Using a Built-in Clinical Decision Support to Improve Phosphate Repletion Practice: A Quasi-Experimental Study.

Background: Inpatient serum phosphate replacement is common, but there is great variability in replacement practice, which leads to overuse. Electronic health record (EHR) interventions with clinical decision support (CDS) can be effective tools to guide clinicians toward best clinical practices. The authors' objective was to use CDS tools to reduce overuse of hypophosphatemia corrections at a large safety-net health care system.

A Systemwide Strategy to Embed Equity into Patient Safety Event Analysis.

Background: There is a lack of framework to incorporate equity into event analysis. This quality improvement initiative involved the development of equity tools that were introduced in a two-hour interactive, case-based training across 11 acute care facilities at the largest municipal health care system in the United States. A pre and post survey (which included analysis of a clinical vignette) was also conducted to assess for knowledge and comfort embedding equity in patient safety event analysis, and to measure discomfort or distress during the training.

Initiative to reduce unnecessary routine daily testing of complete blood counts across 11 safety net hospitals.

Objectives: National societies recommend against performing routine daily laboratory testing without a specific indication. Unnecessary testing can lead to patient harm, such as hospital-acquired anemia. The objective of this study was to reduce repeat complete blood counts (CBCs) after initial testing.

Choosing Wisely and reducing the simultaneous ordering of erythrocyte sedimentation rate and C-reactive protein testing in a large safety net system.

Objectives: C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are commonly used inflammatory markers. C-reactive protein is more sensitive and specific for monitoring acute inflammation. However, it is commonly co-ordered with ESR despite recommendations against this.

Imaging Wisely Campaign: Initiative to Reduce Imaging for Low Back Pain Across a Large Safety Net System.

Objectives: Low back pain is a common clinical presentation that often results in expensive and unnecessary imaging that may lead to undue patient harm, including unnecessary procedures. We present an initiative in a safety net system to reduce imaging for low back pain.

Methods: This quality improvement study was conducted across 70 ambulatory clinics and 11 teaching hospitals.

Reducing Overuse of 3-Day Repeat Type and Screen Testing across an 11-Hospital Safety Net System.

Background: According to the American Association of Blood Banks, a Type and Screen (T&S) is valid for up to three calendar days. Beyond a limited number of clinical indications such as a transfusion reaction, repeat T&S testing within 3 days is not warranted. Inappropriate repeat T&S testing is a costly medical waste and can lead to patient harm.

Reducing daily dosing in opioid prescriptions in 11 safety net emergency departments.

Background: The United States continues to face a significant issue with opioid misuse, overprescribing, dependency, and overdose. Electronic health record (EHR) interventions have shown to be an effective tool to modify opioid prescribing behaviors. This quality improvement project describes an EHR intervention to reduce daily dosing in opioid prescriptions in 11 emergency departments (ED) across the largest safety net health system in the US.

Reducing duplicate genetic testing in inpatient and outpatient settings across a large safety-net system.

Objectives: To develop a system-wide electronic health record (EHR) intervention at a large safety-net hospital system to reduce wasteful duplicate genetic testing.

Methods: This project was initiated at a large urban public health care system. An EHR alert was designed to be triggered when a clinician attempted to order any of 16 specified genetic tests for which a previous result existed within the EHR system.

Reducing Inappropriate Simultaneous Ordering of Heparin Antibody and Serotonin Release Assays.

Introduction: A 4T score with intermediate or high probability of heparin-induced thrombocytopenia prompts ordering of anti-platelet 4 heparin complex. If positive, a serotonin release assay (SRA) is recommended to confirm diagnosis. Despite these recommendations, overtesting of both anti-platelet 4 and SRA is highly prevalent.

Reducing 25-Hydroxyvitamin D Testing in a Large, Urban Safety Net System.

Background: 25-Hydroxyvitamin D testing is increasing despite national guidelines and Choosing Wisely recommendations against routine screening. Overuse can lead to misdiagnosis and unnecessary downstream testing and treatment. Repeat testing within 3 months is a unique area of overuse.

Reduction of Intravenous Antihypertensives through Clinical Decision Support in a Large Safety Net System.

Background: Asymptomatic severe hypertension (also known as hypertensive urgency) is frequently encountered in the hospital. Previous evidence suggests that management with one-time doses of intravenous (IV) antihypertensives may increase adverse events. Despite this, single-dose treatment remains common in the emergency department and inpatient settings.

Diarrhea don'ts: Reducing inappropriate stool cultures and ova and parasite testing for nosocomial diarrhea.

Background: Diarrhea that develops in patients after 72 hours of hospitalization is likely to have a nosocomial or iatrogenic etiology. Testing with stool cultures and stool ova and parasites (O&P) is not recommended. Our goal was to reduce this inappropriate testing within a large, urban safety-net hospital system.

Nudging to select single-lumen over multiple-lumen peripherally inserted central catheters (PICCs) in a large safety net system.

Background: Peripherally inserted central catheters (PICCs) are increasingly used for vascular access in inpatient settings. Compared to multilumen PICCs, single-lumen PICCs carry a lower rate of complications, including central-line-associated bloodstream infection and thrombosis. Despite this, multilumen PICCs are still overused.

Choosing wisely initiative for reducing urine cultures for asymptomatic bacteriuria and catheter-associated asymptomatic bacteriuria in an 11-hospital safety net system.

Background: Treatment of asymptomatic bacteriuria (ASB) is common. Overtreatment of ASB leads to harm, including adverse effects from antibiotics, antibiotic resistance, and increased length of stay.

Methods: This quality improvement initiative targeted inappropriate urine cultures across 11 hospitals in a safety-net setting.

Tell-a provider about tele: Reducing overuse of telemetry across 10 hospitals in a safety net system.

Background: Telemetry is often a scarce resource at hospitals and is important for arrhythmia and myocardial ischemia detection. Overuse of telemetry monitoring leads to alarm fatigue resulting in failure to respond to arrhythmias, patient harm, and possible unnecessary testing.

Methods: This quality improvement initiative was implemented across NYC Health and Hospitals, an 11-hospital urban safety net system.

SEE the DIFFerence: Reducing unnecessary C. difficile orders through clinical decision support in a large, urban safety-net system.

Background: Clostridioides difficile (C. difficile) is a hospital-acquired infection. Overtesting for C.

Reducing unnecessary routine laboratory testing for noncritically ill patients with COVID-19.

Background: Reducing unnecessary routine laboratory testing is a Choosing Wisely® recommendation, and new areas of overuse were noted during the COVID-19 pandemic.

Objective: To reduce unnecessary repetitive routine laboratory testing for patients with COVID-19 during the pandemic across a large safety net health system.

Designs, Settings And Participants: This quality improvement initiative was initiated by the System High-Value Care Council at New York City Health + Hospitals (H + H), the largest public healthcare system in the United States consisting of 11 acute care hospitals.

Staying Connected In The COVID-19 Pandemic: Telehealth At The Largest Safety-Net System In The United States.

New York City Health + Hospitals is the largest safety-net health care delivery system in the United States. Before the coronavirus disease 2019 (COVID-19) pandemic, NYC Health + Hospitals served more than one million patients annually, including the most vulnerable New Yorkers, while billing fewer than five hundred telehealth visits monthly. Once the pandemic struck, we established a strategy to allow us to continue to serve our existing patients while treating the surge of new patients.

National Outreach of Telepalliative Medicine Volunteers for a New York City Safety Net System COVID-19 Pandemic Response.

The coronavirus disease 2019 surge in New York City created an increased demand for palliative care (PC) services. In staff-limited settings such as safety net systems, and amid growing reports of health care worker illness, leveraging help from less-affected areas around the country may provide an untapped source of support. A national social media outreach effort recruited 413 telepalliative medicine volunteers (TPMVs).

Emergency management of renal and genitourinary trauma: best practices update [digest].

In up to 10% of patients who experience abdominal trauma, renal and urogenital systems will be involved. In polytrauma patients with other potentially life-threatening injuries, renal and genitourinary trauma may be overlooked initially, but a delayed or missed diagnosis of these injuries may result in preventable complications. This review provides a best-practice approach to the diagnosis and management of renal and genitourinary injuries, with an emphasis on the systematic approach needed to identify subtle injuries and avoid long-term urinary sequelae such as hypertension, incontinence, erectile dysfunction, chronic kidney disease, and nephrectomy.

Maxillofacial trauma: managing potentially dangerous and disfiguring complex injuries [digest].

Patients with maxillofacial trauma require a careful evaluation due to the anatomical proximity of the maxillofacial region to the head and neck. Facial injuries can range from soft-tissue lacerations and nondisplaced nasal fractures to severe, complex fractures, eye injuries, and possible brain injury. Though the Advanced Trauma Life Support (ATLS) guidelines provide a framework for the management of trauma patients, they do not provide a detailed reference for many subtle or complex facial injuries.

Noninvasive ventilation for patients in acute respiratory distress: an update [digest].

Over the last 20 years, noninvasive ventilation (NIV) strategies have been used with increasing frequency. The ease of use of NIV makes it applicable to patients presenting in a variety of types of respiratory distress. In this review, the physiology of positive pressure ventilation is discussed, including indications, contraindications, and options for mask type and fit.