Scholarship & History

• Implementing Mobile Text-messaging to Improve Attendance at Well Visits in Primary Care Pediatrics

  Osuagwu, Ngozi E.; Connolly, Mary Ellen (2019-05)

  Background: Missed appointments are a long-standing problem encountered both in the United States and abroad with rates ranging anywhere from 5% to 55%. It is a major cause of inefficiency in the medical system and consequences include poor health outcomes, wasted health care dollars, waste of provider time and adverse effect on patient -provider relationship. Local Problem: No-shows are a significant problem in primary care especially in underserved populations. The implementation site for this quality improvement project provides care to an underserved population with a no-show rate of 35%. The purpose of the DNP quality improvement project was to implement and evaluate the use of mobile text messaging to reduce the non-attendance rate to routine well visits in a primary care pediatric clinic in inner city Baltimore. There is evidence to support the use of text message reminders to improve both medication adherence and attendance rates when compared to other available appointment reminder systems. Intervention: The project was implemented in a sample of patients by nurses, front office staff and providers. The intervention involved sending text message appointment reminders to patients. The attendance rate was later analyzed and compared to the attendance rate prior to the implementation period. Inclusion criteria for the patient population was patients aged 18 years and older or the legal parent or guardian of a patient who was under the age of 18 years. Staff attended a 4-hour training session, which was led by the project leader and I.T. personnel. A preimplementation survey was conducted to determine patients’ and parents’ perception of the planned mobile text-messaging system. The questionnaire was quantified, averaged and the result was favorable. During the implementation period, data was collected that reflected the rate of attendance during the project. This information was aggregated and stored by the EHR system. Data was retrieved from the EHR and Run charts were used for data analysis. Results: The attendance data from the intervention showed that there was no significant increase in attendance to well visits for October, November and December compared to the preceding months of July, August, and September 2019. Conclusions: Though the result of the intervention did not reflect the expected impact, several lessons were learned. There were some positive unexpected findings, including an increase in portal registration, improvement in the update of patient phone numbers in the EHR database, and greater rapport among staff due to teamwork.
• Improving Provider Documentation and Billing Through the Implementation of a Standardized Note

  Silverman, Dawn Marie; Hammersla, Margaret (2019-05)

  Background: As the demand for critical care services grow and the intensivist provider pool diminishes, advanced practice providers are increasingly integrated into intensive care units. However, advanced practice providers often enter the profession without proficiency in the billing practices necessary to ensure their work is reimbursed. Critical Care Management, Current Procedural Terminology codes 99291 and 99291, are services exclusive of any global payment. These two codes represent a significant amount of a provider’s billable activities in the intensive care setting. In the absence of education addressing billing requirements for these codes, provider documentation often fails to meet the standard for reimbursement. Money is left on the table and provider work is not adequately represented in reimbursement. Targeted education and standardized documentation can improve the quality of documentation, billing competency, and contribute to increased revenue. Local Problem: In surveys conducted pre-implementation, the majority of advanced practice providers at the project site reported a lack of billing and requisite documentation training and competency. Additionally, documentation audits validated that, often, advanced practice provider notes did not support their billable activities. The aim of this quality improvement project was to implement and evaluate the effectiveness of a standardized Event Note to improve documentation and billing of critical care management. Interventions: The implementation of this quality improvement project took place over a 12week period. Primary components of the implementation included: pre-implementation survey, pre-implementation online education module, implementation of a standardized Event Note, and post-implementation survey. Data were collected from all primary components. Results: Post-implementation of the standardized Event Note and online education module, 87.2% of providers agreed or strongly agreed with the statement, “The online billing education improved my billing competency.” Additionally, 94.9% agreed or strongly agreed with the statement, “This project heightened my awareness regarding the importance of documenting critical care events.” Further, 116 events notes and 5,777 critical care minutes were documented post-implementation compared with 64 event notes and 2,184 critical care minutes entered in the pre-implementation period. Critical care evaluation and management codes require the reporting of time in minutes. The standardized Event Note includes a prompt to enter the number of minutes spent in exclusive attention to a patient. Twenty-four event notes made no mention of time in the pre-implementation period and only six notes omitted a time element in the postimplementation period. This demonstrates a 75.00% decrease in event notes without a time element. The six event notes without a time element were the result of the provider using free text to document (n=2) or using an older unit-based event note (n=4). Post-implementation, 82.76% of all event notes submitted utilized the vetted, standardized Event Note. Conclusions: Advanced practice provider education and use of the standardized Event Note increased billing competency and awareness related to thorough and timely documentation of critical care management. Engaging providers in targeted education and providing standardized notes, built with attention to communication and required billing elements, is an effective and efficient means of improving documentation and reimbursement.
• Agitation Assessment and Management in the Emergency Department

  Legambi, Tabitha; Michael, Kathleen (2019-05)

  Background: Agitation is common in the emergency department. When agitation is not detected early, patients can become aggressive and violent. This can lead to increased restraint use. When restraints are used, patients and staff are more likely to become injured. Local Problem: An urban emergency department reported a lack of an objective tool for assessing patient agitation. The staff of the ED desired resources to better care for behavioral health patients. Intervention: The aim of the study was to implement the Behavioral Activity Rating Scale (BARS) in the electronic medical record of an urban ED during a 14-week quality improvement project. The goals of the project were early detection and management of patient agitation, reduction of restraint use in the emergency department, and to determine the usability of the BARS using the System Usability Scale (SUS). Results: The results of retrospective chart reviews revealed that BARS was documented frequently (n=4,867 documentations) by ED RN’s to assess patient’s with behavioral health and medical complaints (n=780). Though restraint use decreased in the first two months of the project, overall restraint use was increased in 2018 (µ=5.25; SD=3.10) compared to the previous year (µ=4.75; SD=2.99; p=0.71). However, patients who were placed in restraints, remained in restraints for fewer days in 2018 (µ=1.14; SD=0.69) compared to the previous year (µ=1.68; SD=01.20; p=0.04). The results of the SUS indicated that ED nurses found BARS to be usable. Conclusion: The BARS is a quick and easy tool to assess for patient agitation. With the incorporation of agitation management interventions, the ED team can potentially manage agitation before violence occurs. Further studies are needed on the use of BARS towards managing patient agitation and reducing staff violence in the ED.
• Biology and Bias in Cell Type-Specific RNAseq of Nucleus Accumbens Medium Spiny Neurons

  Kronman, H. (Nature Publishing Group, 2019-05-24)

  Subcellular RNAseq promises to dissect transcriptional dynamics but is not well characterized. Furthermore, FACS may introduce bias but has not been benchmarked genome-wide. Finally, D1 and D2 dopamine receptor-expressing medium spiny neurons (MSNs) of the nucleus accumbens (NAc) are fundamental to neuropsychiatric traits but have only a short list of canonical surface markers. We address these gaps by systematically comparing nuclear-FACS, whole cell-FACS, and RiboTag affinity purification from D1- and D2-MSNs. Using differential expression, variance partitioning, and co-expression, we identify the following trade-offs for each method. RiboTag-seq best distinguishes D1- and D2-MSNs but has the lowest transcriptome coverage. Nuclear-FACS-seq generates the most differentially expressed genes and overlaps significantly with neuropsychiatric genetic risk loci, but un-annotated genes hamper interpretation. Whole cell-FACS is more similar to nuclear-FACS than RiboTag, but captures aspects of both. Using pan-method approaches, we discover that transcriptional regulation is predominant in D1-MSNs, while D2-MSNs tend towards cytosolic regulation. We are also the first to find evidence for moderate sexual dimorphism in these cell types at baseline. As these results are from 49 mice (nmale = 39, nfemale = 10), they represent generalizable ground-truths. Together, these results guide RNAseq methods selection, define MSN transcriptomes, highlight neuronal sex differences, and provide a baseline for D1- and D2-MSNs. © 2019, The Author(s).
• REDUCING UNIT-ACQUIRED PRESSURE INJURIES ON A CARDIAC SURGERY PROGRESSIVE CARE UNIT

  McGinn, Amy E.; Davenport, Joan (2019-05)

  Background: Consequences of pressure injuries can be emotional and physical, including pain, body image distortion, increased risk for infection, increased length of stay in the hospital, and death. Pressure injuries create a significant economic burden for organizations and individuals. Organizations that have the highest incidences of pressure injuries receive less reimbursement for services. Local Problem: Prior to project implementation, 3 pressure injuries were found on the cardiac surgery progressive care unit during a 13-week period. The cardiac surgery progressive care unit in a large academic medical center in the mid-Atlantic region was responsible for 66% of the pressure injuries. The purpose of this quality improvement project was to implement and evaluate the effectiveness of a pressure injury prevention bundle on a cardiac surgery progressive care unit over a 13-week period using the Model for Improvement as a framework for implementation. Intervention: The pressure injury prevention bundle consisted of four steps: the Braden score, a two-nurse skin assessment on admission, a pressure-reducing surface, and a consult to the wound, ostomy, and continence nurse. Two-hundred one subjects were evaluated (n=201). The intervention was evaluated by a before-after design, comparing the number of avoidable unitacquired pressure injuries before project implementation, to after implementation of the PUPB. Results: Post-implementation, 4 pressure injuries were found on the cardiac surgery progressive care unit, but only 25% of the pressure injuries were determined to be the unit's responsibility, and 75% of the pressure injuries were determined to have occurred prior to admission to the unit. A nurse did not complete the two-nurse skin assessment on the one patient who developed a pressure injury during this project timeframe. The pressure injury was discovered 25.5 hours after admission to the unit, deeming it the cardiac surgery progressive care unit's responsibility. Conclusions: The pressure injury prevention bundle should be a standard of care for all new patient admissions. When all of these factors are used together in a bundle, this project demonstrates that the unit could have zero unit-acquired pressure injuries.

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