiplatelet
agent, and increased referrals to ophthalmology and diabetes education. Providers
can increase compliance to standards and improve client outcomes for the care of
clients with DM 2 through the use of decision support tools.
#32
SIR-Spheres: Life Expectancy Before and After Treatment
Megan Brant, Kaela Guerra, and Heidi Weinelt
Pennsylvania College of Health Sciences - Nuclear Medicine Department
[email protected], [email protected], [email protected]
To look at the process of administration of SIR-Sphere treatment and to determine
if SIR-Sphere treatment is making a difference in the life expectancy of the patients
who receive treatment by comparing three different studies. A comparison of the
patients’ prognosis before treatment and how it may have changed after receiving
the SIR-Sphere treatment is conducted. The overall survival rate for the patients
who received the SIR-Sphere treatment was an overall increase. The life expectancy
of the patients started at 3 months and increased to 5-20 months.
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#33
The Benefits of 24 Hour Delay Imaging for the Detection of Gastrointestinal
Bleeding
Andrea Hetrick and Peter Molnar
Pennsylvania College of Health Sciences - Nuclear Medicine Department
[email protected] and [email protected]
Nuclear Medicine plays a key role in helping to diagnosis patients suffering from
symptoms of gastrointestinal (GI) bleeding. However, GI Bleed scintigraphy
protocols vary among hospitals; more specifically, on whether delayed imaging,
including 24 hour imaging is obtained on a routine basis. The research conducted
was to evaluate 24 hour delayed imaging and whether it benefits the patient’s
diagnosis. Within the scope of this research, first a comparison of the protocols
from Memorial Hospital of York (MH), Peninsula Regional Medical Center (PRMC) in
Maryland, and the guidelines established by the Society of Nuclear Medicine were
reviewed. Secondly, radiologist from both MH and PRMC were interviewed in
regards to the positives and negatives of performing 24 hour delayed imaging.
Finally, a retroactive survey of GI bleed scans with 24 hours imaging was conducted
at Memorial Hospital of York. Thirty two case studies were examined, resulting in
six scans that included 24 hour delay imaging, demonstrating a 55% positive
diagnosis. The outcome of this research concluded 24 hour delay imaging of
gastrointestinal bleeding can benefit patients due to the intermittent nature of
bleeding.
#34
Datscan Imaging Is A Useful Tool In Differentiating Between Parkinson’s Disease
And Essential Tremors
Christina Minich, Erika Jones, Sandra Troiani
Pennsylvania College of Health Sciences - Nuclear Medicine Department
[email protected], [email protected], [email protected]
Differentiating early Parkinson’s disease (PD) from Essential tremors (ET) can
present a diagnostic challenge as their symptoms present similarly. DaTscan
imaging allows for visualization of dopamine degeneration in the substantia nigra, a
hallmark of PD. We examined the clinical utility of DaTscan in differentiating
between PD and ET in assisting physicians’ with their diagnostic and clinical
management of patients to improve their quality of life. The medical records of 18
patients were reviewed for abnormal DaTscan results and changes in diagnosis and
clinical patient management. In all patients having a contradicting initial diagnosis
and DaTscan result, their diagnosis was changed along with their clinical treatment.
DaTscan is a useful tool in differentiating early PD from ET.
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#35
Diagnosing Parathyroid Adenoma per Sestamibi Parathyroid Scintigraphy
Robert Moser & Lynn Zeyher
Pennsylvania College of Health Sciences - Nuclear Medicine Department
[email protected] and [email protected]
Primary hyperparathyroidism is generally the result of a functioning parathyroid
adenoma. Sestamibi parathyroid scintigraphy is used to localize the parathyroid
adenoma. The scintigraphy is highly accurate and reliable, thus allowing surgeons
to use less invasive techniques. A minimally invasive parathyroidectomy (MIRP)
allows the surgeon to operate only in the area necessary. In a case study of
patients who had a parathyroid SPECT scan in 2013 at Lehigh Valley Hospital Cedar
Crest, research attained examined the number of patients positively diagnosed with
a parathyroid adenoma by parathyroid scintigraphy who underwent MIRP or neck
exploration, with pathological confirmation of the parathyroid adenoma diagnosis.
The case study consist of 123 patients having a parathyroid scintigraphy from
01/01/2013 through 12/23/2013. Of those studies, 30% were negative, 16%
involved preoperative study for localization with a gamma probe during the MIRP, 2%
were inconclusive results due to a suboptimal study, and 32% had a positive
parathyroid SPECT scan, but to date have not scheduled any follow up or had follow
up at a different facility. Of the remaining 19%, which are the focus group of this
paper, two patients had a sestamibi SPECT scan and preoperative localization, but
required open parathyroidectomy due to other circumstances; the balance of 22
patients underwent MIRP. Sestamibi parathyroid scintigraphy, to determine
parathyroid adenoma, is an accurate method of diagnosis confirmed with postsurgical assay at Lehigh Valley Hospital Cedar Crest.
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#36
Radiation Safety Policies For Pregnancy Should Show Uniformity Throughout All
Medical Facilities
Lindy Seitz and Heather Sorg
Pennsylvania College of Health Sciences - Nuclear Medicine Department
[email protected] and [email protected]
Nuclear medicine is a form of diagnostic imaging that involves the preparation and
administration of radioactive isotopes to patients. As with any type of radiation,
nuclear medicine departments need to make sure that their patients and
technologists are not being overexposed. Pregnant patients and technologists
should be the most cautious because radiation can leave permanent damage and
be life threatening to the unborn child or even to a child still being breastfed. A
study was done to see what types of policies are carried by seven of the ten
hospitals within the Pennsylvania College of Health Sciences consortium. After
conducting the study, it was found that most of the hospitals are required to ask all
female patients between the ages of 12 and 55 if they are pregnant or
breastfeeding. If the patient is unsure, she must have a pregnancy test done prior to
the exam. Tests will not be done on pregnant patients unless the benefits outweigh
the risks. As for female technologists, a declaration of pregnancy must be turned in
so that the proper precautions and monitoring can begin. The policies at the seven
different hospitals are very similar, but had enough differences to conclude that
changes need to be made in order to make a policy that is more uniform
throughout all medical facilities.
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#37
Pediatric Radiopharmaceutical Doses: How They Are Calculated and the Need for
Standardization
Shakira Tassone and Alexis Perez
Pennsylvania College of Health Sciences - Nuclear Medicine Department
[email protected], [email protected]
This poster explores how pediatric radiopharmaceutical doses are being calculated
by seven different clinical sites that are associated with the Pennsylvania College of
Health Sciences’ nuclear medicine program and one major research hospital. Our
research has shown that these eight sites calculate their pediatric doses using
varying methodologies. Some of the methods being used include physician
suggested values, the use of Clark’s Rule, and other sites rely on the guidelines set
forth by Image Gently. While the resulting dose values only differ by a small amount,
we still question why all the clinical sites are not following the Image Gently
Guideline. We propose that if the Image Gently Guidelines were employed as a
regulation it would diminish unnecessarily high doses and educate physicians. In
turn, this would encourage technologists to become more aware of protocol
selections, monitoring mA values, and shielding precautions. The findings and
future proposals presented within this poster are intended to educate physicians,
technologists, and medical institutions on the importance of the implementation of
Image Gently Guidelines. These guidelines provide the safest and most effective
ways to decrease exposure to you and your patient. Thus, solidifying exactly what it
means to “Image Gently.”
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We would like to thank all of the participants in this year’s
poster session.
For more information on this event please contact:
LG Research Institute
717-544-5999
[email protected]
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