Promoting early goals of care conversations in the CICU with a surprise question-based EHR workflow.

Background: The Surprise Question (SQ) - Would you be surprised if this patient died within the next 6 months? - is a validated tool for mortality prediction. The Mount Sinai Cardiac Intensive Care Unit (CICU) incorporated the SQ into a novel EHR workflow to identify patients who would benefit from early initiation of Palliative Care (PC).

Methods: Implementation of the SQ proceeded in two steps.

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.

Reducing low-value ED coags across 11 hospitals in a safety net setting.

Background: Prothrombin/international normalized ratio and activated partial thromboplastin time (PT/INR and aPTT) are frequently ordered in emergency departments (EDs), but rarely affect management. They offer limited utility outside of select indications. Several quality improvement initiatives have shown reduction in ED use of PT/INR and aPTT using multifaceted interventions in well-resourced settings.

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.

An interdisciplinary student-led multifaceted intervention addressing overuse of broad-spectrum antibiotics for patients with penicillin allergies.

Background: Though 15% of hospitalized patients have a documented penicillin (PCN) allergy, fewer than 1% have an IgE-mediated reaction that necessitates avoidance of β-lactam antibiotics.

Objective: Our interdisciplinary team of medical and nursing students led and executed a two-pronged quality improvement intervention to reduce prescribing of non-β-lactam antibiotics (NBLs) for patients with reported PCN allergies. To the best of our knowledge, this is the first multidisciplinary student-led intervention aimed at educating providers on low-risk penicillin allergy and encouraging best antibiotic prescribing practices.

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.

Interventions to reduce repetitive ordering of low-value inpatient laboratory tests: a systematic review.

Background: Over-ordering of daily laboratory tests adversely affects patient care through hospital-acquired anaemia, patient discomfort, burden on front-line staff and unnecessary downstream testing. This remains a prevalent issue despite the 2013 Choosing Wisely recommendation to minimise unnecessary daily labs. We conducted a systematic review of the literature to identify interventions targeting unnecessary laboratory testing.

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.

Student High Value Care Initiative: a Longitudinal Model for Student-Led Implementation and Scholarship.

Background: Educating medical trainees to practice high value care is a critical component to improving quality of care and should be introduced at the beginning of medical education.

Aim: To create a successful educational model that provides medical students and junior faculty with experiential learning in quality improvement and mentorship opportunities, and produce effective quality initiatives.

Setting: A tertiary medical center affiliated with a medical school in New York City.

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.