• PROPOSAL TITLE: Create sedation suite (either in Hem/Onc Treatment Room or PICU) for BCH Oakland
• PROJECT LEAD(S): not sure if anesthesia, surgical services or oncology should lead
• EXECUTIVE SPONSOR(S):
• ABSTRACT - One paragraph summary of your proposed initiative – Limit 1500 characters (with spaces) Establish a sedation suite where either anesthesia or PICU attending uses Propofol only for light sedation for Oakland hem/onc/BMT patients requiring lumbar puncture or bone marrow aspirate/biopsy.  This is standard in most pediatric hem/onc centers around the country (including San Francisco/Mission Bay I believe)
• TEAM - Core implementation team members and titles
• PROBLEM - Background of the problem.  What is the cost associated with this problem?  Why address this problem now? What is the current condition?  Currently Oakland pediatric Hem/Onc/BMT patients get their LPs and BMAs done in the OR.  OR Block time is very limited and does not always correspond with dates that therapy is due.  Patients (most of whom are 1-10 year old leukemia patients) repeatedly having to wait/remain NPO for extended periods of time.  The OR is extremely inefficient in terms of flow and there are limited resources (rooms, RNs, techs, anesthesiologists) so turnover is very slow.  Hem/Onc provider time also wasted waiting for turnover.  The delays are the #1 complaint lodged by parents of these patients.  The problem has gotten worse in recent months with OR room remodeling and loss of many of our anesthesiologists
• TARGET -  What is the goal?  What are the expected benefits, both qualitative and quantitative?  Reduce wait time and turnover time for pediatric onc patients who have mutiple procedures throughout their treatment
• GAPS - Why does the problem exist?  Describe system issues; technological gaps; educational gaps.  No champion to push for creation of designated space for these procedures. inefficiency built into the current system
• INTERVENTION - Describe your proposed intervention and rationale for approach. Describe your practice setting and target population (e.g. department, unit, clinic, patient characteristics, diagnosis group, procedural group, provider characteristics, staff characteristics, etc.). Describe potential barriers to implementation. What are the possible adverse outcomes that may occur that may affect quality of care and patient safety as a result of your proposed intervention?  Same as abstract
• PROPOSED EHR MODIFICATIONS Note: EHR modifications are NOT required for a winning proposal
• What are the clinical problems you are hoping to solve with APeX?
• What APeX tools (patient lists, reports) or workflows (orders, documentation, alerts) are you using now to achieve this goal? How would you want these modified?  Might need to create a new "location" within Apex since procedure would no longer be in OR.  Probably something already exists since this is the current model at Mission Bay campus
• What new APeX tools/workflows do you think you need to achieve the goals of your project? none
• COST - Estimated baseline costs to the health system and projected savings from the proposed project.  I don't have the means to estimate these costs but the current system causes so much extra manual manipulation and coordination that there would be savings from making the system more efficient
• SUSTAINABILITY - If successful, how will this intervention be sustained beyond the funding year?  Who are the key UCSF process owners?  Once established the sedation suite would perpetuate itself 
• BUDGET - Line-item budget up to $50,000 - Briefly identify key areas of the project that will require funding, e.g., salaries, software, printing, etc

• PROPOSAL TITLE: Reduce/mitigate congestion in hallways to ensure quick access for patient beds
• PROJECT LEAD(S): N/A
• EXECUTIVE SPONSOR(S): N/A
• ABSTRACT - An updated hospital policy to help ensure routes and pathways are clear for surgical/transport teams when moving patients through the hospital.
• TEAM - Medical and Engineering/Contractors
• PROBLEM - Elevators 3 and 4 are currently the only elevators large enough to accomidate a hospital bed with patient and medical team.  If the medical staff are moving a patient from one location to another within the hospital, they may come across the engineering staff or contractor/s with an extended containment cart in the hallways leading up to and away from elevators 3 and 4.  This creates a pathway too narrow for the hospital bed to go through, and requires the engineers/contractors to hastily pack up and move the cart out of the way to allow passage for the bed and medical team.
• TARGET -  Create a policy and proedure to mitigate the congestion of hallways when a medical team transport is being conducted.
• GAPS - The hallways are physically too narrow to allow a containment cart as well as a hospital bed in the same location.
• INTERVENTION - Proposal to create or amend policy for medical team to send a runner through the intended route that the proceeding medical team and patient will be taking.  This will give any staff with large obstructions in the way some heads up time to move equipment out of the way ahead of time and allow medical staff the opportunity to quickly and efficiently move to their intended destination. 
• PROPOSED EHR MODIFICATIONS - N/A
• COST - $0
• SUSTAINABILITY - The medical team charged with patient transport will be the key process owners of this policy.  
• BUDGET - No additional funding is required.

Patient waitlists for therapeutic services is a significant problem in the Department of Psychiatry and Behavioral Sciences that has become exacerbated with the pandemic.  This problem is reflective of the broader challenges to access mental health services within our community and field. Waitlists are costly for everyone involved in the health system. They are problematic for both patients and clinical care teams. For the healthcare system, waitlists are the result of limited access to care. Patients can be on the waitlist for a duration of up to one year, particularly in our division where the demand for care is higher than the number of available providers. Waitlists leaves patients without care from the UCSF health system, resulting in prolonging symptoms that  place them at-risk for increased symptom severity and the need for more intensive or prolonged care in the long run. For the clinical team, the time and effort spent in managing the waitlist results in lost productivity and provision of active patient care efforts that negatively impacts every team member from the administrative to the direct care team. Therefore, this proposal aims to reduce the “waste” associated with waitlists for clinical services with a brief care model for families on the waitlist: Bridge Program.

• PROPOSAL TITLE: Pediatric cardiac surgery coordinator for weekends
• PROJECT LEAD(S): Pediatric cardiac surgery NP's, coordinator for surgery
• EXECUTIVE SPONSOR(S): UCSF Benioff Children's Hospital Department of Cardiac-Thoracic Surgery
• ABSTRACT - Providing a cardiac or surgical team member to help navigate the out-patient and family on the weekends, from the front door to the surgery pre-op and waiting areas. Provide answers and act as liason throughut the procedure.
• TEAM - Carol M. Costello, RN Pedi OR; E. Echavarria,RN pediatric cardiac surgery coordinator
• PROBLEM -It has often ben witnessed that the family and patient arriving in the early morning are directed to an empty surgical waiting area or held in the security department as the pre-op and intake areas are not staffed on the weekend. My suggestion is they meet a point person, available the night before, who meets them at the front door of the hospital the morning of surgery. This contact person will stay with family through till the moment their child goes into surgery and offfers support and instruction on where to wait and what to expect through the day. The cost of providing this person is dependent on wether it is a full time or part time, on call position.
• TARGET -  The goal of this proposal is to eliminate confusion and instill increased confidence in admitting a pediatric cardiac patient for surgery.  In addition, the benefit to the patient experience will be altered to reflect a higher level of care model with uninterrrupted personal attention, which can often be over looked on the weekends.
• GAPS - Ibelieve this scenario has developed due to the increasing cardiac surgical patient load as well as patients coming from many destinations state-wide and nationally.   
• INTERVENTION - The need for this proposed intervention has come to the attention of pediatric surgery personel as we have often had to find families that have been deposited in the hospital waiting area- an area that is NOT staffed on the weekends. The pediatric cardiac surgery team is involved in getting the operating room prepared for high acuity and lengthy procedures; very often this can not be interrrupted to locate family and someone less qualified or over-wualified is asked to find the family and bring them to the surgical suite.
• The provider will be a nurse who is well versed in the cardiac surgery service, able to provide answers and support to the family throughout the in-take process day of surgery.I do not foresee potential adverse affects with this implementation, only the increase in patient and family experience of a very high stress and acute procedure.
• COST - The estimated value of this service can not be qualified as it is experience based.
• SUSTAINABILITY - If successful, this service can enhance and increase the level of care provided by the UCSF Benioff Children's Hospital cardiac-thoracic surgery division leading to national recognition as a leading in patient care, ecperience, and outcomes.
• BUDGET - On call or part-time position. UCSF volte phone for inter-hospital use throughout UC systems.

PROJECT LEAD: Elizabeth Holt, MD PhD, Professor of Medicine and Surgery and Director of Inpatient Endocrinology and Transition Care, Division of Endocrinology

EXECUTIVE SPONSOR: TBA and Suneil K Koliwad, MD, PhD, Chief Division of Endocrinology and Metabolism, UCSF

ABSTRACT: Currently the UCSF Inpatient Endocrine Consult Service does not have a standardized protocol for managing diabetes in patients after discharge. Average wait for a follow up Diabetes Clinic visit at UCSF averages 32 days. The 30-day readmission rate for patients with diabetes on the medical service at UCSF is 8.2%, which is 32% higher than the national benchmark of 6.2%. With the Home Sweet Home initiative we aim to standardize and streamline the transition process from hospital to home, reduce disparities in available glucose monitoring technologies for patients at discharge, optimize communication with outpatient Diabetes Clinic providers and improve patient access to Diabetes Clinic APP's who will adjust insulin between discharge and Diabetes Clinic follow up. We aim to reduce disparities in access to Diabetes Clinic providers in the interval between discharge and first follow up visit.  We also aim to reduce the wait time substantially for outpatient follow up appointments in the Diabetes Clinic. Our goals with this initiative include improving patient safety and satisfaction and reducing risk of readmission for patients with diabetes. By being proactive about contacting all patients on insulin after discharge we aim to reduce disparities in diabetes management during the transition period caused by language barriers or lower health literacy. We expect these interventions can be generalized to other acute endocrine conditions and to other services beyond Endocrinology.

TEAM: Esther Rov-Ikpah RN-BC, MS, CDE, Meghan Talbert RN, CNS, CDE

PROBLEM: Diabetes is a chronic illness affecting 11.3% of United States adults or 37 million people nationwide, with a higher burden on those who identify as non-white or have relatively less education (A). One third of hospitalized adults have diabetes (B). Among those in the US with diabetes, approximately 30% use insulin alone or in combination with oral medications (C). Patients with diabetes have a higher rate of 30-day readmission than those without diabetes (up to 22.5 % vs 13.5%) (D), which in some cases is due to suboptimal glycemic control after discharge. Contributors to readmission in the first 30 days for all medical conditions include patients' inability to get to their follow up appointments, patients' not knowing how to reach their physician after discharge, lack of communication between inpatient and outpatient providers, and barriers related to language proficiency and health literacy (E).

TARGET: Goals of the Home Sweet Home initiative that align with the goals of Caring Wisely FY2024 include:

• Reducing Hospital Readmissions
• Improving Hospital Throughput and Reducing Excess Inpatient Bed Days
• Improving Clinic Access
• Improving Health Equity

GAPS:

• Wait time to follow up Diabetes Clinic visit at UCSF after discharge from UCSF system hospitals currently averages 32 days.
• The 30-day readmission rate for patients with diabetes on the medical service at UCSF is 8.2%, fully 32% above the national benchmark as detailed in the Abstract.
• Glycemic control in patients immediately following discharge is often a "moving target" due to changes in contributing factors such as dosing of medications that impact blood sugars (e.g. steroids), diet, renal function, activity level and acuity of illness.
• A supply of Freestyle Libre 2 continuous glucose monitor (CGM) sensors has already been secured by Dr. Robert Rushakoff from the manufacturer, Abbott, to offer to patients with diabetes who are followed by the endocrine consult service.  The sensor is placed at discharge by the Diabetes Education (CDE) team to allow closer monitoring of blood sugars at home.  In addition this device will alarm if glucoses are outside set parameters.  Use of this device requires the patient to download an app only compatible with a newer model smart phone or obtain the manufacturer’s reader to present the data.  The reader is not currently available free of charge, but costs $70-140 to obtain and may not be covered by insurance.  Thus patients with lower resources whose phones cannot use the reader app are unable to make use of the free CGM we offer. 
• The inpatient Hospitalist Medicine service has a series of successful interventions for patients they discharge to prevent complications and readmission such as the Care Transition Outreach Program (CTOP) where patients are contacted after discharge to check for problems or questions. Currently there is no comparable formal system in place within the UCSF Endocrinology practice to track our patients with diabetes after discharge from inpatient medicine, surgery and OB/GYN while they await their Diabetes Clinic appointments. Currently management of our patients' glycemic control during the transition is handled on an ad hoc basis by the consult team with differences in approach from one fellow or attending to the next.
• Patients with language, communication or health literacy barriers may be less likely to reach out for help during the transition period and may benefit from contact initiated by a Diabetes Clinic APP after discharge to ensure their glucose is in satisfactory range.
• Given the current lack of a standardized protocol for monitoring blood sugars by the outpatient Diabetes team immediately after discharge and the month-long average wait for a follow up appointment, we postulate that hospital discharges may be delayed by the consult team to ensure glycemic control is fully optimized. We expect with a reliable standardized protocol for close follow up by the outpatient team during the transition period and with a decreased wait for follow up appointments the consult team will be willing to see patients with diabetes discharged from the hospital earlier.

INTERVENTION DESCRIPTION:
With the Home Sweet Home initiative, our goal is to standardize how patients followed on the UCSF endocrine consult service for diabetes on insulin are monitored and managed as they transition to home and await their next UCSF Diabetes Clinic visit. In addition we aim to reduce the wait time for their next clinic visit from the current average of 32 days to under 14 days. We will offer the Home Sweet Home intervention from the time of discharge until the first outpatient Diabetes Clinic visit to all patients who are at risk for changes in insulin requirement while they await their follow up visit in Diabetes Clinic. This includes patients with anticipated changes in medications that impact blood sugar (e.g. tapering steroids), diet, renal function, activity level and acuity of illness. In addition patients who are new to insulin use or otherwise deemed at risk by the consult team will be offered the Home Sweet Home intervention.

I. Standardizing the transition from inpatient to outpatient care:

1. Preparation of patient prior to discharge with information and supplies for self-monitoring of blood glucose:

• The Freestyle Libre home glucose meter provides glucose measurements via a disposable 14-day sensor applied to the skin that samples extracellular fluid.  Results are accurate enough to inform insulin dosing in most cases.  We will continue to supply every patient who is able to use one with a free 14-day CGM sensor at discharge.
• The CDE team will apply CGM to patient and train patient in use of CGM on the day of discharge.
• Patients whose smart phones can serve as CGM readers will have assistance from the diabetes educators with the necessary app download and its use.  Patients who do not have a compatible smart phone will be provided a free generic Freestyle Libre 2 reader paid for through Caring Wisely funds.
• Patients who decline a CGM will be instructed to continue fingerstick glucose monitoring at a frequency recommended by the endocrine consult team
• Patients going home with a CGM will have it set by the CDE team to alarm for high and low blood sugars.  All patients will be provided on discharge with blood sugar parameters that should prompt an immediate call to the clinic for advice.  This information will be provided in discharge paperwork and communicated verbally by the consult team to the patient and their supports with teach-back to ensure comprehension.

 2. Brief communication between consult team and outpatient UCSF Diabetes Clinic MD and APP at the time of discharge:  A simple templated Staff Message will be sent to the new or existing outpatient diabetes provider to ensure they are aware of the patient’s admission, the reasons for admission, insulin regimen and glucose monitoring plan at discharge, date of follow up visit and any issues to address at follow up. 

3. Clinic-initiated close telephone follow up while awaiting Diabetes Clinic appointment:

• A phone call will be initiated by the APP from the Diabetes Clinic to all patients 1-2 days after discharge to get information on their glycemic control. APP will manage any needed insulin adjustments, following up with patient over the subsequent days as needed until their scheduled clinic visit. This may be billed under code 99091 for remote interpretation of physiologic data and constitutes 1.1 wRVU.
• During the initial phone call from the APP the patient will be reminded of their upcoming clinic visit and any barriers to attendance will be addressed.

II. Decreasing wait time to Diabetes Clinic follow up visit:  We will block out slots in all Diabetes Clinic providers' schedules that are earmarked only for hospital follow up and cannot be filled more than 14 days in advance to allow quicker follow up than currently available. These encounters may be by video, phone or in-person. These clinic slots will be designed to accommodate an total of 2 patients per week initially. The number of earmarked slots will be adjusted with time as we monitor and respond to scheduling needs.

III. Data collection: Data for glycemic control during the transition period, wait time to follow up appointment and reduction in readmission rate will be collected from pre- and post-initiation of the Home Sweet Home initiative.

PROPOSED EHR MODIFICATIONS:
- Creation of a simple smart phrase template in Epic by the Project Lead to communicate at the time of discharge with the patient's primary outpatient Diabetes Clinic MD or APP with a copy to the APP who will be reaching out to the patient 1-2 days after discharge. This message will include major reasons for hospitalization, diabetes regimen at discharge, clinic follow up date, and issues needing follow up in clinic.
- Creation of simple smart phrase in Epic by the Project Lead to provide the patient with individualized glucose parameters that should prompt a call right away to the Diabetes Clinic and the Clinic's contact information. This will also include information on how to have a language interpreter join the call. This information will be added to discharge paperwork.

COST:
$72/generic version of Freestyle Libre reader for patients who do not have compatible smart phone.

One patient per week discharged from endocrine consult service will qualify for the generic Freestyle Libre reader.

SUSTAINABILITY:
Interventions to improve clinic wait time and communication with the outpatient Diabetes team after discharge should be easily sustainable if staffing levels are kept constant or increase. Cost of the CGM kit though the Abbott program may not remain free indefinitely. Our goal in collecting data about the benefits of the Home Sweet Home initiative is in part to assist in securing funding from the Health System to continue with Home Sweet Home after the Caring Wisely budget period is over.  We expect these interventions can be generalized to other acute endocrine conditions and to other services beyond Endocrinology. 

BUDGET: 
Cost of generic Freestyle Libre 2 CGM $72

Number of patients with diabetes discharged from the consult service per week who will qualify for the free CGM reader = 1

$72/week x 52 weeks = $3744/year

REFERENCES:
A. https://nationaldppcsc.cdc.gov/s/article/CDC-2022-National-Diabetes-Stat... (accessed 2/28/2023)
B. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb279-Diabetes-Inpatient... (accessed 2/28/2023)
C. https://www.niddk.nih.gov/-/media/Files/Strategic-Plans/Diabetes-in-Amer... (accessed 2/28/2023)
D. Ostling, S., Wyckoff, J., Ciarkowski, S.L. et al. The relationship between diabetes mellitus and 30-day readmission rates. Clin Diabetes Endocrinol 3, 3 (2017). https://doi.org/10.1186/s40842-016-0040-x
E. Auerbach AD, Kripalani S, Vasilevskis EE, et al. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med. 2016;176(4):484–493. doi:10.1001/jamainternmed.2015.7863

• PROPOSAL TITLE: Improvement of  Interoperability with pre-assessment screening of planned surgical candidates within the UCSF system 
• PROJECT LEAD(S): To be determined 
• EXECUTIVE SPONSOR(S): Case management department 
• ABSTRACT - As per diem case manager servicing the Mount Zion ortho campus, I, Charles Bell have found a common occurrence of patients admitted for planned procedures without adequate pre-operative screening or the communication of the results. The standard of care for all planned surgeries is for a pre-operative screening to occur with details such as support post-operatively, financial concerns (including insurance), transportation for post-discharge, and if indicated, discussions about options for home health, SNF, or acute rehab facilities. My experience is that documentation or discussion of mentioned standards is not addressed in the pre-operative screening or if it does the information is not available for the inpatient case manager to view. This lack of information collected or inability to view causes tremendous barriers to discharge planning, frustration with patients and families, burnout of inpatient case managers due to increased workload, increased length of stay, denial from insurance companies due to lack of medical necessity for continued stay, delay in appropriate treatment of patients and ultimately loss in revenue for the UCSF system. 
• TEAM - Team members for the project would include the case management department both inpatient and outpatient.  Pre-screening individuals in the surgeon's office, physical and occupational therapist. Informatics department 
• PROBLEM - The problem is the failure to create interoperability between systems at UCSF to allow for inpatient, outpatient teams, and the surgeon's offices to communicate effectively.  I would imagine the cost of this problem to be tremendous.  Maybe to be in the millions of dollars on a yearly basis. I believe that addressing poor utilization of resources to maximize revenue is always something to be looked into for the betterment of the system. 
• TARGET - To create interoperability with the use of existing technologies for the betterment of patient outcomes and overall job satisfaction of employees.  I firmly believe that with a little effort, revenue can be maximized and patient outcomes and staff job satisfaction can improve dramatically 
• GAPS - A problem exists due to the lack of interoperability between existing technologies. I believe that creating simple lines of communication with outpatient,  inpatient case management, and surgeon's offices would help to reduce gaps 

• INTERVENTION - My intervention plan would be to create a workflow improving lines of communication between the surgeon's office, and outpatient and inpatient services.  This could be through the use of digital technologies such as Voalte or through the EPIC assessment tab.  In other words, information could be passed to the inpatient case managers once the prescreening of patients has occurred allowing for better planning.  This would include a population of planned surgeries for all campuses at UCSF.  Barriers to implementation would be buy-in from the staff potentially as initially, this would involve a change in workflow.  However, I believe that ultimately it would improve the work environment tremendously.  I do not anticipate any negative outcomes for patients from this proposal 
• PROPOSED EHR MODIFICATIONS Note: I believe that UCSF has the technology in place to facilitate the transfer of this information between interdisciplinary team members.  i just believe that it is not being utilized. I believe the problems solved here will be happier staff and patients due to a decrease in stress levels from better planning. In addition, research has shown that the increased length of staff for inpatient status increases the risk of nosocomial infections. 

• Why does the problem exist? Poor utilization of resources 
•  Describe system issues; technological gaps; educational gaps with APeX?  I believe that lack of education about good discharge planning is part of the issue.  Once practitioners understand the dynamics of great case management then they will see improvements in the workflow through the utilization of technology 

• COST - I believe the financial gain from improvements would be tremendous.  Surgical services are the highest income for hospital systems and any improvement in workflow would show tremendous gains. I do not believe the financial cost of implementation would be costly.  This is a problem that I believe could be solved without complex interventions. UCSF has the existing staff and technology in place.  
• SUSTAINABILITY - I do not believe further funding would be necessary as key players in implementation are already in the plan
• BUDGET - Line-item budget up to $50,000 -  There could be the potential for adjustment in digital technology systems such as Voalte or other EPIC adjustments. 

PROJECT LEAD(S): Jane Jih, MD, MPH, MAS and Atrejo "Trey" Patridge, NP, UCSF Health Mount Zion Division of General Internal Medicine General Medicine (DGIM) Practice

EXECUTIVE SPONSOR(S): Adele Anfinson, Eric McNey

ABSTRACT: The overall health of our patients is linked to their social and economic conditions, and access to transportation is integral to well-being and delivery of patient-centered primary care. By providing some of our most vulnerable patients with reliable transportation, we believe we will advance the health of our patients by improving continuity of care with their primary care team and could reduce the need for unnecessary visits to the ER, reduce avoidable hospital readmissions, and improve patient satisfaction with the healthcare system. Leading up to this project, our team has been iterating on an approach to implement a transportation voucher program for patients that have a high no show rate and transportation barriers to engage in primary care. The main goal of this proposal is to implement a ride share voucher pilot for a subset of DGIM patients that have a high no show rate, screen positive for transportation barriers and have medical complexity that require follow up in the UCSF Health Mount Zion Division of General Internal Medicine General Medicine Practice every 2-3 months. This work would provide the proof-of-concept and allow us to assess if the ride share voucher results in increased follow up, reduced no shows and improved patient experience as well as the financial implications of this work for UCSF Health that could make a persuasive case to UCSF Health Primary Care Services administrative leaders to extend this program beyond the proof-of-concept pilot.

TEAM:
* Jane Jih, MD, MPH, MAS co-project lead, general internist, Associate Professor of Medicine, Co-Director of UCSF Multiethnic Health Equity Research Center, Physician Champion for Social Determinants of Health in UCSF Primary Care Services
* Atrejo "Trey" Patridge, NP, co-project lead, nurse practitioner at UCSF Health Division of General Internal Medicine
* Tiffany Chinn, project coordinator
* Sara Abrahams, MD, UCSF Primary Care Resident (PGY-2) who is conducting her Resident Scholarship Project as part of this proposal

PROBLEM: In our pilot work leading to this application, 13% of DGIM patients screened for transportation barriers self-identified as having transportation issues that affect their ability to obtain medical care. Transportation barriers greatly impact patient access to healthcare and impact their health. Many patients surveyed report missing medical appointments due to transportation barriers. The downstream effects to patients of missing primary care visits can result in increased utilization of the ER, after hours calls to the clinic, worsening health conditions, and reductions in overall health status. Increased utilization of healthcare beyond the primary care setting often leads to increased health care costs for the patient and the health care system.

Transportation barriers disproportionately affects people of color, those that do not speak English (particularly Spanish-speakers), older adults, individuals with less education, and those with lower incomes. These are also individuals with the worse healthcare outcomes, and therefore, in greatest need of intervention to address transportation challenges. Currently, there are very limited resources and solutions available for patients with transportation barriers to have this need addressed, particularly for patients that do not meet the strict eligibility criteria for Paratransit. When it comes to public transportation, many of our patients choose not to rely on it for reasons like personal safety concerns with riding crowded buses, having to take more than one bus/train to clinic, or trouble navigating directions due to language barriers.

TARGET:
1) Can providing ride share vouchers reduce no shows? We will use quantitative data by looking in the electronic health record to determine the number of in-person visits completed in the pilot and the number of visits that utilized round trip ride share vouchers. We will also use the electronic health record to assess any changes in chronic disease care (including blood pressure, hemoglobin A1c, medication adherence) and any pre- and post-changes to healthcare utilization including emergency room visits and urgent/acute care visits.

2) Does providing ride share vouchers improve patient experience? We will use a blended quantitative and qualitative approach. For all patients, we will conduct a brief pre- and post-pilot survey to assess their impressions of the pilot project including questions from the patient-oriented Press Ganey UCSF Health Survey including:
-Our practice's sensitivity to their needs
-How well staff cared about patients as a person
-How well everyone at UCSF Health worked together to care for patients
-Likelihood of recommending our practice to others
At the end of the pilot project, we will also conduct brief interviews with a subset of patients in the pilot to ask about how the ride share affected their chronic disease care and how it impacted their experience as a patient in the practice as well as areas to improve or work on.

3) How does a ride share voucher pilot for patients with high no show rate, high medical complexity and transportation barriers affect the clinician experience? We will conduct brief interviews with a subset of clinicians who had their patients participate in the pilot to gather their impressions of ride share program and its impact on delivering primary care to a vulnerable population of patients.

4) What is the financial impact of providing ride share vouchers on the clinical revenue generated? To support our proof of concept, we will determine if it is to the financial benefit of Primary Care Services to have a patient complete a primary care visit and receive the revenue that visit generates, minus the costs incurred to supply a roundtrip ride share for a patient, vs the revenue lost when a patient no-shows to a visit.

GAPS: Qualitative interviews of DGIM patients with transportation barriers identified a number of issues including lack of automobile access, transportation costs, safety concerns with public transportation, and unreliability of arranging taxi rides using taxi vouchers, to name a few, many resulting from structural inequities and racism. Transportation barriers disproportionately affect older adults, non-English speaking patients, and those with multiple complex medical conditions. Paratransit has strict eligibility criteria based on disability and functional status and is therefore limited to only a small portion of patients. Patients have expressed dissatisfaction with public transportation for reasons that include safety concerns, having to take more than one bus/train to get to a medical appointment, and unpredictable schedules. Patients have also expressed frustration with taxi vouchers, with some reporting challenges scheduling rides due to language discordance, scheduled rides that never show up, and even an inability to get an operator on the phone when calling to schedule. Rideshare apps have also traditionally relied on the user to have a smartphone, and to interface in English.

INTERVENTION: The main goal of this proposal is to implement a ride share voucher proof-of-concept pilot for a subset of DGIM patients that have a high no show rate, screen positive for transportation barriers and have medical complexity that require follow up in DGIM every 2-3 months. This work would provide the proof-of-concept and allow us to assess if the ride share voucher results in increased follow up, reduced no shows and improved patient experience as well as the financial implications of this work for UCSF Health that could make a persuasive case to UCSF Health Primary Care Services administrative leaders to extend this program beyond the proof-of-concept pilot.
Working with clinicians and clinic leadership including practice and nurse managers, we will enroll 60-70 medically complex adult patients into the pilot project and offer then ride share vouchers for all DGIM visits over 6-9 months (anticipate up to 3 visits per patient on average). The eligibility criteria for patients to participate are: a) high no show rate (25%+) to DGIM General Medicine Practice visits in the last year; b) screened positive for transportation barriers (screening question in APeX in the social determinants of health wheel: in the past 12 months, has lack of transportation kept you from medical appointments or from getting medications?); and c) have chronic disease burden necessitating follow up every 2-3 months as identified by trend of prior visits and/or primary care clinician referral. Patients will also be ineligible or unable to use Paratransit services.

Potential barriers to implementation include patient buy-in. Leading up to this application, we conducted a pilot randomized controlled trial of 46 patients who had a higher no-show rate at DGIM. Patients in the intervention group received a mailed reminder letter of their upcoming visit and a taxi voucher with the letter explaining the purpose of the voucher and how to use it. Only two individuals in the intervention group used the taxi voucher. Follow-up calls of the patients in the intervention arm of the pilot trial informed us that many that received a taxi voucher by mail were suspicious – even though we explained in the letter why we had mailed the taxi voucher, they hadn't expected their doctor's office to mail them a taxi voucher. We expect to avoid this skepticism with our proposed project as our administrative colleagues, internal staff members who our patients interface with regularly, will be the ones to call patients and arrange rides using the UberHealth rideshare platform. Language discordance may also pose a potential barrier to some patients, which is why we have opted to partner with UberHealth, which offers notifications to riders in 14 different languages. And patients who have traditionally found technology to be a barrier to accessing transportation will find that, unlike traditional rideshare apps, having a smartphone is not a requirement to using the service, as the feature allows patients with any cellular phone that receives text messages to participate, and those without a mobile device can use a landline phone that accepts incoming calls.

Adverse outcomes are likely few. Patient safety throughout the duration of a patient's rideshare trip is of the utmost concern to us. Our staff will have the ability to track rides, share rides alerts with a patient's trusted contacts, and we will survey patients about their experience with the ride.

PROPOSED EHR MODIFICATIONS: An APeX dashboard/indicator that shows the number of missed and completed visits at DGIM for a chosen time period would help us identify patients with the higher no show rates to achieve the goals of this project and support future work to address no shows. Currently, APeX provides us a patient's percent no-show rate for all visit types across all of UCSF for the patient's entire time of care at UCSF.

COST: The cost savings of this pilot is unclear. A goal of this proposal is to evaluate the financial impact of providing ride share vouchers on the clinical revenue generated. As part of the project, we will calculate the clinical revenue generated from a completed visit, minus the costs incurred to supply a roundtrip ride share for a patient versus the revenue lost when a patient no-shows to a visit.

SUSTAINABILITY: This project will provide proof of concept and the potential financial model to make such a program permanent and supported by UCSF Health. In speaking to administrative leadership of UCSF Health Primary Care Services, UCSF Health Primary Care Services is very interested in learning if this type of intervention could be cost neutral or generate revenue that would be otherwise lost if patients no showed for their visit as well as the patient satisfaction and potential for downstream health outcomes and clinician satisfaction. Primary Care Services has expressed support in this work and potentially scaling up the intervention if it is cost neutral or revenue generating.

BUDGET:
Salary support
• Project co-lead Jane Jih, MD, MPH, MAS. $9,617 (0.3 calendar months)
• Project co-lead Atrejo "Trey" Patridge, NP. $9,600 (stipend)
• Project coordinator: Tiffany Chinn, BS. $11,464 (1.2 calendar months)
• Practice Coordinator Champions (To Be Named): $4,000 to support 2-3 practice coordinators. Since these activities are not yet part of the job description for a practice coordinator, we will offer quarterly gift cards in appreciation of the added role and responsibilities.

Uber Health Ride Share Rides. $14,819. For up to 70 patients, we estimate to $70 for each round-trip ride share per patient per visit and estimate up to a total of 210 round trips (up to 3 round trips per patient).

Patient participant incentives. We request funds in the amount of $500 to be used to as an incentive to recruit 25 patients ($20/patient) for in-depth post-project interviews to evaluate the project and its effect on patient experience and chronic disease care.

UCSF Data Network Recharge (if required) $53.
Computing and Communication Device Support (CCDSS Premium Rate) (if required) $66.

ABSTRACT  

Between 2021 and 2022, 22 children received tracheostomies at UCSF, with an average length of stay (LOS) of ~180 days. Discharge for this population is a complex process, including arranging for medical equipment, home care nursing, and training caregivers, which can all lead to delays in discharge and prolong hospital stays. While it's not always possible to control the lack of medical equipment and nursing, we can have an impact on caregiver training. Children who have undergone a tracheostomy require intensive caregiver education, and despite multidisciplinary team efforts, home caregivers may experience fragmented care and communication during the transition from hospital to home^1,2,3,4. A study found that the second most common cause of discharge delays were due to caregiver training delays, with a median range of discharge 41 days after they were deemed medically stable². Other studies have reported similar findings highlighting the challenges of the transition from actively supporting a critically ill patient to physically providing primary care, which can be emotionally complex and involve a steep learning curve ^3,4,5.  An early caregiver training program has the potential to reduce inpatient LOS and healthcare costs^5,6. The primary aim of this project is to reduce LOS by enacting a high fidelity simulation training program integrated with bedside education for caregivers with the secondary goal of reducing readmission rates and improving caregiver competency. 

TEAM 

• Department of Pediatric Pulmonology: Kelly Kim (project lead), Sanaz Vaziri (project lead), Ngoc Ly (Executive sponsor) 

• Inpatient Respiratory therapist lead: David Woolsey 

• Outpatient Respiratory therapist leads: Minh Huynh, Crystal Diaz, Phyllis Moore 

• Clinical Nursing Coordinators: Jeannie Chan (ICN), Shelley Diane (PICU)

• ENT: Pamela Chan  

PROBLEM – Delays in caregiver education lead to delays in discharge. 

Although the number of patients who are trach/vent dependent may not be substantial, their intricate care needs and extended hospital stays create a considerable burden on the healthcare system. A study has shown that the average cost to the hospital for caring for a single child requiring a tracheostomy and prolonged mechanical ventilation is > $600,000 for the initial admission⁷. Previous studies, and most intensive care providers’ anecdotal experience, take note of the lengthy admissions and slow progress of this patient population toward discharge^1-3. These patients also have high rates of complications and hospital readmissions, and the financial costs and resources utilized that are associated with caring for them can be a large burden to the health care system^7,8. 

 Per hospital policy, tracheostomy and ventilator patients can only be housed in the intensive care units (PICU, CICU, ICN). During high-census periods, the lack of available inpatient beds can lead to the diversion of critically ill patients, canceled surgical procedures, or postponement of scheduled admissions. As a result, reducing the length of stay in a safe manner has become even more crucial. We can effectively alleviate some of the strain on hospital resources and make more beds available for those who need them. This will ultimately benefit both patients, families, and the hospital system.

 As soon as the need for chronic ventilation has been established, a family care conference is held with the multidisciplinary team and caregivers to discuss the intricacies of a tracheostomy. Approximately 1-2 weeks later, the tracheostomy is performed and the first tracheostomy tube change is completed 7 days post-surgery. Caregivers have a checklist of skills they need to complete prior to discharge. Typically, the teaching process begins 2-3 weeks after the first tracheostomy tube change due to various factors including scheduling difficulties, learning difficulties, language barriers or lack of familiarity/apprehension with tracheostomies; reasons commonly seen at other institutions. Teaching can also be interrupted due to medical instability, which usually occurs at multiple points during admission.  Teaching also takes place using a low fidelity simulation doll. Many caregivers feel that the doll does not simulate a real tracheostomy or provide a realistic understanding of tracheostomy care. Many caregivers continue to feel discomfort with teachings prior to discharge and require re-education and additional support which often leads to discharge delays. 

 The transition from hospital to home can also be very stressful for families resulting in 26%–30% of tracheostomy-dependent children readmitted within 30 days post discharge, with a subset of these readmissions seen in patients with caregiver delays in teaching. Furthermore, we found that a significant number of readmissions might have been avoidable with quality care at home. Caregivers frequently report feeling unprepared and uncomfortable caring for their children and their medical devices at home despite receiving training in the hospital. As a result, they have a low threshold to seek care for their children through the ED or hospital, with subsequent impact on their children’s health outcomes.

 In patients with tracheostomy and ventilators, standardizing discharge processes has been shown to decrease overall length of stay and readmission rates without jeopardizing patient safety. Baker et. al reduced mean overall length of stay by 42% after interventions including education materials, chronic ventilation road map for caregivers, team-based care coordination, and high-fidelity simulation trainings. While our institution has some of these in place, we have identified certain areas in caregiver education and documentation of discharge readiness which can contribute to reducing length of stay. 

TARGET: reduce length of stay in the ICU by minimum of 7-10 days. Secondary target: improve caregiver confidence, reduce readmission rates 

The primary aim of this initiative is to reduce the length of stay in the ICU by a minimum of 1 week by enacting a high fidelity simulation training program which will start even prior to insertion of a tracheostomy. Our secondary aims are to reduce readmission rates and improve caregiver competence in tracheostomy care through simulation training both inpatient and outpatient which we also predict will have an impact on reducing length of stay and readmission rates.

There are many discrepancies in standard discharge education for parents of pediatric tracheostomy patients which lead to lack of caregiver knowledge, and variations in quality of life in the home environment. Caregiver anxiety related to the tracheostomy can also lead to improper care and increased risk of complications which can also lead to increased readmission rates. While caregivers receive training on emergency scenarios, it's important to acknowledge that such situations may not be as common in a hospital setting. This can limit their exposure to true emergency management, which may make them feel less confident or capable. In studies where simulation training was enacted, it resulted in increased caregiver competence in routine tracheostomy care and emergency scenarios⁹. A high fidelity simulation doll has the ability to control the stoma size so that learners can practice on realistic tracheal tube insertion and emergency scenarios such as simulate a false passage, mucus plugs, abnormal breathing patterns, and cardiopulmonary arrest. With high fidelity simulations, caregivers were also able to attain proficiency in the necessary skills without having to repeatedly practice on their child and had the flexibility to practice on the simulator at their own convenience⁶. Providing realistic experiential learning introduced families to the stress they will face at home and unmasks false confidence, allowing for review and targeted re-education prior to discharge. Research has confirmed that repetitive caregiver education improves survival rates, decreases frequency and lengths of hospital stays, readmission rates, and decreases complications and costs for these children^4,5,6,10. 

Beyond just financial benefits, providing care for these patients at home can have important psychological and developmental benefits. Long hospital stays can disrupt the family unit and impede a child's development. 

Once these children are home, there is a high risk for mortality and readmissions. Ensuring close follow-up care and giving caregivers the opportunity to continue education and training while outpatient can also be instrumental in helping families re-learn skills and reducing readmissions⁸. 

GAPS

Traditionally, home tracheostomy and ventilator management is taught via a combination of didactic instruction and bedside skills demonstration. However, the current approach to teaching these skills is inconsistent and highly dependent on the caregivers' schedules, as well as the availability of nursing and respiratory therapists. Typically, most of the tracheostomy care occurs during the day. If caregivers are unable to be at the bedside due to work commitments, childcare, or long distances from home, this becomes a missed opportunity. On preliminary chart review, about 20% of our tracheostomy/ventilator patients in 2021-2022 were noted to have training delays identified in their notes (in line with similar studies). In a subset of these patients, the third caregiver did not start training until 1-2 weeks prior to discharge which may not provide sufficient time for them to become fully comfortable with the teachings and care. 

Caregivers receive education on how to care for the stoma, detect signs of infection, suction secretions, change the tracheostomy tube, and manage potential airway emergencies. For some pediatric patients, home mechanical ventilation is also required, necessitating additional education. At times, teaching is carried out using a low fidelity simulation doll. While using this type of doll for training may be useful, it may not always provide a comprehensive and accurate representation of the intricacies involved in tracheostomy change or care. This could pose challenges for many families, as they may not be able to fully achieve the desired, life-like effects they aim for, potentially limiting the value of the training. As a result, they may struggle to apply the knowledge and skills they have gained to actual situations, underscoring the importance of using effective training tools to enhance patient care.

INTERVENTION 

 By adding a high-fidelity simulation mannequin to interventions that are already implemented, start training even prior to insertion of the tracheostomy, and implement an outpatient re-education on emergency scenarios, we hope to optimize tracheostomy education. 

 Typically, there is a 3-4 week period between the initial discussions surrounding tracheostomy and the first post-surgical tracheostomy tube change. This presents an ideal opportunity to start making an impact through training. By starting an early tracheostomy education program using a high-fidelity mannequin, caregivers will have a better understanding of the intricacies of the tracheostomy, which can speed up the learning and education process. This, in turn, can have a positive impact on both the length of stay and caregiver confidence which in turn can reduce readmission rates. The NICU, PICU and CICU are homes to many of our patients with tracheostomies.  The mannequin has the benefits of being portable and will be able to move between the units. The simulation tracheostomy dolls offer an opportunity for caregivers to practice the skills they have learned during the pre and early post-operative weeks when they are unable or hesitant to practice on their child. They also have the opportunity to practice these scenarios throughout their child’s stay and have the ability to work on specific areas they are uncomfortable with at their own pace.

 Current interventions already in place: 

• Weekly rounds with multidisciplinary team- ENT, Pulmonary, RT, and OT

• Trach/vent monthly meeting group 

• Outpatient monthly trach/vent clinic with ENT, OT, RT and Pulmonary- started March 2022

• Dedicated NP in place for inpatient and outpatient trach/vent patients

• Low fidelity simulation doll to practice trach care on 

 Phase 1: prior to placement of a tracheostomy

• Family meeting takes place with multidisciplinary team. Tracheostomy binder outlines the necessary information and a roadmap which contains a comprehensive checklist of competencies that caregivers must complete prior to their child's discharge 

• Learning at the bedside- caregiver becomes familiar with tracheostomy and supplies, introduction to the tracheostomy doll and trach teaching begins

• Identify upcoming training dates for teaching 

 Phase 2:  Post tracheostomy surgery, Prior to the first tube change (up to post op day 7)

• Caregivers continue to learn skills on high fidelity mannequin through demonstration and practice. The goal is for each caregiver to complete at least one trach change, change trach ties, and suctioning prior to phase 3

 Phase 3: after 1^st tracheostomy tube change- prior to discharge

• Learning at the bedside continues. Caregivers practice skills they acquired with the high fidelity simulation doll like tracheostomy tube changes and suctioning on patient. Simulation doll present to continue practicing skills caregivers feel they need more practice on.

• Practice emergency scenarios on high fidelity doll which allows for more realistic scenarios such as abnormal breathing patterns, cyanosis, cardiopulmonary arrest. Mannequin also allows simulation of difficult airway and changes in stoma size. Debriefs following each scenario allowing for questions, skill-building and emotional outlet

• Repeat scenarios monthly throughout stay promoting increased competency and confidence in skills 

Phase 4: Discharge readiness

• Demonstrate comfort and skills competency

• Evaluation of the caregivers ability to perform hands-on skill in 24 hour room in with observation from nursing and respiratory care staff.

 Phase 5: Post discharge

• Follow up in-person appointment in trach/vent clinic where caregivers will continue to practice emergency scenarios on high fidelity simulation dolls as a refresher. Usually seen every 3 months 

• Telehealth appointments with trach/vent NP within a month after discharge 

PROPOSED EHR MODIFICATIONS 

Currently our competency checklist is in our tracheostomy binder which sits by patient bedside. Integrating the tracheostomy binder into Apex would allow the team members to track progress on teaching and discharge readiness. 

COST 

 We anticipate a one time expense of ~$48,000 which will support the costs of a high fidelity simulation mannequin. 

The projected savings: 

• Traditional direct hospital charge cost associated with ICU admission is estimated to be around $5,500 daily. This is only focusing on direct costs. 

• Decreasing ICU stay by minimum of 7-10 days: $38,500-$55,000 in direct costs saved per patient

• If we anticipate that 20% of our tracheostomy patients will have caregiver delays (in accordance with the literature and chart review), by enacting this high fidelity simulation program with the other interventions already in place, we estimate that the total costs savings for reducing LOS by minimum of 7-10 days for 5 patients will result in a reduction of  $192,000-275,000 for the hospital system

• We are not counting  the substantial resources provided daily from respiratory therapists and nurses along with other costs from nebulized medications administered (at least 2-3 medications given twice a day), imaging, blood work, OT and PT therapies, and administering feeds 

• Availability of ICU beds prevents admission diversion and last minute cancellation of surgical cases reducing risks and downstream costs.

SUSTAINABILITY  

Currently we have multiple interventions in place already implemented that standardizes the discharge process and will help sustain this beyond the funding year. 

• Educational materials will be in place to help guide respiratory therapists regarding simulations. Respiratory therapists already provide the bulk of tracheostomy teaching and using a high fidelity simulation doll can be easily integrated

• Identifying days for training at the beginning of tracheostomy discussions will be incorporated in the skills checklist 

• There is a tracheostomy taskforce group that has been established who is already working on standardizing and improving the discharge process which decreasing variations in care practices

• Dedicated nurse practitioner who follows inpatient and outpatient tracheostomy/ventilator patients

• Tracheostomy rounds take place weekly with the multidisciplinary team

High fidelity simulators do not require a lot of maintenance and have the ability to move between units. High fidelity simulators can also be effective in providing training to other healthcare professionals including nurses, respiratory therapists and residents/fellows 

BUDGET: 

SimBaby: $41,000 (https://www.youtube.com/watch?v=iSTHQ0tXKJY) 
SimPad Plus: $1,000: operating device used to control Laerdal manikins and simulators enabling simulations to be run easily and effectively. 
LLEAP License $3,100 License Key providing access to Manual Mode, Automatic Mode, and Log Viewer Application
Laptop (patient monitor) $2150

• • PROPOSAL TITLE: Reducing disparities in lung cancer screening in vulnerable populations 
  • PROJECT LEAD(S): Joan O'Mahony
  • EXECUTIVE SPONSOR(S): Laurel Bray-Hanin
  • ABSTRACT - 

  Findings from the National Cancer Institutes National Lung Screening Trial established that lung cancer mortality in specific high-risk groups can be reduced by annual screening with low-dose computed tomography (CT).  Access to these services can reduce inpatient/outpatient healthcare cost with patients being screened at an early stage.  Through community outreach, education, and the development of culturally relevant public health programs, greater support and awareness for screening can help to reduce disparities in screening, diagnosis, and treatment. This project proposal aims to partner with high risk patients, healthcare systems, and community providers to access screening services and offer resources (i.e. grant funding, surveillance, etc.) to high-risk patients in the absence of insurance or other appropriate funding source. If the patient does not fit the criteria, this proposal further aims to procure and utilize a system to track incidental findings to provide early lung cancer care, education, or intervention demonstrating a commitment to patient health and wellbeing. This project is in alignment with the National Institute of Nursing Research (NINR) 2022-2026 strategic plan to inform practice, optimize health, and advance health equity looking through the health equity, population and community health, prevention and health promotion, and systems and models of care lens. Using the center of excellence delivery framework, the Thoracic Surgery Oncology team would like to leverage this work to identify screening gaps, implement best practices, and support the patient and healthcare system positioning UCSF to become the epicenter for lung cancer screening for vulnerable populations in the Bay area.

  • TEAM - Shaterra Davis (RN Nurse Manager), Andrew Mullen (PA), Dr. Johannes Kratz (MD)
  • PROBLEM - Lung cancer is the third most common cancer in the United States.  Although the incidence of lung cancer has decreased over the past decades, disparities in survival and treatment modalities have been observed for black and white patients with early-stage non-small cell lung cancer. African Americans are one of the populations with a higher incidence and mortality for lung cancer. Like other cancers, most people with early stages of lung cancer do not have symptoms until the disease is well advanced.  Lung cancer can be cured if detected early with a proper screening method. Racial Disparities are predominant, as black males have the highest lung cancer rates of age- adjusted lung cancer incidence among all U.S. racial/ethnic groups, specifically 73.5 per 100,000, versus 63.5 per 100,000 white males.  This racial disparity in incidence persists in both smokers and never-smokers.  Black males also have the highest lung cancer mortality compared with other racial/ethnic groups and develop lung cancer at an earlier age. Black Americans with lung cancer were 15% less likely to be diagnosed early, 19% less likely to receive surgical treatment, 10% more likely to not receive any treatment, and 12% less likely to survive five years compared to white Americans. $23.8 billion was spent on lung cancer care in 2020.Approximately 1 in 4 lung cancer patients will be diagnosed in the earliest stage, when the disease is most treatable and the 5-year survival rate is much higher. In California, 1% of those at high risk were screened, which was significantly lower than the national rate of 6%. 29% of Black Americans with lung cancer in California did not receive any treatment, significantly higher than the rate of 22% among Black Americans nationally, and significantly higher than the rate of 25% among whites in California.
    Over the last five years, the early diagnosis rate in California did not change significantly, which is the opportunity for this proposal. 
  • TARGET -  Reducing disparities in lung cancer screening in high-risk patients by increasing access to CT scans in the community and outpatient setting for early detection lung cancer. Expected benefits include improved health and wellness and decreased incidence of patients diagnosed at later stages with lung cancer. 
  • GAPS - In 2021, the US Preventative Services Task Force (USPSTF) expanded the eligibility criteria for low-dose computed tomographic lung cancer screening to reduce racial disparities that resulted from the 2013 USPSTF criteria for lung cancer screening recommendations. The recommended changes will nearly double the number of people eligible for lung cancer screening.  Among smokers diagnosed with lung cancer, 32% of African Americans versus 56% of whites were eligible for screening with the previous screening criteria. This recommendations are not being consistently followed, especially during the time of the COVID-19 pandemic. Radiology access (e.g. appointment availability), prioritization of more acute scans, lack of education and awareness of new guidelines, and insurance/financial barriers complicate the problem. 
  • INTERVENTION - The Thoracic Surgery Oncology clinic is an ambulatory outpatient clinic with 2 RNs, 2 APP, and 5 MDs who assess, diagnose, and treat all stages of lung cancer. The target population is African American and/or other adults at high risk for lung cancer. The proposed intervention would implement financial, clinical support, education, and advocacy for early lung cancer screening. Long term, we would like to purchase a Lung GPS program that can be integrated into apex system for incidental lung nodule findings as well as database for follow up and surveillance. Funding for CT scan screening for scans is the goal to help build a case for a longer term solution. Other interventions include patient & clinician education seminars and increased marketing. Long-term ideas include mobile units for screening in the community, equip satellite clinics in high risk areas to provide screening for lung cancer in the underserved community. Potential barriers include lack of funding to provide access to screening, lack of access to radiology. The possible adverse effect to the program is finding that with proactive screening, the volume will be high and there is not available funds to cover the volume for those without access to screening. Patient safety is promoted as we have the clinical support to see the patient. 
  • PROPOSED EHR MODIFICATIONS- Lung GPS surveillance software integration. Clinical problems to solve with APeX- screening, and system to keep track of patients with incidental findings or smaller nodules. APeX tools (patient lists, reports) or workflows (orders, documentation, alerts) are you using now to achieve this goal? None.
  • COST - TBD
  • SUSTAINABILITY - If successful, this intervention will provide the baseline for a ROI proposal to sustain the project and seek government funding to use in high-risk and vulnerable populations. The number of incidental findings and level at which cancer is found could provide quantitative support for funding beyond the funding year. Key UCSF process owners are the Thoracic Surgery team, radiology? APEX team?
  • BUDGET - Key areas of the project that will require funding include software, payment for CT scan, marketing and education material.  

   

Revitalizing Transfers: Creating an EHR-based admission and lateral transfer decision support tool to identify patients for transfer to non-Parnassus sites

PROJECT LEAD: Timothy Judson, MD, MPH. Medical Director of Care Delivery Transformation, Office of Population Health. Medical co-Director, Adult Care Transitions, UCSF. Physician Informaticist, Center for Digital Health Innovation. Assistant Professor, Division of Hospital Medicine.

EXECUTIVE SPONSOR(S):

Adrienne Green, MD, SFHM, FACP. Chief Medical Officer, Adult Services. VP Regulatory and Medical Affairs. Professor of Clinical Medicine, Division of Hospital Medicine.

Michelle Mourad MD, Vice Chair of Clinical Affairs and Value, Department of Medicine. Clinical Informatics Lead, Center for Digital Health Innovation. Professor, Division of Hospital Medicine.

Brad Monash, MD, Vice Chair of Clinical Affairs, Division of Hospital Medicine. Professor of Clinical Medicine and Pediatrics

ABSTRACT: It is currently challenging to determine which medicine patients may be eligible for admission or transfer to non-Parnassus sites of care (e.g. Mount Zion, Saint Mary’s Medical Center (SMMC)). Admitting physicians must manually check clinical and social inclusion criteria and bed availability for each site, an inefficient process that may lead to suboptimal use of available non-Parnassus beds. The process of identifying medicine patients appropriate for lateral transfers is similarly tedious and because it is dependent on physician referral, it fails to capture a large proportion of potentially eligible patients. We propose creating 1) an EHR-based, admission clinical decision support tool to guide admitting physicians in determining the optimal site of admission for medicine patients, and 2) a workbench report to identify admitted patients appropriate for lateral transfer to a non-Parnassus site of care. The combination of these tools will reduce the time needed to identify and transfer appropriate patients, increasing use of unfilled, staffed beds at non-Parnassus sites. This will increase tertiary/quaternary bed availability at Parnassus, creating an estimated $1.79M/year in contribution margin by better matching patient acuity to the appropriate site of care.  This will also improve patient and provider experience of the admission and transfer process.

TEAM

• Toni Workman-Braden, DNP, RN, Patient Care Director of Capacity Management, Integrated Transfer Center, Patient Capacity Management Center
• Maggie Jones MD, Associate Professor, Division of Hospital Medicine, Director of Swing Service and ED triage
• Rashmi Manjunath MD, Assistant Professor, Division of Hospital Medicine, Director of Mount Zion Medicine Service
• Raman Khanna MD Associate Professor of Medicine, Division of Hospital Medicine, Medical Director of Inpatient Informatics at UCSF Medical Center
• Jill Reynolds, Technical Program Manager, Patient Capacity Management Center

PROBLEM: This proposal is aimed at solving two related problems that contribute to capacity constraints at Parnassus, where inpatient capacity is currently over 90%.

First, when a medicine patient is being admitted from the emergency department, the Medical Officer on Duty (MOD) must decide where the patient should be admitted. There are currently three sites where hospital medicine patients may be admitted (Parnassus, Mount Zion, SMMC) with two additional sites (Hospital at Home and Chinese Hospital) being considered. The patient inclusion and exclusion criteria for each site is different (an example in Supplementary Materials), as are conditions necessary for acceptance, including bed availability and nurse staffing. Triaging physicians refer to frequently changing protocols and criteria to determine candidacy and manually confirm availability and acceptance at the receiving facility. This process of chart reviewing and seeking approval from multiple parties often takes 2+ hours from start to finish. This inefficient process may cause delays and lead to suboptimal bed usage, as some eligible patients are not identified and get admitted to Parnassus beds before they can be admitted to other sites.

Second, when Mount Zion beds are available, we aim to transfer lower acuity medicine patients from Parnassus. These patients typically have longer than usual length of stay (average 15.8 days), so transferring them can create significant capacity at Parnassus. Potentially eligible patients are currently identified based on referral from primary teams, and manually tracked on an APeX list by the Flow MD and MZ MD. This process is suboptimal for multiple reasons. First, referrals often do not yield enough candidates to fill available beds. When leadership has instead resorted to chart reviewing patients on the medicine census—akin to finding needles in a haystack of 180-200 patients – they have consistently identified more than double the number of potential MZ transfer candidates that were identified by referral.

TARGET: The goals of building these tools and implementing new workflows around medicine admissions and lateral transfer would be to:

1. Increase tertiary/quaternary bed availability at Parnassus by increasing use of unfilled, staffed beds at non-Parnassus sites. Specifically, we aim to:
   1. Increase monthly average daily census at MZ by 1.0 in FY24 compared to FY23
   2. Reduce unfilled bed capacity at all non-Parnassus sites by 50% in FY24 compared to FY23
2. Improve the provider experience by decreasing the amount of time that physicians take to identify and transfer patients to non-Parnassus sites
3. Improve patient experience by decreasing ED boarding times and improving transfer efficiency

GAPS: The process of determining which medicine patients may be eligible for admission or transfer to non-Parnassus sites is currently manual and referral dependent. The UCSF Patient Capacity Management Center (PCMC) has developed tools to solve similar problems. For example, they have developed a report that uses objective criteria to determine whether a patient is appropriate for the discharge lounge, and have begun to identify surgical patients appropriate for lateral transfers from Parnassus to Mission Bay.Prior to the creation of the PCMC, there was no central group with visibility into all admitted UCSF patients that could be responsible for maintaining and overseeing such a tool.

INTERVENTION: We propose to work with the UCSF Patient Capacity Management Center to create two related tools and associated workflows to improve the process of admitting and transferring patients to non-Parnassus sites.

1. Admission Clinical Decision Support (CDS) Tool: To better identify adult medicine patients on admission who are eligible for care at non-Parnassus sites (e.g. Mount Zion, SMMC, Hospital at Home), we propose an EHR-based, automated clinical decision support tool. This APeX tool would incorporate data from multiple sources to determine whether a patient meets inclusion and exclusion criteria for admission to a non-Parnassus site of care. This tool would capture data from discrete fields in APeX (e.g. insurance, home address, diagnosis, anticipated level of care) and via a short provider click-through form (e.g. need for telemetry or in-person specialty consultation). The tool will then incorporate real-time bed availability and staffing data, overseen by the Patient Capacity Management Center, to determine the recommended site of care. The MOD would use this tool prior to admitting the patient. If the tool recommends a non-Parnassus site of care, MOD would confirm assent from the patient and begin the admission process.
2. Medicine Lateral Transfer Identification Report: We propose building a workbench report to improve the process of identifying potential patients for lateral transfer to Mount Zion (and Hospital at Home in the future). This would include APeX metrics that help determine eligibility for transfers, such as current consults, expected discharge date, case management disposition, telemetry use, and AMPAC score (a measure of mobility). The Flow Physician on Duty (and/or MZ MD) would use this list as a starting point for identifying eligible patients for transfer. The PCMC team would also view the list in real time to better manage patient flow. The list will also be able to be filtered by bed type so that if, for example, there is not hemodialysis capacity available at Mount Zion, patients needing hemodialysis can be filtered out.

These tools would be first built for use with Hospital Medicine patients, given the immediate need. The tools could then be replicated for other services. If successful at UCSF, the tools could be shared with affiliates, and adapted to be used for transferring T/Q patients from regional affiliates to UCSF.

We have considered possible barriers to project success. First, some data may need to be manually entered by the admitting physician if it is not available in a discrete field (e.g. overall clinical stability). However, that entry would be brief, and could ultimately be streamlined by adding new fields to APeX (e.g. a “clinical stability” field). Second, bed availability data will be key to project success. We believe the UCSF Patient Capacity Management Center will be able to maintain this information in near-real time, but this may be more challenging for non-APeX sites like St. Mary’s and may continue to require confirmation via Voalte. Third, providers must know to use the tool for it to be successful. Fortunately, change management would be simplified because only specific attending hospitalist roles hold the MOD pager, and the MZ hospitalist is primarily responsible for identifying lateral transfers (see workflow diagram figure 1). There is already a robust onboarding process for each of these roles, and service leadership would ensure these changes are reflected in future onboarding.

PROPOSED EHR MODIFICATIONS: Described above in intervention section.

COST: Based on available data, we believe the average cumulative number of staffed, unfilled non-Parnassus beds is at least 2-4 per day. For example, the average daily census for hospital medicine patients at Mount Zion in 2022 was 14.2, which is 79% of the technical MD cap of 18 beds (though this may not account for MD/RN staffing changes that may increase or decrease this cap). This cap recently increased to 30 patients, which may increase the potential impact of this tool going forward. However even with that higher cap, the March ADC was 21.1. Similarly, median bed utilization at SMMC was 78% over the past 9 months.

Financial Benefit: Increase T/Q revenue. Using both the admission and transfer tools, we aim to increase tertiary/quaternary bed availability at Parnassus by increasing use of unfilled, staffed beds at non-Parnassus sites. Each time a low-acuity Parnassus patient is transferred to a non-Parnassus site, this Parnassus bed can be filled with another patient. Realistically, these open Parnassus beds may be filled with any type of adult patient. For that reason, in our calculations we use the contribution margin for all adult patients, not just T/Q patients. Specifically, we aim to:

1. Increase monthly average daily census at MZ by 1.0
2. Reduce the number of non-Parnassus unfilled, staffed beds by 50%

*This calculation assumes backfill with a mix of all adult patients (not just T/Q patients)

Other benefits of this project would include:

1. Benefit Hospital at Home: These tools would be integral to the success of future capacity-building programs such as Hospital at Home, which rely on proactive patient identification for both admission and lateral transfer. These tools could decrease the need for additional FTE to be hired for the purpose of patient identification in Hospital at Home. 
2. Decreased physician transfer/admission work, (resource-intensive workflows visualized in tan boxes in Figure 1, with plan to replace with much more efficient tool in green) resulting in:
   1. Increased clinical productivity and billable activities (e.g. admission hospitalist/MOD can conduct History and Physical’s instead of spending time on triage). This benefit is difficult to quantify in the absence of a dedicated time study, so we did not include this in the value calculation above.
   2. Increased provider satisfaction (e.g. inc. time for teaching instead of coordinating transfers)
   3. Improved patient outcomes, safety and experience (e.g. by allowing MZ hospitalists to focus on discharge education rather than identifying transfers)
   4. Potential to decrease ED boarding: While there are other confounding factors, more efficient use of non-Parnassus beds could decrease ED boarding, ED LWBS rates and PACU boarding.
   5. Empower the PCMC: This tool would increase transparency of clinical acuity and admission characteristics, allowing the PCMC to prioritize which non-Parnassus beds to fill first, and giving them more data regarding the number of patients potentially eligible for lateral transfer.

SUSTAINABILITY: These tools would require some upkeep by service directors and the APeX team to reflect changes in clinical criteria for admission to non-Parnassus sites. We have support from Hospital Medicine service leaders, PCMC leadership, Department of Medicine leadership, and the Chief Medical Officer of Adult Services, so are confident the tools would become part of standard work for admissions and transfers.

BUDGET

• APeX modifications: $25k
• Technical project management support: $5k
• Subject matter expert salary support: $20k

SUPPORTING DOCUMENTS

Figure 1a: Admission Current and Future State Workflow (SEE ATTACHED)

Figure 1b: Lateral Transfer Current and Future State Workflow (SEE ATTACHED)

Mount Zion Medicine Exclusion Criteria

• TCU level of care
• Actual or anticipated LOS >8 weeks** (only applies to lateral transfers)
• Patients requiring high flow nasal cannula
• Patients too unstable for transfer
• Patient requiring in person consultant evaluation (primarily telemed consults)
• Patients needing administration of chemotherapy (oral or IV)
• Patients with significant expected specialty involvement, specifically
  • Active co-morbid or primary surgical disease
  • Active co-morbid or primary neurologic or neurosurgical disease
  • Active hematologic disease
  • Active oncologic disease
  • Severe cardiac disease (i.e., active/unstable CAD, decompensated heart failure, severe pHTN)
  • Decompensated liver disease or liver transplant patient
  • Pregnancy
  • Hemodialysis (not an exclusion criterion, but patient must be cleared by MZ Nephrology prior to admit/transfer. Those who may need emergent/urgent dialysis for decompensated renal disease should not be transferred)
  • Peritoneal dialysis (relative exclusion, only possible with lateral transfers + coordination with Nephrology/nursing)
  • 5150 or very active comorbid or primary psychiatric disease
    
    

CW Transfer Tool Round 1 Reviewer Comments/Questions and Responses

1. Your proposal would be strengthened if you can comment on how you would ensure that providers who are tasked with transferring patients to non-Parnassus beds would know to utilize your tool, and how they would utilize your tool. Outlining a proposed workflow is a great starting point for this key behavior change that would be required for your project to be successful.

• We have included current state and proposed future state workflow diagrams in our revised proposal. The green boxes in both the admission and lateral transfer workflows indicate where the use of the digital tool would replace the time consuming process (tan box) in the current state.
• For the lateral transfer tool, change management would be straight-forward, because the MZ hospitalist already references an Apex list to try to find patients. If the lateral transfer tool were built, the hospitalist would just use that tool instead.
• The admission CDS tool would be a new process for the MOD, but only 3 hospitalist roles currently hold MOD, and each receive orientation and onboarding via email/wiki pages. We feel confident that given the engagement of service leadership in this proposal, we would be able to achieve universal use of these tools.

1. It would be helpful to know if identification of patients who would qualify for non-Parnassus beds is a key contributor to unfilled non-Parnassus beds. Prior work and health systems kaizens have been conducted to optimize this transfer process, and utilizing these prior learnings will also strengthen your proposal. In other words, how do we know that solving the problem of more efficient patient identification will result in increased transfers to SMMC and/or Mt. Zion? There are other gaps/barriers in this complex process as well, and how will your project team also address these barriers?

• There are certainly several barriers to optimizing the transfer process. Based on discussions with our team and past improvement efforts, we would group these barriers into 2 categories:

1) Bed availability including staffing challenges often limits volume of possible non-Parnassus admissions/lateral transfers. Bed availability would not be impacted by this proposal.

2) Patient factors may lead to available beds not being filled. Patient factors Include identifying appropriate patients, getting their assent, confirming they have appropriate insurance, etc. This proposal would increase the size of the pool of potential patients, which should result in more beds being filled, even without directly addressing issues like assent or insurance.

• It is challenging to measure missed opportunities for transfers. However, the best evidence available comes from recent experience. When the MZ hospitalist team recently increased its cap to 30, there were not enough patients on the APeX list of potential lateral transfers, so service leadership manually chart reviewed all patients on the medicine census. They identified more than double the number of patients who were on the transfer list, supporting the hypothesis that we are missing potentially appropriate lateral transfers. Despite the Mount Zion medicine cap being raised to 30 in February, March ADC was ~21.1, attributed in part to difficulty identifying enough patients.
• The Adult Capacity Management Dashboard consistently shows that the bed occupancy rates at MZ and SMMC (~75-80% max) are much lower than those at Parnassus (>90%). This imbalance suggests an opportunity to better match patient acuity to bed availability.
• We feel that these tools would be immediately valuable in our current state. In addition, we want to emphasize that improving these workflows would be essential if we continue to expand our non-Parnassus capacity (e.g. Chinese hospital, Hospital at Home). Without such tools and revised workflows, it would get increasingly complex and resource intensive to identify patients for the correct disposition, and we would fail to identify potentially appropriate patients.

3.     We would strongly suggest connecting with Jahan Fahimi, Brandon Scott, and Kim Berry to discuss your cost savings / increased revenue projections. Many of the patients who will benefit from filled non-Parnassus beds are already patients in the ED who are awaiting admission and thus there may not be a true increase in health system revenue.

We connected with Brandon Scott, Kim Berry, Jahan Fahimi and Cat Lau. They agreed with our approach. We did make the following adjustments to our value model based on their feedback:

• Clarified that we are referring to increased contribution margin (I had mistakenly written revenue in prior version)
• Used Kim’s figure for contribution margin per bed day instead of the prior figure (~10% difference)
• Adjusted our specific aims: We believe that the bulk of the benefit from this tool in the short term will come from increasing lateral transfers to MZ, so we revised our goal to increase monthly ADC at MZ by 1.0 (from 0.5). Our calculation assumes that we will fill an additional cumulative 1.5 beds per day accounting for all non-Parnassus sites. We would therefore estimate that 0.5 of this ADC would be in increase at SMMC, or other non-Parnassus sites opened in the future.

TITLE: Optimizing the Vascular Access Specialty Team Throughput with Lean Methodology: One Needlestick Every time using the ONE VAST Bundle

PROJECT LEADS: Vascular Access Support Team Members: Michele Nomura, MSN, RN, VA-BC, CNRN; Riza Magat, MS, BSN, RN, VA-BC; Felix Piamonte, MS, BSN, RN, VA-BC

EXECUTIVE SPONSORS: Lynne Tom, MSN, BSN, RN (Unit Director, VAST), Elizabeth Sin, MS, BSN, RN (Patient Care Director) 

 ABSTRACT:

Peripheral intravenous catheter (PIVC) insertion is the most common invasive procedure a hospitalized patient will experience. Data shows that 350 million PIVCs are sold in the United States, and 37 million hospital admissions occur annually. The numbers indicate an average usage of 10 PIVCs per patient admission, indicating a high failure, low success rate, and excess cost. Recognizing that IV access is vital to the administration and delivery of treatment, the leadership must consider efforts to establish timely access as a strategy for hospital cost reduction and patient safety.

In FY2022, the Vascular Access Specialty Team (VAST), received 5,640 requests for ultrasound guided peripheral intravenous catheters (USGPIVs) and was able to assist with 2,192 requests. The number of requests received exceeded the number of placements. The team's mandate is to support patient flow by prioritizing peripherally inserted central cathters (PICCs) and midlines (ML) for discharge, TPN, and chemotherapy. USGPIV insertion support is contingent on the team's availability and timing which leads to variability in PIVC insertion practices, multiple insertion attempts, delays in care, escalation of inappropriate PICC and ML orders, and dissatisfaction from clinicians and patients. 

The proposal aims to support UCSF Health True North Pillars of creating an exceptional patient experience, optimal work environment, improving clinical outcomes, and supporting solid financial performance and learning health system. The proposal will utilize the Lean methodology to define, measure, analyze, improve, and control processes of the PIVC insertion practices at UCSF Parnassus. The systematic approach will improve throughput by eliminating variations in practice while identifying areas of waste that will lead to increased efficiency and cost reduction. The Lean method led the team to create a bundle named ONE VAST.  

TEAM 

Adult Vascular Access Specialty Team at UCSF Parnassus Campus

PROBLEM

PIVC failures cost the health care system millions of dollars in waste, redundancy, and inefficiency. PIVC failures lead to multiple insertion attempts, wasted nursing and other clinician time, wasted supplies and inefficient care delivery. Multiple PIVC replacements contribute to patient pain, distress and dissatisfaction with care, interruptions and delays in treatment, increased burden to nursing and medical workload.

The team comprises of eight vascular access nurses with advanced training, experience, procedural competency and proficiency assuring 99% first stick success rate. The group supports the organization's need to facilitate patient flow by prioritizing PICC and ML insertions for discharge, chemotherapy, and total parenteral nutrition (TPN). VAST hours of operation are from 0700 hours until 1930 hours, seven days a week. USGPIV insertion is contingent on the team's availability. As a result, several clinician groups including bedside nurses, advanced practice providers and medical doctors are attempting to establish a PIVC, and there are an excessive number of patients requiring more than two attempts or inappropriate escalation of requests to PICC and ML catheters due to failure to establish a PIVC. The team conducts on average 45-minute thorough chart review for all venous access insertion orders, course corrections and recommendations based on clinical indication, duration of treatment, and appropriateness. In 2022, the team corrected 840 orders that may have led to a potential reduction and avoidance of central line days and other PICC and ML complications such as central line-associated bloodstream infection (CLABSI) and venous thromboembolism (VTE). Furthermore, the response time to a PIVC request is variable and can take up to an average 6 hours of wait time. A decentralized approach to insertion and maintenance increases the risk for vein injury, vein depletion, infection and other preventable PIVC complications such as occlusion, phlebitis, and infiltration. The proposal aims to identify the PIVC dwell time and related complications, catheter discontinuation, or catheter failure. Furthermore, the proposal aims to examine the value of a VAST centralized model for PIVC insertion and maintenance, promoting system efficiency, and avoiding procedure redundancy and practice variations. The proposal aims to explore the cost avoidance or aversion as a result of inserting a PIVC instead of PICC or ML. 

Apart from the economic impacts of a PIV team, the proposal aims to support bedside clinicians from developing the "second victim" phenomenon where clinicians feel personally responsible for the failed PIVC attempts and second-guess their clinical skills and knowledge base. In an era, where short staffing and patients require the most complex care, the proposal has the potential of saving nursing hours that can be utilized for clinical tasks other than PIVC insertion. Moreover, patient satisfaction with care received may suffer due to losing trust in the clinician's ability to establish venous access. The proposal aims to examine the difference in patient experience and satisfaction with PIVC insertion with VAST and bedside clinician. 

TARGET:

The goal is to perform one needle stick every time when establishing a peripheral venous access for all admitted intervention group patients at UCSF Parnassus by implementing the ONE VAST bundle. By doing so, we aim to:

• increase patient satisfaction through timely PIVC placements from VAST with 99% first stick success rate. 
• relieve bedside clinician's burden of establishing a PIVC.  
• proactively assess and anticipate current and future PIVC needs for the inpatient.
• reduce the request response time from six hours to one hour or less.
• promote inpatient throughput by reducing delays in administering treatment and diagnostic tests requiring a PIVC.
• promote cost savings by mindful use of supplies and VAST. 
• reduce inappropriate and premature ordering of PICC and ML catheters for failure to establish a PIVC by 10%.
• advocate for each patient the most appropriate vascular access device based on the treatment plan (i.e., vesicant infusion, duration, and vasculature considerations).

GAPS:

UCSF Parnassus currently has a VAST team which is composed of eight vascular access nurses with advanced training, experience, procedural competency, and proficiency, assuring a 99% first-stick success rate, supporting the organization’s need to facilitate patient flow by prioritizing PICC and ML insertions for discharge, chemotherapy, and TPN. PIVC support is contingent on the team's availability rendering multiple failed attempts by bedside clinicians in establishing a venous access. Current workflow results in variations in practice, delays in therapy and treatment, inefficient use of resources, and supply waste. The current method of documenting PIVC attempts, successes, failures, and consultations must be more consistent. Additionally, the existing workflow relies on the accuracy of the clinician to text the patient identifier information (i.e., patient name and bed number) to VAST via Voalte, which is sometimes inaccurate or missing information. VAST then manually adds the patient to a team share folder within APeX to identify which patients are awaiting USGPIV placement. This leads to inefficient use of time texting multiple clinicians on the same patient. The current design to support bedside clinicians who failed to establish venous access is reactive instead of proactive, which makes PIVC requests unpredictable and challenging for VAST to meet all demands, particularly towards the end of the day. Limited to no time is allotted to learning opportunities about the value and harms associated with various vascular access devices. For instance, in January 2022, the VAST course corrected 30 inappropriate PICC and ML orders by placing USGPIVs. Most of these orders were prematurely escalated due to the failure to establish a PIVC before seeking a VAST consultation. VAST course corrections have substantial quality and safety implications for CLABSI and VTE prevention. It is essential to note that significant savings and harm reductions are achieved by avoiding inappropriate use of PICC and ML.

It is important to note that multiple reasons affect the VAST team's current workflow for PIVC placement. The reasons are but not limited to:

• The team is not designed as an elective service and procedure requests or orders cannot be pre-scheduled and can come throughout the day.
• Requests and orders are reactive, depending on when a need for VAD is identified.
• Dependent on patient availability and consent to the procedure.
• Dependent on when the provider writes the order.

In particular, the PIVC requests are most unpredictable when they get to the VAST team, affecting our ability to respond promptly and effectively. The initiative aims to improve workflow and efficiencies within the VAST team, identify and utilize areas of opportunity to proactively assess the functionality of the current PIVC, or intervene if a new PIVC is needed. Creating predictability within the VAST workflow by influencing when a PIVC need will be achieved by early daily rounding and assessment of PIVC functionality. Furthermore, early assessment can also lead to early identification of a need for an alternative device like a ML or a PICC.

INTERVENTION:

The proposal will utilize the Lean Method and will define, measure, analyze, improve, and control work processes using the ONE VAST care bundle. The method originated with the Toyota's Production system with focus on delivering value as defined by the consumer, eliminating waste, reducing costs, and continuous process improvement. The team will identify a medical-surgical unit to conduct a small test of change for three to six months based on the following steps:

1. The first step is to define the goal of one needle stick when establishing peripheral venous access for all admitted intervention group patients at UCSF Parnassus.
2. The second step is to review the short PIVC consumption for FY 2022. VAST will collect the data from yearly supply chain records. Identifying PIVC usage is a challenge to extract from the electronic health record (EHR) due to inconsistent or lack of accurate charting of PIVC attempts by clinicians. Current PIVC consumption will be measured and identified from the test unit.
3. The third step is to analyze the annual PIVC consumption against the UCSF Parnassus patient admission to establish the total and average PIVC use per patient admission. The action will identify the supply and labor costs utilized for PIVC insertion. Supply includes PIVC, IV start kit, and normal saline flush. VAST supply cost is similar to bedside clinicians with the addition of the ultrasound (US) gel. Data shows that the VAST time allotted for PIVC insertion is 20 minutes. The step will also identify the bedside clinician hours savings. VAST will analyze the current average PIVC usage from the test unit.
4. The fourth step is to improve and control workflow by implementing the ONE VAST PIVC care bundle. See Table 1.

A.             ONE- One Needlestick Everytime is the goal to minimize waste and costs and promote patient satisfaction with PIVC care.

B.             Vein means inserting the right and the most appropriate venous access device at the right time for the right clinical indication and not due to failure to establish a PIVC. Vein preservation means always using the ultrasound machine for assessment, using optimal vein and catheter selection, and avoidance of areas of flexion and joints and the hands.

C.             Advanced Assessment and Accurate Review mean a VAST RN will proactively round on all patients in areas identified for small tests of change. VAST will document daily assessment of current PIVC (catheter function through NS flushing or documentation of line in use or infusing, site assessment, dressing adherence, and patient satisfaction) on the PIVC assessment flowsheet and a VAST data collection tool. PIV VAST RN will enter a new PIVC consult and insert the device if the need is identified during rounding. PIVC is maintained by the VAST until no longer clinically indicated.

D.             Specialty and Supplies mean utilizing experienced and proficient VAST RNs trained in USGPIV assessment and placement. Supplies are standardized for insertion, securement, and dressing to minimize supply waste. Of note, PIVC will be of polyurethane material only.

E.             Technology and Transformative Training mean utilizing the US on all PIVC insertions avoids "blind sticks." It provides real-time guidance in placing a cannula into a peripheral vein under the direct vision of the machine. The US allows real-time assessment of the quality of the vein, therefore, aids the VAST RNs' decision-making in providing the most appropriate PIVC (gauge, length, and depth) that the vein can safely accommodate. Technology means utilizing the EHR to streamline work processes and improve efficiency. Transformative training means that the VAST team will continue to provide learning opportunities for bedside clinicians and learners on USGPIV and the fundamentals of PIVC insertions, care, and maintenance.

Proposal Workflow: See Table 2.

1. Build a VAST PIV consult in the EHR. RN, MD, and other APP to document the number of failed insertion attempts or enter the reason for not attempting, i.e., difficult intravenous access (DIVA), deep vein thrombosis (DVT), arteriovenous fistula/graft (AVF/AVG), obesity.
2. Consult will appear on the VAST workflow.  
3. Triage PIV consults according to the urgency of the request.
4. Start PIVC according to the care bundle.
5. Enter requests into the VAST data collection tool, i.e., vein selection, location, number of insertion attempts, date of insertion, catheter type, size, and length, type of inserter, visual aids, procedure satisfaction scale, date, and reason for PIVC removal.
6. Modify the existing PICC Navigator flowsheet to capture PIV activity in the VAST detail summary report.
7. Build a report to capture 1, 5, and 6.
8. Identify nursing units to implement a small test of change: At this time, approval from 10CVT leadership has been established.
9. VAST RN will proactively round on all intervention group patients in areas identified for small tests of change (daily assessment of current PIVC function through normal saline flushing or infusion, site assessment, dressing adherence) in place will be documented on the PIV assessment flowsheet and VAST data collection tool. PIV VAST RN will enter a new PIV consult if VAST identifies the need to insert a new PIVC during rounding.
10. PIV VAST RN will be responsible for the daily rounding and insertion of new PIVC requests or recommend alternate lines such as ML or PICC per clinical indication.
11. PIV VAST RN will be responsible for doing a chart review for the control group to include LDA assessment and documentation, dwell time, reason, date, and time of removal. 

PROPOSED EHR MODIFICATIONS: See Informatic PPT attachment.

Our existing EHR system will be modified to capture PIVC consult and insertion requests. Currently, PIVC requests are texted or called through Voalte. The team already uses the "Adult-Inpatient PICC and/or ML" consult and insertion order sets. The same system can be created for PIVC requests for better data collection and efficient workflow. The proposed modification will reduce unnecessary phone calls, inaccurate patient identifiers, and duplicate texting between VAST and bedside clinicians. The current APeX PIV Data Collection Report will capture data points relevant to PIVC insertion location, vein used, complications, catheter failure or removal causes, and dwell time.

COST: 

The team estimated that the proposed cost would be spent on VAST RNs' time to implement the small tests of change and materials such as posters, flyers, and quick reference cards for the ONE VAST bundle. Leveraging the VAST expertise on PIVC management and care and the use of US technology is standard work for the team. Still, process improvements need to happen regarding EHR modifications to track and capture sources of waste and inefficiencies accurately. Simplifying supplies and work processes and standardizing VAST workflow will allow a comprehensive examination and assessment whether additional FTEs will be required in order to sustain a dedicated PIVC team if implemented throughout UCSF Parnassus.

For FY 2022, UCSF Parnassus admitted 27,332 patients and used 86,020 PIVCs, which gave an average of 3.14 catheters used per patient visit. Bedside clinicians' standard work time of 20 minutes is dedicated to PIVC insertion, meaning that 28,673 bedside clinician hours were utilized annually. The average hourly rate of a bedside nurse is $98, therefore labor costs for a 20-minute PIVC insertion procedure is $32.67. The supply cost per PIVC insertion is calculated at $5, which includes the PIV catheter, PIV start kit, and NS. The total cost for a PIVC insertion, including labor and supply costs, is $37.67. The VAST USGPIV model has a 99% first-stick success rate. Applying the same numbers of PIVC consumption to the first-time insertion success illustrates the value of a VAST-led dedicated PIV team. 

Published evidence reports that the average cost of short PIVC insertion is $28 -35 for a straightforward first stick. Patients with PIVC failure have prolonged and more expensive hospitalizations averaging two additional hospital days at over $3,000. The failure of one PIVC initiates a damaging and costly cycle of catheter removal and reinsertion at $69. Accidental dislodgement is reported to be more than $266 million annually. PIVC failure rates and complication incidence are as high as 53%, or approximately 1 in 2 catheters fail to make it to 5 days or the end of treatment. The proposal aims to identify the PIVC dwell time and related complications, catheter discontinuation, or catheter failure. 

Given that VAST hours of operation only cover 12 hours in 24 hours, the proposal adjusted the cost savings to reflect a conservative distribution of 50%, assuming this is the percentage that happens between the two shifts. Anecdotally, the majority of patient admissions, diagnostic procedures and care activities requiring a PIVC happen during the day shift. Intravenous medications are more frequently administered during the day shift than night shift. Many PIVC requests overflow from the night shift to the VAST team. The VAST productivity only reflects output produced during the day shift. The proposal aims to examine the economic impacts of the VAST model of care by measuring the nursing hours savings and cost savings. Additionally, an assumption of 10% of the overall catheter usage happens in 10CVT. See Table 3.

Economic Impacts of PIV Team Proposal comparing the Bedside Clinician vs. VAST Model 

• Annual Time Savings  = 14,304 - 4,555 = 9,749 nursing/other clinician hours
• Annual Cost Savings  = $1,616,457 - $514,798 = $1,101,659

Bedside Group on a 12 hour Day Shift (Annualized: *27,332 admits and 86,020 catheter usage for FY22)

• Calculation Based on a 12-hour day shift                                                                      (10%)
• Admits in 12 hours day shift                                      13,666                                    (1,367)
• Insertion Attempts                                                      3.14                                        (3.14)
• Total PIVC Usage at 3.14 attempts                            42,911                                    (4,291)
• Total bedside hours used for PIVC                            14,304                                    (1,430)
• Labor Cost per RN, attempt at 20 minutes                $32.67                                     ($32.67)
•  
• IV Costs: 
• Labor cost (42,911 X  $32.67)                                   $1,401,902.37                       ($140,190.23)
• Supply cost (42,911 X  $5.00 )                                  $214,555.00                           ($21,455.60)
• Total                                                                           $1,616,457.37                       ($161,645.74)

 VAST Intervention Group on a 12 hour Day Shift (Annualized: *27,332 admits and 86,020 catheter usage for FY22) 

• Calculation Based on a 12-hour day shift                                                                      (10%)
• Admits in 12-hour day shift                                        13,666                                    (1,367)
• Insertion Attempts x1                                                1                                              (1)
• Total PIVC Usage at one attempt                              13,666                                    (1,367)
• Total VAST RN hours used for PIVC                         4,555.33                                  (456)
• Labor Cost per VAST RN attempt at 20 minutes       $ 32.67                                    ($32.67)
•  
• IV Costs:
• Labor cost for a (13,666 X  $32.67)                           $446,468.22                           ($44,646)
• Product cost in (13,666  X  $5.00)                             $68,330.00                             ($6,833)
• Total (Cost of Intervention)                                        $514,798.22                           ($51,479.82) 

In FY2022, the VAST team corrected 840 orders that may have led to a potential reduction and avoidance of central line days and other PICC and ML complications such as CLABSI and VTE. For instance, in January 2022, the VAST course corrected 30 inappropriate PICC and ML orders by placing USGPIVs. VAST course corrections have substantial quality and safety implications for CLABSI and VTE prevention. Significant savings and harm reduction may be realized by avoiding the inappropriate use of PICCs and ML. According to AHRQ, management and care of each CLABSI case can cost up to $48,000, and each PICC and ML-associated DVT is $16,000. Assuming that one or all 30 course corrections resulted in these complications, cost avoidance ranges from $48,000 up to $1.4 million and $16,000 up to $480,000 respectively. The course corrections of inappropriate PICC and ML orders have significant savings in supply and labor costs.

 SUSTAINABILITY: 

The VAST team is a unique and highly specialized group with a shared desire to improve patient outcomes. As this proposal outlines, the current decentralized approach and VAST team's "insertion when available only” lead to variations in practice, wastes, and increased costs, affecting patient satisfaction with care. Once the economic impacts of a VAST PIVC model are proven with small tests of change, the proposal can be replicated throughout the hospital. Hardwiring the new work process will be sustained through the EHR modifications and in partnership with nursing and provider educators about PIVC management, care, and maintenance. The engaged executive leadership can help facilitate the spread of the proposal and support with addressing potential barriers to facilitations.

BUDGET: 

• Apex modifications: $10,000
• Material costs (photocopies, badge buddies, posters, info flyers, binders): $1,000
• Salary for project implementers (VAST Team): $36,225
• Breakfast/lunch incentives for test units: $1,000
• TOTAL Budget: $48,225

SUPPORTING DOCUMENTS: See attached PDF file and PPT.

• PROJECT LEAD(S): Sarah Imershein, Molly Shane
• EXECUTIVE SPONSOR(S): Pat Patton
• ABSTRACT – The Department of Care Management and Patient Transitions oversees a large volume of purchased services coordinated by Social Workers and Case Managers.  These are non-billable services, that are not (currently) tracked in a structured way in APeX.  This is predominantly transportation and lodging, but may include medication assistance, post-acute care, or other services we cover to facilitate more timely discharge, e.g. negotiating post-acute care for $50,000 for a year is far less costly to the Health System than the > $1M it would cost to keep a patient admitted.  Most expenses are much smaller, in the $20-200 range, but this amounts to >$1.5M of purchased services/year, and continues to grow.  As of FY23, the Department oversees both Adult and Peds, East and West Bay, as well as many services coordinated through Ambulatory clinics.   Utilization has historically been tracked retrospectively via the invoice process, but is hampered by the long lag-time, and lack of utilization detail in line item variance reports (e.g. “Other Services” is one line item). We propose optimizing the invoicing process and link to the patient-level upstream utilization, so that costs can be tracked more prudently, appropriate patients are connected with appropriate resources (e.g. social determinants of health are addressed), and purchased services that facilitate speedier discharge are leveraged to the fullest.
• TEAM – Sarah Imershein, Patient Transitions Operations Manager; Molly Shane, Executive Director Care Management and Patient Transitions; Trevor Haines, Assistant Director Peds Case Management;, Don Rowland, Assistant Director Adult Case Management; Meher Singh, Assistant Director Adult Social Work; Emily Price, Social Services Operations Manager Oakland; Shabren Harvey-Smith, Director Social Services Oakland; Rosa Solorzano, Assistant Director Peds Social Work; Sharly Lembkey, Executive Assistant.
• PROBLEM –
• Long LOS/avoidable bed days
• Unmet gaps in social needs
• Over-/under-utilization of purchased services
• Deteriorating vendor relationships
• There is currently no mechanism to connect patient level utilization to the monthly variance reports used for tracking cost.
• Utilization of purchased services has been increasing with only anecdotal understanding of the drivers, including which departments, hospital services, or units are highest utilizers; what patient types tend to use services; and whether patients with identified social needs are getting appropriately connected to these services.   There is hypothesized to be a large unmet need of eligible patients currently NOT receiving services, that if did, would facilitate shorter LOS, decrease avoidable days, improved throughput, and higher volumes. 
• TARGET -  The goals of this project:
• Decrease avoidable bed days by 10% from 2511 avoidable days annually to 2260 avoidable days by coordinating appropriate purchased services.  This would generate $958,198 of incremental margin
• Analyze utilization patterns of purchased services to identify areas of over-/under-utilization
• Increase the % of patients with identified gaps in social determinants of health with appropriate services
• GAPS – 
• Technology –
• Significant technology barrier in that whatever system is devised (off-the-shelf or custom built), it must be able to handle P4-level PHI.  Invoices often contain the records of the services provided, including Patient Name, MRN, etc (e.g. list of all ambulance rides in an invoice, or LOAs that must be included to confirm authorization of payment).  Currently, products like Smartsheets cannot be used as a solution since there is no BAA between Smartsheets and UCSF. 
• Currently, UCSF uses a paper-based system to obtain authorizations for large ticket items that needs to be made electronic. 
• Structured data collection at the patient level – currently there is minimal structured collection of data on purchased services at the patient-level – APeX has had FLO rows added recently, but incomplete across all disciplines and types of services that must be tracked – no roll up into an integrated system to track utilization
• Trend analysis –
• Currently utilization is monitored only retrospectively once vendor invoices are received, often months, if not years later, making timely course correction not possible. 
• Currently, there is no close-the-loop function between AP and the Department to notify when vendors are actually paid, resulting in wasteful re-submitting of invoices, and deterioration of vendor relationships.
• SDOH Screening (Social Work)
• New SDOH screening has been implemented partially in Social Work, and is impending health system wide with new CMS rules this coming year (FY24)
• Inconsistent linkage to services when SDOH gaps identified
• Discharge Planning Screening (Case Management)
• Case Management currently follows ~ 40% of adult inpatients and >90% of pediatric inpatients – potential to miss non-CM patients that if provided minimal additional services (e.g. transportation), may discharge faster
• INTERVENTION – 
• Intervention
• Invoice Tracking System – modification of existing (Excel-based), or new solution for tracking individual invoices and categories of utilization (details not included in monthly variance reports); linkage to patient-related information (authorizations, LOAs, etc.); close-the-loop communication with AP to decrease payment cycle time
• Gather Upstream Patient-level utilization data - APeX FLOs developed to capture when purchased services are administered to patients – some existing already; some need development – including in-basket or other communication mechanism for authorizations
• Cost Analytics – Utilization trends analyzed so areas of under/over-utilization addressed to facilitate speedier discharges; joining of SDOH screening to purchased service interventions as evidence of addressing unmet social needs
• Setting – Hospital Encounters and some Ambulatory encounters, Adult and Peds, East/West Bay
• Barriers –
• Tiny expenses - historically tiny expenses (e.g. “a muni token”) have not been tracked robustly and changing behavior to document thoroughly may be challenging;
• SDOH universal screening is not yet implemented – limited set of identified high risk patients, or those identified through social work assessments – will not have complete picture of need until universal screening and workflows established
• Accounts Payable – AP does not have communication channels established back to departments when invoices are processed – need coordination to meet their needs
• Organizational Change – Tracking all these expenses is new - change in how resources are allocated
• Adverse outcomes – no known adverse outcomes
• PROPOSED EHR MODIFICATIONS Note: EHR modifications are NOT required for a winning proposal
• Problem to be solved - tracking patient-level utilization of purchased services
• Tools -  Flowsheets currently implemented for Social Work, but has not been robustly rolled out or given audit feedback – need to expand to Case Management, as well as ensuring all Adult and Peds stakeholders have access; in-basket or other communication tool needed for alerting managers to high ticket items (transition out of email); SQL report or other reporting needed to feed into utilization database – May be other APeX “solutions” other than Flowsheets that could accomplish this goal
• COST – In CY2022, Case Management documented 2511 Avoidable Days related to Community Delays, Patient/Family Delays, and Payer Delays.  Many of these delays have potential to be mitigated by using purchased services to facilitate discharge.  If eliminated, this represents $9.6M in incremental bed day margin (Average daily contribution margin for all UCSF inpatient visits in CY22 is $3,816).  We propose to reduce these avoidable days by 10% from 2511 to 2260 avoidable days, for $958,198 generated incremental margin.

• SUSTAINABILITY – This project is to establish the infrastructure mechanism for tracking this activity that would be sustained indefinitely within the Department.  The staffing and desire to perform this function already exists, just lacking the technical tools, APeX enhancements, and implementation support to make it a reality.
• BUDGET – 
• Project Management salary support $20,000
• Smartsheets or other applicable software implementation $8,000
• Dashboard development, contracted vendor $22,000

PROPOSAL TITLE:Improving Guideline-Concordant Antibiotic Administration At UCSF Health: An Order Panel and Decision-Making Tool to Guide Antibiotic Prescribing

PROJECT LEADS: Allison Bond, MD, Waseem Sous, DO

ABSTRACT:Clinicians frequently prescribe antibiotics discordant with guidelines, with a 30-50% performance gap between ideal prescribing and current practice. This exposes patients to the side effects of antibiotics and fosters antibiotic resistance, costing the healthcare system more than $4.6 billion yearly. One intervention that decreases inappropriate antibiotic use and length of therapy is providing guidance regarding appropriate antibiotic prescribing at point-of-prescription, such as order panels in the electronic health record (EHR). Additionally, Infectious Disease Society of America guidelines suggest the development of facility-specific clinical practice guidelines, which includes order sets and order panels, to optimally address antibiotic use. Community-acquired pneumonia (CAP) is a frequently treated infectious condition that has a clearly delineated treatment course to which clinicians frequently do not adhere. Therefore, CAP treatment presents a chance to improve patient care and cut costs. We propose a multidisciplinary approach to education and prescription guidance for clinicians at UCSF Health for CAP by developing and implementing an order panel providing treatment-related education and guidance. Our multifaceted approach includes a pre-intervention survey to optimize clinician buy-in and tailor the order panel to clinician priorities; development of inpatient and outpatient order panels in APeX for treatment of community-acquired pneumonia; monitoring the rate of use of the order panel after rollout; and comparison of duration and selection of antimicrobial therapy for CAP before and after our intervention.

TEAM:

–       Allison Bond, MD, MA (Hospital Medicine faculty; project co-lead)

–       Waseem Sous, DO (Hospital Medicine HEAL fellow; project co-lead)

–       Sarah Doernberg, MD, MAS (Director of Antimicrobial Stewardship)

–       Armond Esmaili, MD (Hospital Medicine UBLT Medical Director; project mentor)

–       Ripal Jariwala, PharmD (Infectious Diseases Clinical Pharmacist)

–       Emily Kaip, PharmD (Infectious Diseases Clinical Pharmacist)

–       Raman Khanna, MD (Director of Informatics)

PROBLEM:

• At UCSF, antibiotic treatment for all infectious syndromes besides Clostridioides difficile and sepsis is prescribed via placement of individual antibiotic orders, without suggestions for standard-of-care antibiotic agents or durations. Research has shown that providers err on the side of prescribing a longer duration, and sometimes use broader agents, than is needed.
• On the individual level, this exposes the patient to adverse events related to antibiotics – estimated by some research to affect 20% of patients who receive antibiotics.
• On the population and systems levels, this fosters antimicrobial resistance, of which the threat has never been more imminent. This also creates unnecessary healthcare costs via the cost of the antibiotic(s) and the cost of administering the medication(s). In addition, this is an inefficient process which costs clinicians time and raises the possibility of error, because clinicians who wish to adhere to institutional guidelines for antimicrobial prescribing must toggle between UCSF Infectious Diseases Management Program (IDMP) guidelines and APeX when ordering treatment.
• Although an inpatient order set pertaining to the treatment of pneumonia exists (“IP Pneumonia”), this is rarely – if ever – used, does not contain decision-making support or education, and does not focus on the antibiotic treatment of CAP. Due to time constraints with regards to data retrieval, we were unable to ascertain exactly how many times (if ever) the order panel has been used in the last year, but the fact that neither the project leads nor the Director of Antimicrobial Stewardship and Informatics were initially aware that this set existed indicates its use is likely very rare.

TARGET:

• Our primary goal is to reduce the duration of antibiotic treatment for community-acquired pneumonia (CAP) to the course that is known to be safe and is considered standard of care.
• Secondary goals include the dissemination of provider education regarding optimal duration of treatment for CAP as per institutional and national guidelines; decreasing antibiotic-associated adverse events (such as acute kidney injury, Clostridioides difficile, and allergic reactions); and decreasing the use of unnecessarily broad antibiotic therapy intended to treat CAP.

GAPS:

• Educational gap: Many clinicians lack awareness of CAP treatment guidelines with regards to antimicrobial selection and/or antibiotic duration.
• Technological gaps: Research shows that even when prescribers are aware and in agreement with antimicrobial prescribing guidelines, they prescribe antibiotics in a way that veer from these guidelines. There is no system in APeX to guide clinicians towards guideline-concordant antibiotic prescribing for the treatment of CAP. When prescribing an antibiotic in APeX, clinicians are required to select the infectious syndrome they intend to treat, but no feedback or guidance is provided regarding optimal treatment.

INTERVENTION:

• Incorporating the major tenets of change management, we will use pre-disposing, enabling, and reinforcing interventions.
• Predisposing: Provider survey and expert focus group: We will disseminate a brief survey to inpatient and outpatient providers in the Departments of Medicine, Emergency Medicine, and Surgery to evaluate their knowledge of institutional CAP treatment guidelines and to explore in which ways an order panel may be most relevant to their clinical practice. There has already been high interest in this project from representatives in Divisions and Departments across UCSF Health, including Pediatrics, Pediatrics Infectious Diseases, Emergency Medicine, and Adult Infectious Diseases, and we have a focus group planned with representatives from each of these in attendance to solicit feedback regarding what is needed to guarantee the success of the order panel, as well as to recruit project champions to promote buy-in of the project amongst their colleagues. We already have buy-in and support from Informatics (Raman Khanna) and Antimicrobial Stewardship (Sarah Doernberg).
• Enabling: Development of Order Panel: We will submit a proposal to the APeX clinical Content Committee requesting the development of inpatient and outpatient order panels that prompt providers to select the type and duration of antimicrobial agent intended to treat CAP while providing a one-sentence summary of institutional guidelines and an external link to full institutional guidelines and/or national. The order panel will be activated both if providers attempt to prescribe one of the antibiotics frequently used for pneumonia, e.g. ceftriaxone, and if they type “pneumonia” into orders.
• We will also educate providers across disciplines about the new order panel via media campaign and UCSF Health departmental/divisional champions.
• Reinforcing: Post-Rollout Feedback: Based on reductions in excess antibiotic use for CAP, positive institutional feedback regarding cost savings and benefits to patients will be disseminated by department.
• Potential barriers: Development of the APeX order panel would be feasible and straightforward. One key barrier to implementation will include clinician awareness and uptake of an order panel, as the culture at UCSF thus far is to order most things via individual orders. This is the primary reason we anticipate using order panels for this intervention, which are activated when placing standard orders in Epic, rather than order sets, which require tabbing into a separate section of orders in Epic and which are anticipated to have lower clinician uptake. We also plan to address this barrier via our pre-intervention survey.
• Other potential barriers to our intervention could include clinician resistance to use of the order panel if the patient is felt to fall outside of the population of patients for whom antibiotic prescribing guidelines are recommended.

PROPOSED EHR MODIFICATIONS:

• There is currently no order panel or decision-making guide for prescribing antimicrobials for common infectious conditions in Apex; instead, prescribers manually enter the antibiotic type(s), duration, and dosage(s) that they want to use.
• We will add an antibiotic order panel in APeX that would be summoned both if clinicians search for the antibiotic type and the condition they intend to treat. The order panel will include a brief summary of institutional recommendations for antibiotic selection and duration, an external link to full prescribing recommendations, and click-boxes to allow clinicians to select suggested antibiotic type and dosage (including second-line therapies in the case of the presence of antibiotic allergies) and duration.

COST:

• We anticipate that taking into account all inpatients, emergency department (ED) patients, and outpatients treated for CAP at UCSF Health, the cost savings offered by cutting excess antibiotic therapy for CAP will exceed $250,000 per year.
• Our intervention will cut costs primarily via two ways: Decrease in length of stay and cost savings related to antimicrobial therapy.
• Length of Stay Cost Savings:
  • One study found that patients admitted to the hospital with CAP who were treated using a pneumonia pathway/order set had a statistically significantly shorter length of stay than patients admitted with CAP who were treated without the order set (length of stay: 5 days with order set, 6.7 days without, p = 0.01).
  • Cost per day (room and board) for medical/surgical floor inpatients at UCSF Health (per UCSF Finance): $1,586
  • We were asked to determine how many patients were treated at UCSF Health for CAP after initially providing data on how many patients were treated for all types of pneumonia.
  • We reviewed APeX data of patients treated with the antibiotics that are considered standard-of-care for CAP (ceftriaxone, doxycycline, azithromycin, and/or azithromycin) AND for which “lower respiratory tract infection” was listed as the indication when ordered by the clinician on UCSF Health’s inpatient services during a one-week period from 1/9/2023 to 1/15/2023.
  • We found that 83 patients were treated for CAP during that week in January 2023.
  • Based on these data, 4,316 patients are treated for CAP on all inpatient services combined at UCSF Health per year.
  • We appreciate the feedback regarding the length-of-stay-related cost savings. Based on the feedback and the limited literature available regarding reductions in length-of-stay (aside from the study presented above), we have modified the length-of-stay reduction to 0.2 (from 1.7). Based on this adjustment, we anticipate the following:
  • Estimated length-of-stay-related cost savings for all UCSF Health inpatients treated for CAP in 2022:
    • 4,316 patients x 0.2 days = 863 inpatient days saved
    • 863 inpatient days saved x $1,586/d = $1.37M
• Even if our intervention’s effect on length of stay is much smaller than what is found in the literature, cost savings would remain significant.
• Antimicrobial Therapy Cost Savings:
  • Cost of CAP treatment per day: Via the UCSF Charge Description Master list, the cost of each day of antibiotic treatment of antibiotics that are standard-of-care for CAP are as follows: Ceftriaxone - $21; azithromycin - $30 (500 mg)/ $18 (250 mg); levofloxacin - $9; doxycycline $48 ($24 per dose).
  • Because various combinations of these antibiotics are used to treat CAP, the total cost per day of CAP treatment regimens are:
    • Ceftriaxone with azithromycin (CA): $51
    • Ceftriaxone with doxycycline (CD): $69
    • Levofloxacin (L): $9
• As above, we estimate4,316 patients were treated for CAP on all inpatient services combined at UCSF Health in 2022.
• Studies have indicated that 2,526 excess days of CAP treatment occur per 1,000 patients hospitalized with pneumonia. Therefore, we estimate that in 2022, there were 10,902 excess days of CAP treatment among inpatients at UCSF Health.
• Estimated antibiotic-related cost savings for all inpatient services at UCSF Health treated with standard regimens for CAP range from $98,118 - $752,238 per year:
  • CA regimen: 10,902 excess antibiotic days x $51/d =$556,002 saved/year
  • CD regimen: 10,902 excess antibiotic days x $69/d = $752,238 saved/year
  • L regimen: 10,902 excess antibiotic days x $9 = $98,118 saved/year
  • Total anticipated cost savings (including length-of-stay and antibiotic-related costs): $1.46M to $2.12M per year
  • These cost savings are an underestimate as the above includes only UCSF Health inpatients treated for CAP, without accounting for UCSF Health outpatients treated for CAP. Indeed, treatment courses for CAP may not be accounted for in our prior figure, given there are 2.5 million outpatient visits to UCSF Health each year, and CAP incidence rates in the literature range from 20.6 to 79.9 per 10,000 person-years.
  • The cost esimates above were verified with UCSF Finance with the assistance of the Caring Wisely team.
  • Additional cost savings mechanisms via this intervention that can be explored decreased use of broader and often more expensive antibiotics (e.g. vancomycin); increased clinician efficiency; decreased medication errors; and/or decreased duration of the administration of intravenous antibiotics.

SUSTAINABILITY:

• Moving forward, we envision expanding our order panel initiative to encompass many other clinical

syndromes, including hospital-acquired pneumonia, urinary tract infections, skin and soft tissue infections, intraabdominal infections, meningitis, and neutropenic fever.

• Our intervention will be sustained in part through the permanence of the order panel and through dissemination of clinician education.
• We also have a sustainable plan to keep the order panel up to date:
  • When IDMP guidelines are updated (e.g. when national guidelines change), the leads on this project will be alerted and will liaise with the Informatics team to concomitantly update the order panel. We are already collaborating closely with the UCSF Antimicrobial Stewardship Program (ASP), Informatics team, and the Infectious Diseases Management Program (IDMP). Specifically, the ASP and Informatics teams are aware of and support the project. In addition, the project leads presented this work during an IDMP meeting in April 2023, which the Antimicrobial Stewardship team also attended, where the initiative was well-received. We will continue to gain input from and collaborate with these groups during and after the Caring Wisely year to continuously make updates to the order panel, learn from leaders in informatics and antimicrobial stewardship at UCSF, and ensure that the IDMP guidelines are reflected in the order panel.
  • There has also been multi-departmental interest in this work, which represents the opportunity to foster sustainability by soliciting Divisional/Departmental champions who can communicate with and offer feedback on behalf of their colleagues regarding the order panel. We have convened a multidisciplinary working group to facilitate communication between clinicians from various clinical departments; Informatics; and the ASP about this initiative. Should the project leads be unable to continue to facilitate updates to the order panel further in the future, another member of the working group will be selected to fill the role.

BUDGET:

• Please see separately attached budget.