PROPOSAL TITLE 

The UCSF Meningioma Program tumor board and multidisciplinary clinic

PROJECT LEADS

David R. Raleigh, MD, PhD, Associate Professor of Radiation Oncology, Neurological Surgery, Pathology

Nancy Ann Oberheim Bush, MD, PhD, Associate Professor of Neurology, Neuro-Oncology, Neurological Surgery

Jennifer Viner, DNP, ANP-BC, CNRN, Nurse Practitioner of Neurological Surgery and Neuro-Oncology

EXECUTIVE SPONSORS

Alan Ashworth, PhD, FRS, Professor and President of the UCSF Comprehensive Cancer Center

Edward Chang, MD, Professor and Chair of Neurological Surgery

Mitchel S. Berger, MD, Professor of Neurological Surgery and Director of the UCSF Brain Tumor Center

John de Groot, MD, Professor of Neurology and Director of Neuro-Oncology

Catherine Park, MD, Professor and Chair of Radiation Oncology

Susan Chang, MD, Professor of Neuro-Oncology

Arie Perry, MD, Professor of Pathology and Director of Neuropathology

ABSTRACT. Meningiomas are the most common primary intracranial tumors. It is estimated that that 40,000 meningiomas are diagnosed in the United States each year, and that 1% of humans will develop a meningioma in their lifetime. Nevertheless, there are no comprehensive meningioma programs in any medical centers. The objective of this proposal is to develop a comprehensive meningioma program organized around principles of clinical excellence, scientific discovery, multidisciplinary collaboration, and education. To do so, we will use translational science as an engine for clinical trials and patient recruitment to cement UCSF as the physical hub of the nation’s first meningioma program. We have a successful track record of meningioma investigation and treatment that we are poised to amplify through institutional support. Our portfolio of discoveries and innovations include predictive biomarkers and prospective registries that are already changing the standard of care for patients with meningiomas, and new small molecule, biologic, and theranostic treatments that we are testing in clinical trials. We hypothesize that development of (1) a meningioma tumor board and (2) a multidisciplinary clinic will refine postoperative treatment and imaging surveillance paradigms for patients with meningiomas, thereby reducing variation in practice and inequity, improving outcomes, reducing costs, and enriching revenue.

TEAM

Javier E. Villanueva-Meyer, MD, Associate Professor of Radiology (Neuro-Radiology)

Ramin Morshed, MD, Assistant Professor of Neurological Surgery

W. Patrick Devine, MD, PhD, Assistant Professor of Pathology and UCSF Clinical Cancer Genomics Laboratory

Kanish Mirchia, MD, Clinical Instructor of Pathology and UCSF Clinical Cancer Genomics Laboratory

William C. Chen, MD, Clinical Instructor of Radiation Oncology

Charlotte Huie, MSN, Nurse Practitioner of Neuro-Oncology and Neurological Surgery

Isha Sethi, BS, Clinical Research Coordinator of Radiation Oncology and Neurological Surgery

PROBLEM. Meningiomas comprise 40.5% of primary intracranial tumors and are the only brain tumors that are more common in women, Black, and elderly patients, who are underrepresented in brain tumor clinical trials^1,2. Meningioma treatments are largely restricted to surgery and radiotherapy, whereas systemic therapies remain ineffective or experimental^3,4. Historically, the World Health Organization (WHO) has graded meningiomas according to histological features such as mitotic count⁵. Most WHO grade 1 meningiomas can be effectively treated with surgery or radiotherapy, but many grade 2 or 3 meningiomas are resistant to treatment and cause significant neurological morbidity and mortality³. Moreover, some WHO grade 1 meningiomas develop recurrences that cannot be predicted from histological features, and some WHO grade 2 or grade 3 meningiomas are unexpectedly well controlled with surgery and radiotherapy. In recognition of the controversies surrounding meningioma risk stratification and treatment, the NRG BN-003 and EORTC 1308 Phase III clinical trials currently randomize patients with primary WHO grade 2 meningiomas to postoperative surveillance or postoperative radiotherapy after gross total resection⁶. The only multicenter prospective studies of meningiomas that have reported data are RTOG 0539 and EORTC 22042, and these Phase II clinical trials provide safety and non-randomized radiotherapy outcome data based on clinical criteria that do not predict radiotherapy responses in most retrospective series^7–10. Thus, there are urgent, unmet needs for improved risk stratification, development of medical therapies, and prediction of postoperative radiotherapy responses for patients with meningiomas.

In 2021, the WHO revised meningioma grading criteria to incorporate rare DNA mutations alongside traditional histological features¹¹. The WHO 2021 update reflects a growing understanding of the molecular landscape of meningiomas from diverse bioinformatic studies. DNA sequencing^12–15, copy number variant (CNV) analyses^16–18, RNA sequencing^19,20, or DNA methylation profiling^21–24 have been used to classify meningiomas based on recurring somatic short variants^12–15, chromosome gains or losses^16–18, differentially expressed genes^19,20, or DNA methylation probes²³, families²⁴, groups²², or subgroups²¹. Integrated systems have been proposed based on (1) CNVs, CDKN2A/B status, and histological features¹⁶, (2) CNVs, DNA methylation families, and histological features¹⁷, or (3) CNVs, DNA methylation profiling, RNA sequencing, and DNA sequencing which reveal biological groups and subgroups of meningiomas that are concordant with results from DNA methylation profiling or RNA sequencing alone^18,21,22. Clinical implementation of these complex biomarkers requires multidisciplinary discussion and consensus recommendations, barriers that we propose to overcome in this project through the development of (1) a specialized tumor board and (2) a multidisciplinary clinic that will refine postoperative treatment and imaging surveillance paradigms for patients with meningiomas at UCSF.

Over the past 6 years, we have used federal and philanthropic support to discover biological drivers, new targets, predictive biomarkers, and imaging features that provide a framework for redefining clinical paradigms for meningiomas (Vasudevan et al. Cell Reports 2018, Magill and Vasudevan et al. Nat Commun 2020, Choudhury et al. Nat Genet 2022, Chen et al. Nat Med 2023, Lucas et al. Nat Genet 2024). Our scientific discoveries in meningioma biology are permeating WHO and National Comprehensive Cancer Network (NCCN) guidelines and have inspired investigator-initiated and cooperative group trials (NCT04659811, NRG-BN2222). Students, residents, postdocs, and fellows are now specializing in meningioma investigation at UCSF, and patients with meningiomas are increasingly traveling to UCSF for specialized care. Nevertheless, UCSF lacks a multidisciplinary meningioma program to coordinate care across providers and departments and provide access to survivorship programs, such as is routinely available for most other tumor types. We have developed the necessary expertise and personnel to address this problem, and we have implemented prospective registries and clinical trials that we will use as catalysts for self-sustaining clinical, translational, and basic science research. 

TARGET (SMARTIE)

1. Specific: We will implement a bi-monthly meningioma tumor board that will be staffed by physicians from Radiation Oncology (Raleigh, Chen), Neuro-Oncology (Oberheim Bush), Neurological Surgery (Morshed), Neuro-Radiology (Villanueva-Meyer), and Neuropathology (Mirchia). The tumor board will meet in person from 9:30-10:30 am on Thursdays at the UCSF Parnassus Medical Center in room M380. A telehealth option will be available for providers who may intermittently be at other UCSF campuses. Biomarker and clinical data will be reviewed (anticipated 12 cases/meeting), and consensus recommendations will be conveyed through written and verbal communication from our project team to referring providers and patients. Bi-monthly multidisciplinary clinics on alternating Thursdays staffed by physicians from Radiation Oncology (Raleigh, Chen), Neuro-Oncology (Oberheim Bush), and Neurological Surgery (Morshed) will provide patient consultation, treatment, follow-up, imaging surveillance, and survivorship and caregiver support. 
2. Measurable: The primary endpoint will be refinement of postoperative treatment and imaging interval recommendations based on consideration of meningioma biomarkers alongside traditional clinical criteria. As described in the Return on Investment section, we anticipate refining recommendations for approximately 30% of patients (Chen et al. Nat Med 2023). Tumor board recommendations before and after consideration of meningioma biomarkers will be recorded by the Clinical Research Coordinator who is assigned to this project (Sethi). The secondary endpoints will be patient enrollment on clinical trials (NCT04659811, NRG-BN2222), patient referral to the UCSF Brain Tumor Center Supportive Care Services program, and patient enrollment on 2 prospective registries that we have created to more broadly track the success of our program and develop the next generation of predictive biomarkers and treatments for meningiomas. The first is the BEAM program (Biomarker Evaluation for All Meningiomas), a prospective registry that is assembling multidisciplinary clinical and molecular data for all patients with meningiomas who are evaluated at UCSF. The BEAM program allows us to incorporate new investigations of blood and cerebrospinal fluid alongside our well-established workflows for tumor tissue. The second prospective registry is the Living with Meningioma program, a once-yearly survey that is compatible with handheld and standard computing devices and is being used to track patient-reported survivorship in collaboration with the Eureka Research Platform through the UCSF Department of Epidemiology and Biostatistics.
3. Achievable: In terms of identifiable intermediate actions and milestones, we have identified two nurse practitioners who will support inpatient (Viner) and outpatient (Huie) meningioma care at UCSF. Both are experts in neuro-oncology paradigms, and both will participate in tumor boards, multidisciplinary clinics, and inpatient postoperative consultations to recruit and retain patients in the UCSF Meningioma Program. Both nurse practitioners and Dr. Bush from Neuro-Oncology have access to the broad range of supportive care services that span caregiver and survivor resources and education, including a cognitive health clinic. 
4. Relevant: All necessary medical staff, knowledge, and time are available for successful completion of the primary endpoint of this proposal, including the infrastructure that is required for meningioma biomarker evaluation, as described below in the Proposed EHR Modifications section. We request funding for SRA and CRC salary, and for online and print materials, to support and publicize this program. 
5. Timebound: We will initiate tumor board meetings and multidisciplinary clinics in July 2024. We will review our progress toward primary and secondary endpoints during once-monthly virtual meetings between the project leaders, team members, and executive sponsors on the third Friday of each month from 12-1 pm. 
6. Inclusive: Our tumor board and multidisciplinary clinic will be open to all medical professionals who are interested and able to dedicate their time and expertise to improving treatments for patients with meningiomas. Although we have assembled a team of physicians, nurse practitioners, and staff who will be essential for the success of this program, our long-term goals are to increase awareness of meningioma and drive patient volume at UCSF. To achieve these goals, we must be inclusive in our activities and decision making in a way that shares power, and we will organize yearly conferences to publicize our efforts. We will also organize meningioma support groups that will be made available to patients and caregivers. 
7. Equitable: In contrast to many other intracranial tumors, patients with meningiomas often have a protracted disease course, long lifespan, and are from demographics that face barriers to healthcare access. There has been a lack of attention and focus on meningioma survivorship in the brain tumor community, and the rates of returning to work after craniotomy and cranial radiotherapy are abysmal. We will use the Living with Meningioma program to ensure our efforts are responsive to patient- and caregiver-reported experiences, broadly generalizable, and enhance meningioma survivorship. More broadly, we will use this app to publicize and  leverage cognitive rehabilitation services focused on work accommodation and return to work efforts. 

GAPS. Limited understanding of meningioma biology and the misconception that all meningiomas are “benign” has encumbered medical and scientific advances for patients. Despite these misconceptions, meningioma recurrence is the leading cause of death in patients with meningiomas that are resistant to standard interventions²⁵. We will establish UCSF as the global destination for meningioma patients and the premier center to train the next generation of leaders in meningioma treatment and investigation. Using translational science as an engine for clinical trials that incorporate predictive biomarkers, novel medical therapies, and patient- and caregiver-reported outcomes, this program will further distinguish UCSF from other regional medical centers and increase our market share of patients with the most common primary intracranial tumor. In doing so, we will minimize loss-to-follow for the at-risk patient population who is most likely to develop meningioma. No comprehensive meningioma programs exist at any other medical centers, but the scientific and clinical expertise necessary to develop this program are present at UCSF.

INTERVENTION. We hypothesize that development of (1) a meningioma tumor board and (2) a multidisciplinary meningioma clinic will refine postoperative treatment and imaging surveillance paradigms for patients with meningiomas at UCSF, thereby reducing variation in practice and inequity, improving patient outcomes, reducing costs, and enriching revenue to the healthcare system. We will integrate predictive biomarkers for meningioma outcomes (Choudhury et al. Nat Genet 2022, Chen et al. Nat Med 2023, see supporting files) with traditional clinical criteria to offer the highest level of multidisciplinary care to all patients regardless of barriers to healthcare access. This is a collaborative project between the UCSF Comprehensive Cancer Center, the UCSF Clinical Cancer Genomics Laboratory, the UCSF Departments of Neurological Surgery, Radiation Oncology, Radiology, and Pathology, and the UCSF Division of Neuro-Oncology. The multidisciplinary team we have assembled for this proposal is comprised of existing UCSF faculty and staff with expertise and interest in meningioma treatment and investigation. To overcome potential barriers to implementation, we have recruited a multidisciplinary team of executive sponsorswho are responsible for implementing and overseeing meningioma investigation and treatment. We do not anticipate adverse outcomes to reducing variation of practice, but to ensure a culture of continuous improvement we will discuss patient- and provider-reported concerns during meetings between project leaders, team members, and executive sponsors on the third Friday of each month from 12-1 pm.

PROPOSED EHR MODIFICATIONS. As part of routine clinical practice at UCSF, all meningiomas undergo reflexive genomic testing with the UCSF500 next-generation targeted DNA sequencing assay for detection of short somatic variants and CNVs, and RNA sequencing for gene fusion detection and gene expression profiling (Chen et al. Nat Med 2023, see supporting files). Members of our team (Devine, Mirchia) are also members of the UCSF Clinical Cancer Genomics Laboratory (CCGL) where these tests are performed, and the CCGL will soon offer DNA methylation profiling (Choudhury et al. Nat Genet 2022, see supporting files). Thus, we will use pre-existing workflows to populate our tumor board and multidisciplinary clinic with patients whose meningiomas have completed genomic analyses. These workflows will allow us to identify patients (1) who may benefit from individualized postoperative surveillance, radiotherapy, or medical therapy, (2) who may be candidates for enrollment in the prospective BEAM registry or the prospective Living with Meningioma program, or (3) who may benefit from support through Neuro-Oncology (https://braintumorcenter.ucsf.edu/supportive-care). As part of this process, we request development of a meningioma order set through Apex that will be comprised of referrals to neurological surgery, neuro-oncology, radiation oncology, integrative medicine, social work, and brain imaging. 

RETURN ON INVESTMENT (ROI). By implementing biomarkers that predict meningioma responses to radiotherapy (Chen et al. Nat Med 2023) or to medical therapy (Choudhury et al. Nat Genet 2022) in our tumor board and multidisciplinary clinic (stating July 2024), this project will enhance revenue into the health care system and reduce costs without transferring those costs onto patients or insurers. We showed that predictive biomarkers can be used to refine postoperative management for approximately 30% of patients with meningiomas (Chen et al. Nat Med 2023), including identification of clinically low-risk but molecularly high-risk meningiomas that benefit from early postoperative radiotherapy (19.7%) and identification of clinically high-risk but molecularly low-risk meningiomas where radiotherapy may be safely omitted in favor of imaging surveillance (10.1%). By refining postoperative management recommendations and reducing variation in practice, we will (1) improve patient outcomes through early identification of meningiomas that benefit the most from postoperative radiotherapy, and (2) reduce costs by sparing patients with molecularly low-risk tumors from unnecessary postoperative radiotherapy and frequent imaging surveillance. The cost of meningioma radiotherapy ranges from $50,000 to $250,000 per patient. Over the last 10 years, an average of 142 meningioma resections/year (range: 118-155) and 102 meningioma radiotherapy treatments/year (range: 83-117) were performed at UCSF. By refining postoperative radiotherapy recommendations for 29.8% of 102 patients (~30 patients, net anticipated increase in radiotherapy for 10 patients), we anticipate the ROI for FY2025 of this project will be at least $500,000-$2,500,000 (by July 2025), not accounting for reduced healthcare costs by reducing toxicity in patients where postoperative radiotherapy may be omitted. These ROI calculations also do not include additional anticipated benefits from refined surveillance imaging (with fewer MRIs for patients with molecularly low-risk tumors, which cost $1100/MRI), removal of equity gaps for the underrepresented patient population that is most likely to develop meningiomas, increased meningioma patient volume at UCSF, and the benefit of experimental therapies that we are currently testing in clinical trials. Most importantly, this wholistic and comprehensive program will enhance the quality of life of patients. 

SUSTAINABILITY. Our team has a successful track record of R01 and philanthropic support for meningioma research (Raleigh) and contains leaders in the UCSF Comprehensive Cancer Center (Ashworth), Neurological Surgery (E. Chang, Berger), Radiation Oncology (Park), Neuro-Oncology (de Groot, S. Chang), and Neuropathology (Perry). Thus, the process owners who are responsible for implementing and overseeing meningioma treatment at UCSF are already committed to the success of this program, and we have initiated discussions to budget operational funds to continue this program beyond FY2025. Moreover, multiple federal grants to support this program have already been written and submitted, and more will be written and submitted over the course of FY2025 (Raleigh, Oberheim Bush, Villaneuva-Meyer, Morshed, Devine, Chen, Mirchia). Most recently, a P01 entitled Imaging and genomic signatures of brain tumor heterogeneity and evolution to optimize patient management that incorporates meningioma investigation in 3 of 4 projects received a fundable score and a NOA is anticipated in May 2024 (S. Chang, Raleigh, Oberheim Bush, Villaneuva-Meyer, Chen, Mirchia). 

BUDGET (Total $50,000)

Website and social media promotion of the UCSF Meningioma Program and associated trials/registries  $2,000

Patient brochure development to outline the UCSF Meningioma Program and tumor board/clinic             $5,000

SRA salary support for increased meningioma genomic testing in the UCSF CCGL                                 $18,000

CRC salary support for patient enrollment on trials/registries and database development/maintenance  $25,000

REFERENCES

See supporting files

PROPOSAL TITLE: Reducing Unnecessary Respiratory Virus Testing in the Pediatric Emergency Department

PROJECT LEADS: 

• Emily Roben, MD, MS, Director for Quality and Safety, UCSF Benioff Children’s Hospital Emergency Department, Oakland
• Israel Green-Hopkins, MD, Director for Quality and Safety, UCSF Benioff Children’s Hospital Emergency Department, San Francisco

EXECUTIVE SPONSORS:

• Jacqueline Grupp-Phelan, MD, MPH, Division Chief, Pediatric Emergency Medicine (UCSF)
• Karim Mansour, Section Chief of Pediatric Emergency Medicine (Oakland ED)

TEAM:

• Daniel Shapiro, MD, MPH, Assistant Professor of Emergency Medicine, UCSF Benioff Children’s Hospitals
• Rob Lewis, RN, Quality Improvement Specialist, BCH Pediatric Emergency Department
• Yahaira Colorado, RN, Service Line Administrative Director, Emergency Services
• Kate Farley, RN, Unit Director, Mission Bay Children's Emergency Department
• Steven Bin, MD, Medical Director and APeX SME, Mission Bay Children's Emergency Department
• Jim Naprawa, MD, APeX SME, Oakland Children's Emergency Department

ABSTRACT: Testing for respiratory viruses has not been shown to change management or improve clinical outcomes for most children seeking acute care for common illnesses. Accordingly, the Choosing Wisely™ campaign has recommended that limiting the use of these tests should be a national priority. Despite these recommendations, in 2023 respiratory virus tests were performed in 16.3% (N=11,838 tests) of children discharged from the pediatric emergency departments (EDs) at UCSF. The aim of this proposed initiative is to reduce the proportion of children discharged from EDs at UCSF Benioff Children’s Hospitals who have a respiratory virus test performed by 60% (i.e., to 6.5% of encounters) in FY2025. Through a series of interventions including audit and feedback, implementation of a clinical pathway, clinician education, electronic decision support, and electronic order modifications, this project will have an estimated direct costs savings of $261,117 during FY2025.

PROBLEM: Respiratory viruses are responsible for most pediatric emergency visits in the United States.¹ Although testing for and identifying respiratory viral pathogens may provide reassurance for families and diagnostic closure for clinicians, clinical trials and observational studies have demonstrated that respiratory virus testing does not influence management decisions or clinical outcomes for most children.^2-4 At the same time, respiratory virus testing carries financial costs, is physically and emotionally traumatic for children, exposes nurses to respiratory virus particles, may result in false certainty about a viral diagnosis, and may encourage unnecessary healthcare utilization for the sole purpose of obtaining a viral test. For these reasons, the Choosing Wisely™ campaign considers these to be low-value tests in most circumstances.⁵

Despite a lack of evidence to support routine use of respiratory virus tests, these tests are frequently performed in children with and without respiratory illnesses, both nationally and at UCSF. In 46 Children’s hospitals in the United States, the frequency of respiratory virus testing for children discharged from the ED has increased 4-fold in the last 7 years, resulting in monthly charges of approximately $500,000 per hospital.⁶ In children discharged from pediatric EDs at UCSF in 2023, respiratory virus testing was performed in 8,260 (16.3%) of children with any diagnosis and in 4,740 (33.7%) of children with fever or respiratory illness. These findings suggest that there is an opportunity to improve the value of pediatric emergency care by reducing the frequency of unnecessary respiratory virus testing.

TARGET: Our goal is to reduce the frequency of respiratory virus testing in children discharged from pediatric EDs at UCSF Benioff Children’s Hospitals by at least 60% (i.e., to <6.5% of discharges) by the end of FY2025. 

The goal of 60% was chosen based on prior published results of a similar intervention that successfully reduced the proportion with viral testing by >80% at a pediatric emergency department (to a proportion lower than our target of 6.5%).⁷ There were no unintended harms to patients as a result of the intervention. We chose a slightly more modest goal that we felt was achievable, would produce a relevant change, and would account for the unique considerations for our patient population, some of whom have chronic illnesses that may require different considerations for viral testing.

As outlined below, one quantitative benefit of this project is to reduce the direct costs associated with respiratory virus testing by an estimated $261,117. Because the charges for these tests (up to $2,000/test) exceed the direct costs to UCSF ($47/test), we expect the financial cost savings to the healthcare system to far exceed the estimated direct cost savings. Additional qualitative benefits include fewer traumatic nasal swabs for children; less exposure of nursing staff to infectious particles while performing tests; additional time for nursing staff to complete other important clinical tasks; less time spent by laboratory personnel running the tests; and less time spent by ED staff calling families to report test results after discharge. Additionally, if changes in testing practices result in a culture shift away from indiscriminate testing, then families may not present to the ED for the sole reason of obtaining a test for mild, self-resolving illnesses. This could potentially reduce the financial and time costs associated with low-acuity ED visits.

In the comments below, we provide an estimate of time saved by bedside nurses (822 hours/year), lab personnel (843 hours/year), and follow-up nurses (561 hours/year).

GAPS: The table below summarizes the gaps identified, the multifactorial potential drivers of the problem, and the corresponding proposed interventions to address each driver. 

INTERVENTIONS

Practice setting: UCSF Benioff Children’s Hospital EDs, San Francisco and Oakland

Target population: Clinicians caring for children discharged from ED with any diagnosis.

Proposed interventions and rationale: See the table below.

Potential barriers to implementation: Clinicians and parents may have strong preferences for testing, even in cases when testing is not evidence-based. The proposed interventions are designed to provide information to stakeholders and make it easier to forego testing when it is not indicated, while leaving space for stakeholders’ beliefs and preferences to guide individualized care.

Possible adverse outcomes of proposed interventions: Similar interventions in other EDs have resulted in large reductions in viral testing without adverse clinical outcomes. We will monitor rates of ED return visits with/without hospitalization during the intervention period. Additionally, while designing and monitoring the interventions, we will consider potential unintended effects on clinicians such as alert fatigue and task interruption. 

Plan to measure and close equity gaps: The team will measure and monitor the primary outcomes according to patient race, ethnicity, sex, and preferred language. Any identified inequities in testing practices will be communicated to ED attendings at faculty meetings, and efforts to close potential gaps will be developed and incorporated into the interventions.

PROPOSED EHR MODIFICATIONS: The current APeX order set offers 3 options for viral testing: COVID, COVID/influenza/RSV, or comprehensive respiratory viral panel. Clinicians select the order without any guidance on why one (or any) order might be indicated. While any revisions to the order set will depend on insights from focus groups with stakeholders, we will consider using forcing functions, educational decision support, and/or requirements to select/input the rationale for testing prior to placing an order.

RETURN ON INVESTMENT (ROI): The table below includes the estimate for the direct cost savings to UCSF. Given that prior similar efforts have reduced rates of testing by >80%, we believe that these are conservative estimates.

*Based on estimates from Bryson Reedy, senior decision support analyst, UCSF Medical Center 

Based on the estimated number of avoided tests (5,447), the percentage of tests that require additional PPE to be worn by nurses (50%), and the estimated cost of PPE ($1.35/unit), we estimate and additional $3,696 in direct cost savings on PPE. Please see sources for these calculations in the comments.

SUSTAINABILITY: If successful, this intervention will be sustained by the ED’s quality improvement team, led by Drs. Roben and Green-Hopkins. The care pathway for viral testing will be reviewed and updated in the same way that other clinical pathways are updated based on new evidence and invited feedback from stakeholders. Similarly, process and outcomes measures—including equity measures—will be monitored after the funding year. Our Quality and Safety leadership team has a strong foundation in data analytics and cohort monitoring. Accordingly, we are confident in our ability to maintain workflows/analytics and to ensure continuous improvement without the need for additional funding beyond FY2025.

BUDGET:

References:

1. McDermott KW, Stocks C, Freeman WJ. Overview of Pediatric Emergency Department Visits, 2015. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. 2006.

2. Vos LM, Bruning AHL, Reitsma JB, et al. Rapid Molecular Tests for Influenza, Respiratory Syncytial Virus, and Other Respiratory Viruses: A Systematic Review of Diagnostic Accuracy and Clinical Impact Studies. Clin Infect Dis. Sep 13 2019;69(7):1243-1253. doi:10.1093/cid/ciz056

3. Rao S, Lamb MM, Moss A, et al. Effect of Rapid Respiratory Virus Testing on Antibiotic Prescribing Among Children Presenting to the Emergency Department With Acute Respiratory Illness: A Randomized Clinical Trial. JAMA Netw Open. Jun 1 2021;4(6):e2111836. doi:10.1001/jamanetworkopen.2021.11836

4. Mattila S, Paalanne N, Honkila M, Pokka T, Tapiainen T. Effect of Point-of-Care Testing for Respiratory Pathogens on Antibiotic Use in Children: A Randomized Clinical Trial. JAMA Netw Open. Jun 1 2022;5(6):e2216162. doi:10.1001/jamanetworkopen.2022.16162

5. Pediatrics AAo. Choosing Wisely: Five Things Physicians and Patients Should Question in the Practice of Pediatric Emergency Medicine. Accessed February 23, 2023. https://www.aap.org/en/news-room/news-releases/aap/2022/choosing-wisely-five-things-physicians-and-patients-should-question-in-the-practice-of-pediatric-emergency-medicine/

6. Children's Hospital Association, Pediatric Healthcare Information System.

7. Ostrow O, Savlov D, Richardson SE, Friedman JN. Reducing Unnecessary Respiratory Viral Testing to Promote High-Value Care. Pediatrics. Feb 1 2022;149(2)doi:10.1542/peds.2020-042366

Abstract:

Diabetes and asthma impact the lives of millions of Americans in the United States today. Insulin is used to manage inpatient diabetes care when patients are hospitalized, and insulin at UCSF’s adult hospital is delivered through multi-dose insulin pens. At times of transition (such as transfers to other patient care units), patient-specific bulk medications such as, but not limited to, insulin pens and multi-dose inhalers are frequently wasted because of incomplete bulk-medication transfer across units. Bulk medications are either dispensed from the inpatient pharmacy or automatic medication-dispensing Pyxis devices, and multiple pens or inhalers can be pulled from different Pyxis locations across the hospital. This often leads to duplicate insulin pens or inhalers being dispensed resulting in increased waste. Another common source of waste involves inappropriate storage of a patient’s bulk medication in the patient room, which leads to nurses pulling new medications when an existing one is already at the patient’s bedside.

Medication waste has a significant impact on the healthcare budget and detrimental effects on the environment. These duplicated, inefficient practices generate waste and environmental burdens, adding unnecessary costs to the patients, our institution, and the health system at large. Additionally, streamlining bulk medication utilization will increase equity and resiliency in our health system considering the ubiquitous drug shortages, the limited access to these lifesaving drugs, and how diabetes and asthma disproportionally affect communities experiencing health disparities.

In the future, we can evaluate avenues to enhance health equity and access to critical medications while simultaneously minimizing waste and optimizing patient outcomes. Through comprehensive assessment and strategic planning, we can identify opportunities for dispensing medications in a manner that addresses disparities in healthcare access such as with patients who cannot afford insulin/inhalers or are discharged at a time of night when they have limited access to pharmacies. By implementing sustainable practices and leveraging innovative solutions, we can reduce waste, decrease costs of paying for proper disposal of partially used medications (hazardous pharmaceutical waste), reduce carbon emissions, and ensure that every individual has equitable access to essential treatments, thereby promoting healthier communities and improving overall well-being.

TEAM - Core implementation team members and titles

Esther Rov-Ikpah, MS, RN, CDCES, Diabetes Care and Education Specialist

Kethen So, PharmD, MBA, DPLA, BCSCP, FCSHP, Pharmacy Manager

Jimin Lee, PharmD, BCPS, Pharmacy Supervisor

Meghan Talbert, MSN, RN, AGCNS-BC, CDCES

Lisa Hartmayer, MSN, RN, ANP-C, CCTN

Gina Stassinos, PharmD, Staff Pharmacist, Emergency Department

Robert Rushakoff, MD, Clinical Professor, Diabetes and Endocrinology

Samantha Scott-Marquina, MS, RCP, Director of Respiratory Care Services

Brian Daniel, RCP, Respiratory Care Clinical Specialist

Kaiyi Wang, MS, Sustainability Analyst, Sustainability

Seema Gandhi, MD, Clinical Professor, Anesthesiologist and the Medical Director of Sustainability

Problem: 

Insulin pens and inhalers are common bulk medications used for inpatient management of diabetes and asthma, respectively. Hyperglycemia affects up to 38% of hospitalized patients, most of whom will require at least one type of insulin (Malcolm et al., 2018). Insulin pens are dispensed from automatic medication-dispensing Pyxis devices, and multiple pens can be pulled from different device locations across the hospital. This increases the likelihood that a new pen will be pulled when a patient is transferred to a different location, rather than ensuring that the existing medication is properly transferred with the patient. Waste can also occur when pens are left at the patient’s bedside instead of being placed in the appropriate location in the room or medication room, which can lead to practices of pulling new pens when an existing one is already available. We consider a duplicate insulin pen as waste when a patient has more than 1 insulin aspart and 1 insulin glargine pen pulled from the Pyxis during the hospital stay. Based on FY23 data, 4764 insulin apart pens, and 2272 insulin glargine pens were considered duplicates, which amounted to $549,838 in wasted cost (Table 1). Similarly, depending on the inhaler, it is dispensed from inpatient pharmacy or the automatic dispensing Pyxis machine. Duplicate inhalers dispensed amounted to $79,003 in wasted cost (Table 2). The most widely dispensed meter dose inhaler uses a powerful greenhouse gas that contributes to climate change (Wilkinson et al., 2020). These wasted bulk medications pose significant financial and environmental burdens on our health system.   

Table 1. Estimated wasted cost for insulin Aspart and insulin Glargine pens that are used for in-patient diabetes management based on FY23 data

*Further data review is needed to consider readmitted patients in FY23 to capture exact duplicated/wasted pen data.

Table 2. Estimated wasted cost for different types of inhalers that are used for in-patient asthma management based on FY23 data

Bulk medication waste is not a problem exclusive to our health system. A 240-bed community hospital in the Johns Hopkins Health System reported on average 1 insulin aspart pen and 0.8 insulin glargine pen were wasted per patient. A statistically significant reduction in the number of pens wasted per patient and annual cost savings of $66,261 were documented after a series of workflow interventions. (Najmi et al., 2021). Similarly, a sampling study conducted at Fraser Health in British Colombia reported that 19.3% of patients had at least one duplicated inhaler, which resulted in a loss of $5,151.12 among the 189 sampled patients. (Aeng et al.,2020). Both studies indicate that bulk medication waste is a widespread issue in in-patient management and substantial financial savings can be achieved with focused interventions.

Gaps:

While reviewing the workflow at UCSF, we observed that the current practices for bulk medication prescription and use result in significant duplication and waste. These practices include a lack of standardized protocol for medication transfer between locations and inconsistencies in bulk medication placement at the patient’s bedside.

Major contributing factors include inconsistent workflow, lack of education regarding proper bulk medication transfer protocol, and lack of consistency in hand-off documentation and oversight.

1. Bulk medications are sometimes misplaced at patients’ bedside and are not returned to the cassette in the med room.
2. Frequently, medications are not packaged in medication transport bags and handed to the transport team. There is no standardized process of handover to the receiving team in the new unit.
3. In some units, we observed that medication transport bags were not present or not accessible.
4.  Inconsistent documentation of medication transfer in the Transfer Navigator in EPIC
5. Lastly, when pulling new insulin pens or inhalers from the pyxis device, reminders to verify existing medications pulled are lacking.

Targets:

With the support of our executive sponsors, the Caring Wisely team, and the dedicated efforts from our team, we have set targets for this project to:

S:  Reduce the insulin pen waste by50% and reduce the number of wasted multi-dose inhalers for all inpatients by 50% by June 2025

M: We will be working with Pharmacy to track dispense data and duplication ordering monthly.

A: We are confident that our multidisciplinary team through the education of staff and transport teams, working with the Epic build team, and periodic audits and feedback over the year of the award, this project will be impactful from a financial and environmental perspective.

R: Per CDC, in the last decade the incidence of diabetes has increased from 10.3% to 13.2% in Alaska native and non-Hispanic blacks, and similarly the incidence of asthma exacerbations related to wildfires and poor air quality has increased. The need for these bulk medications will only go up and the efforts to decrease waste are crucial.

T: We have started conversations with multidisciplinary stakeholders and plan to continue this work across the health system. Support and focus from Caring Wisely will be integrative and a key center point needed to integrate the data collection and interventions for a sustained change in practice.

I:  UCSF prides itself in serving a diverse and marginalized population not only in California but from across the country and efforts to decrease insulin waste and MDIs, which contribute to cost and emissions reduction, are very timely.

E: Our project focuses not only on reducing financial waste at UCSFH but also tackles a crucial topic of decreasing emissions from US healthcare, where 20 % of emissions are attributed to pharmaceuticals and chemicals.

Interventions:

Through an established workgroup and prior meetings, we have assembled a diverse group of team members that include representatives from Pharmacy, Diabetes Management, Nursing, Respiratory Care, Emergency Department, and Sustainability. Each team member will bring their unique perspectives with respect to their roles to engineer effective solutions for process improvement. Dr. Seema Gandhi, who previously received a Caring Wisely award in 2020, has extensive experience in successfully implementing sustainability-related quality improvement projects and will be a huge asset and provide leadership for this project.

The initial stage of the project will focus on evaluating the medication transfer process through audits and education of existing and new staff on awareness of the problem and standard protocol. Stakeholders’ interviews will be conducted to identify critical points of inefficiency in the transfer process that lead to waste. We are proposing a multi-prompt approach from education, physical, and digital reminders, to EHR modifications. Some of the modifications have already been implemented (in italics) as part of the pilot.

1. Added alert message “Check for existing insulin pen(s)” when pulling insulin pens from Pyxis (Implemented on 10/17/23)

2. Added medication rows to the Transfer Navigator (Implemented on 11/14/23)

3. Moved Handoff/Receiving row under “Patient Belongings” for more visibility in the Transfer Navigators and added this row to the Oncology units (11L, 12L) (Implemented on 1/9/24)

4. Nursing education on medication transfer protocol and cost awareness (Annual Review Module created for all inpatient Adult RNs, implemented on 10/1/23, reinforcement required). Presented at Staff meetings across the medical center to direct care staff RNs (17 unit staff meetings to ~510 direct care staff RNs including unit leaders).

Our future efforts will be aimed at:

1. Education of nurses and transfer support staff via in-person presentations at staff meetings in Emergency Rooms, ICUs, PACU, and inpatient units. We will create a video and a voiceover presentation that will be accessible to all nurses and staff. Furthermore, we will work on signage for a transfer checklist.

2. We will also track the utilization of the transfer navigator during the transfer of patients and conduct focused education to improve the utilization of the Transfer Navigator for the documentation of medication transfer.

3. Evaluate processes for onboarding new staff regarding training on medication transfer processes.

4. Implement signage in the medication room to return bulk medications to cassette and transfer patient bulk medications when transferring patients.

5. PCAs are vital to the success of this process and educating and empowering them to ask “Are there medications I need to take to the new unit” will ensure a second tier of check.

6. Establish a respiratory care-driven bronchodilator pathway to ensure timely and clinically appropriate transitions to bronchodilators.  

7. Establish a Pyxis/MAR clinical alert when dispensing inhalers

8. Educate Respiratory Care Practitioners on medication transfer protocol, cost, and environmental impact awareness of MDIs.

Potential barriers to implementation include resistance to workflow change from staff and competing priorities, especially for EPIC modifications. However, with increasing awareness and education surrounding this issue, we anticipate that we will have adequate support from staff and leadership to achieve the project targets. We do not anticipate any adverse outcomes associated with our proposed interventions.

PROPOSED EHR MODIFICATIONS

1. Addition of a Best Practice Alert (BPA) that triggers when nurses release a transfer order and will prompt the nurses at the receiving end to check for transferred medications when the patient arrives at the new unit. EHR modification options will be discussed with a multidisciplinary team of stakeholders to ensure adoption and compliance. Members of our team have experience and success in creating a BPA to decrease anesthesia gas consumption that has been adopted nationally.

2. Currently version of the PACU navigator lacks a medication sent/receive tab, we will plan to add “Medications sent/Medications received” rows in the PACU navigator to correspond with the newly improved Transfer Navigator for consistent documentation across all patient transfers in the hospital.

RETURN ON INVESTMENT (ROI) - Estimated direct cost savings and/or revenue enhancement to the health system from the proposed project

Table 1. Cost savings projection based on FY23 insulin pen and multi-dose inhaler waste data when achieving the targeted goals of 50% reduction.

Based on FY23 estimated waste data from insulin pens and multi-dose inhalers, with a conservative estimate of a 50% reduction in waste for both medications, a total saving of $314,420 can be achieved at a minimum

In addition, during our detailed observations, we might identify waste opportunities in other bulk medication waste, such as eye drops and compounded drugs, during the project which can be targeted during future endeavors.

There are other financial and environmental benefits in reducing bulk med waste disposal. Medication such as insulin pens are considered hazardous waste and must be disposed of in the black bins to be incinerated. The cost savings associated with decreased hazardous waste disposal will be determined as part of the proposed work.

Sustainability:

We reviewed preliminary results for the interventions that were already in place. For November 2023, the percentage of insulin pen duplicates was 33.4%, compared to 46.2% for FY23, and the total wasted cost was $25,895 versus the monthly average of $45,820 for FY23. This indicated an encouraging improvement from our baseline assessment.

Ongoing monitoring of the interventions will be conducted by the Diabetes Care and Education Specialists, who will report back to the existing committees for improving inpatient diabetes management (Diabetes Champion group and Inpatient Diabetes Management committee). Existing project leads will continue leading this work after project completion, and data for trends of insulin pen waste will be evaluated quarterly to assess the efficacy of the interventions. The Director of Sustainability and her waste reduction team will continue audits of the new process.

Budget:

Signage for all Medication rooms: $2000

EHR analyst support: $5000

Lead clinician time support: $20000

Research Analyst support: $5000

Informatics support: $5000

Creating educational material: $8000

Conference dissemination and publication support: $5000

Total Budget Requested: $50,000

References:

Malcolm, J., Halperin, I., Miller, D. B., Moore, S., Nerenberg, K. A., Woo, V., ... & Diabetes Canada Clinical Practice Guidelines Expert Committee. (2018). In-hospital management of diabetes. Canadian journal of diabetes, 42, S115-S123.

Najmi, U., Haque, W. Z., Ansari, U., Yemane, E., Alexander, L. A., Lee, C., ... & Zilbermint, M. (2021). Inpatient insulin pen implementation, waste, and potential cost savings: a community hospital experience. Journal of Diabetes Science and Technology, 15(4), 741-747.

Aeng, E. S., Dhaliwal, M. M., & Tejani, A. M. (2020). A cautionary tale of multiple‐dose drug products: Fluticasone and salmeterol combination inhaler waste. Journal of Evaluation in Clinical Practice, 26(6), 1699-1702.

Wilkinson, A.J.K., Anderson, G. Sustainability in Inhaled Drug Delivery. Pharm Med 34, 191–199 (2020).

PROPOSAL TITLE: Implementation of transcutaneous bilirubinometers to reduce unnecessary blood testing and improve patient outcomes in the Intensive Care Nursery (ICN)

PROJECT LEADS: Christine Studenmund, MD, Eisha Jain, MD, Katelin Kramer, MD

EXECUTIVE SPONSORS: Elizabeth Rogers, MD (Neonatologist; Director, ICN Roots Small Baby Programs) and Diane VonBehren, MS, RN, NEA-BC (Associate Chief Nursing Officer, UCSF BCH-SF)

ABSTRACT: Neonatal hyperbilirubinemia requires universal screening of all newborns given its high prevalence and irreversible neurologic consequences if left untreated.¹ Monitoring bilirubin historically required frequent phlebotomy, putting infants at risk of poor short- and long-term outcomes due to frequent painful procedures and iatrogenic anemia.^2–4 The transcutaneous bilirubinometer (TcB) is an excellent alternative as it performs point-of-care bilirubin measurements without puncturing the skin. It is well-studied as a safe and valid tool for bilirubin screening,^5–9 and now is part of the American Academy of Pediatrics practice guidelines.¹ Its use can decrease unnecessary labs in neonates, leading to direct cost savings and improved patient outcomes.^10–12 Despite this, TcBs have not yet been introduced to the Mission Bay ICN. There is an urgent need to align our practices with AAP guidelines. Our QI project aims to reduce phlebotomy for bilirubin screening for all newborns admitted to the ICN by 50% during the first two weeks of life. The primary intervention will be to purchase and roll-out TcB monitoring using QI methodology. In addition to aligning our practices with national standards and reducing patient and family harm, success would result in over $70,000 saved per year from laboratory costs alone, as well as over $250,000 per year in expected direct savings from reduction in blood transfusions and shortened length of stay.

TEAM:

• MD leads: Katelin Kramer, MD (Neonatologist), Christine Studenmund, MD, Eisha Jain, MD
• Executive sponsors: Elizabeth Rogers, MD (Neonatologist; Director, ICN Roots Small Baby Programs), Diane VonBehren, MS, RN, NEA-BC (Associate Chief Nursing Officer, UCSF BCH-SF)
• CNS: Jeannie Chan, MS, RN, NNP, CNS and Gabby Byers, MSN, CNS, RNC-CIC
• Nursing leadership: Jennifer Gantz, MSN, RN, RNC-NIC, Jordan Davis, PhD, MS, MPH, RN, Monica Merino, MSN, RN, RNC-NIC
• NNPs: Laurel Pershall, NNP and Michele Evans, NNP
• Child life: Taylor Park, CCLS
• Parent Liaison: Diana Rogosa

PROBLEM: In our Mission Bay Intensive Care Nursery (ICN), we rely on frequent high-resource, invasive procedures for bilirubin monitoring, while point-of-care (POC) monitoring has been widely adopted for term and preterm infants elsewhere. Our reliance on total serum bilirubin (TsB) measurement via phlebotomy on a daily or more frequent basis negatively impacts patient outcomes, workflow efficiency, and healthcare costs. Frequent phlebotomy-associated noxious stimuli and iatrogenic anemia are associated with poor outcomes for neonates, especially preterm infants. Any opportunity to reduce these risks should be implemented. Transcutaneous bilirubinometer (TcB) utilization in the ICN for POC monitoring of neonatal jaundice is an opportunity to both reduce harm and save healthcare resources.

There have been multiple attempts to purchase TcBs through the traditional avenues in the ICN, however this has been unsuccessful due to budget constraints. Additionally, a successful roll-out of this intervention requires additional QI support up front. To truly see decreased blood draws and cost savings, Apex changes, nursing and provider education, and project champions are needed.

Background - All newborns in care undergo monitoring for neonatal hyperbilirubinemia in the first weeks of life due to its high prevalence and risk of deleterious neurologic effects if missed.¹ This is a universal practice in intensive care nurseries around the world, regardless of gestational age at birth, birthweight, or risk factors. Historically, this practice relied on obtaining daily or more frequent blood draws for TsB monitoring. Guidelines have since adopted non-invasive, easy to use, POC screening with the advent of TcBs, reducing iatrogenic blood loss and frequency of painful procedures, Figure 1 in Supporting File.^5,6,10,11

The American Academy of Pediatrics (AAP) practice guidelines currently recommend TcB screening in infants above 35 weeks gestation to triage the need for TsB collection.¹ Several high quality studies have also found TcBs to reliably predict bilirubin levels in newborns under 35 weeks gestation.^5,7,8 TcB validity in infants as young as 22 4/7 weeks gestation was demonstrated in a California study in 2022 involving 8 local ICNs, including BCH-Oakland.⁵ This study, amongst others, also suggested TcB validity during and after phototherapy when performed on skin protected from blue light treatment.^5,13,14 These findings recommend expanded TcB utilization in preterm infants as well as before and after jaundice treatment.

Associated Costs - The cost of frequent TsB-associated phlebotomy in our ICN reaches upwards of $70,000/year in direct costs of obtaining and processing TsB labs that could otherwise be avoided with TcB utilization (Table 1 in Supporting File). Costs are even greater when accounting for secondary consequences of frequent blood draws described below.

• Poor patient outcomes: Each TsB collected requires 1.0 mL of blood volume. Iatrogenic blood loss, particularly in preterm infants, can worsen anemia of prematurity and need for blood transfusions. Additionally, phlebotomy puts infants at risk of procedure or line-associated infection and subsequent increased length of stay. Finally, frequent painful procedures are associated with injury to the developing brain, with studies showing an independent association with white matter loss, long-term neurodevelopmental delays,² and long-term mental health problems including anxiety and depression requiring care.³
• Psychological harm: The families of our patients also report stress associated with observing their child undergo frequent blood draws. Limiting TsB-associated blood draws would therefore reduce early patient trauma as well as family distress.
• Inequitable care: TcBs are currently utilized in our Newborn Nursery’s (NBN) neonatal jaundice screening protocol, but not our ICN. Non-Hispanic Black infants are more than twice as likely to deliver preterm, have significantly higher rates of ICN admission, neonatal mortality, and comorbidities compared to non-Hispanic White newborns.¹⁵ Our misalignment in care between hospital units and gestational age, therefore, directly contributes to inequitable care.
• Resource utilization: TsB collection and processing requires time and labor, sterile equipment, and lab processing technology that may otherwise be saved for higher risk cases. Unnecessary TsB collection thus burdens our employees and inhibits workflow efficiency.

Urgency - The current neonatal jaundice screening and monitoring practices in our Mission Bay ICN do not effectively follow AAP recommendations and do not align with current practices in our NBN or other ICNs in California, making this an urgent matter. The prompt introduction of TcB monitoring in the Mission Bay ICN is imperative at this time to address unfavorable clinical protocol variability and close gaps in care rooted in socioeconomic differences.

Current Condition - Currently, the Mission Bay ICN relies solely on phlebotomy for screening and monitoring of neonatal jaundice, as described above. Infants are subjected to unnecessary painful procedures and blood draws despite there being a non-invasive option available.

At this time, we have achieved widespread buy-in for a neonatal jaundice protocol change involving TcB introduction from ICN providers, nurses, trainees, and leadership, and intend to act on it as soon as possible. We foresee this initiative to be an extension of our existing NEOBrain work, an active multidisciplinary QI group that aims to reduce noxious stimuli and improve neurodevelopmental care in preterm infants. This team is currently significantly limited in the scope of QI work able to be done with no protected time for QI champions.

TARGET: Our aim is to reduce unnecessary phlebotomy in screening and management of neonatal jaundice in the Mission Bay ICN in order to improve patient outcomes, increase efficiency, and reduce healthcare costs. Our SMARTIE goal is to achieve at least a 50% reduction in phlebotomy for bilirubin screening during the first two weeks of life for neonates of all gestational ages admitted to the Mission Bay ICN within the first year of utilizing TcB monitoring. We believe that our goal is achievable and surpassable.

GAPS: Unnecessary phlebotomy and variability in care across hospital units related to neonatal jaundice screening and monitoring in the ICN exist due to inaccessibility to non-invasive, POC bilirubin testing. Funding is a key missing resource limiting our division’s ability, not only to purchase the TcB devices but also to provide the QI support, Apex support, and education needed for this roll-out to be successful.

Educational and systems gaps also exist that will need to be addressed in order to transition to a lower cost protocol for evaluation of neonatal jaundice in the ICN. These gaps include:

• Practice guidelines for TcB use in neonatal jaundice screening for patients < 35 weeks gestation do not currently exist at Mission Bay.
• Providers, trainees, and nursing staff are not currently trained in using TcB devices and interpreting results.
• Order sets and bilirubin data flowsheets and visualization tools in the ICN EHR context are not currently optimized for a TcB-integrated neonatal jaundice protocol.

INTERVENTION: We propose introducing TcB monitoring in the 58-bed ICN for patients of all gestational ages using hand-held bilimeters (e.g., Drager BiliMeter). Using funds from Caring Wisely, we plan to leverage the resources from an existing interdisciplinary QI team (NEOBrain) composed of neonatologists, neonatology fellows, pediatric residents, hospitalists, neonatal NPs, RNs, RTs, PT/OTs, Child Life, and parent liaisons.

Prior to implementation we plan to develop practice guidelines with the help of our QI team. Bedside nurses will obtain the TcB measurements, as is current practice in the NBN. We propose EHR modifications (see below) that will aid nurses and ordering providers in adopting this new protocol. Nurses and providers will receive training on the new protocols, both with in-person didactics, videos, and flyers / posters located at highly visible locations on the unit. We will use Apex reports (see below for proposed report creation) to solidify our understanding of the baseline rates of TcB and TsB measurements and then follow these rates over time to assess success of our intervention, stratifying data by gestational age and race / ethnicity.

Barriers - Potential barriers to implementation include time, with nurses needing to incorporate obtaining TcB measurements into their care schedule. However, obtaining the measurement takes less than 10 seconds and we will include a streamlined nursing workflow within our practice guidelines. A new protocol will need to be established with consensus among the division for thresholds to verify TcBs with TsB, especially for preterm infants when there is less comfort with this practice.  Changing existing protocols can be challenging, particularly in the ICU setting with critically ill patients where there often is a mindset of frequent serum monitoring. We aim to mitigate this challenge through multiple presentations of the growing body of literature on the validity of TcBs in all gestational ages. We also plan EHR modifications and hosting in-unit training on the new protocol. We will track the outcomes of this QI initiative on the huddle board in the ICN to display the results of this QI effort as a motivating factor.

Possible adverse outcomes - There are very minimal potential adverse outcomes. Studies have demonstrated that incorporating TcB monitoring rarely results in extreme bilirubin measurements or delay in phototherapy.¹⁶ We will use extreme serum bilirubin values as a balancing measure and plan to compare these to pre-intervention rates. Our practice guidelines would create clear TcB levels at which a serum confirmatory measurement would be required, further reducing the risk of adverse outcomes.

PROPOSED EHR MODIFICATIONS: We propose modifications to existing EHR tools as well as creation of new tools below. These modifications will help integrate the practice guidelines into the EHR, decreasing the likelihood of human error and facilitating adoption of the protocol by providers.

• Modification of Bilirubin Summary Tab: Addition of TcB measurements in bilirubin summary tab for the ICN. Currently this only exists in the NBN. Will also propose adding an additional line that is 3 points below the phototherapy threshold at each postnatal age. This would create a visual representation to see if the TcB is above this line, then a TsB is required.
• Creation of bilirubin screening Order Set: Currently, TsB is ordered as needed and there is no option to order TcB in the ICN. An order set would be helpful that includes qAM TcB order with PRN TsB confirmation order.
• Modification of Documentation Flowsheet: Adding TcB to the nursing documentation flowsheet, which is currently only available in the NBN. These values would then pull into the results section and bilirubin summary tab. If possible, the input would include an alert pop up after entering the TcB either stating: 1) No TsB required 2) Obtain confirmatory TsB. The criteria for requiring a TsB will be finalized through meeting with stakeholders.
• Creation of Report: Report for # of TcB and TsB / 100 patient days, stratified by gestational age. 

ROI: The projected savings to the healthcare system are significant. One direct source of cost savings is the reduction of serum bilirubin tests that need to be performed in the laboratory. There is the potential for significant direct cost savings beyond running the lab test, including reducing blood transfusions, length of hospitalization, and rates of infection.

TcB measurements estimate TsB levels within 3 mg/dL if the TsB level is under 15 mg/dL in neonates > 35 weeks gestation. For TcB values > 15 mg/dL or within 3 mg/dL of phototherapy threshold, the AAP recommends confirmatory TsB testing.¹ For preterm infants, studies have shown the same cut-offs for the need of serum bilirubin confirmation.⁵ We estimate that term infants have an average of ~2.5 TsBs drawn per patient. For term infants, TcB screening has been shown to reduce the need for serum confirmation by 70-80%.¹¹ Given term infants in the ICN are more critically ill which puts them at slightly higher risk of hyperbilirubinemia, we conservatively estimate at least a 50% reduction in TsBs with the utilization of bilimeters. We estimate that preterm infants have an average of ~7-10 TsBs drawn per patient. With the roll-out of TcBs, we also estimate at least 50% reduction in TsBs. The N for term and preterm infants admitted in 2022 is in Table 1, attached in the Supporting File.

If we accomplish our goal, we will reduce the number of TsBs performed by 2,047 in a 1 year period (Table 1). Given that the median cost to run TsB is $34.50 per sample, this would result in $70,622 direct cost savings per year from avoided TsBs. This suggests that over 3-4 years, the direct savings will be >$250,000 from laboratory costs alone.

Extremely preterm infants lose at least 1/3 of their blood volume from iatrogenic lab draws, with the vast majority of blood loss occurring in the first week of life.⁴ Reducing serum bilirubins will directly impact blood loss early in life. For example, a 1 kg infant has an estimated blood volume of 100 mL (blood volume ~100 mL/kg). If this premature infant required 7 serum bilirubin measurements at 1.0 ml each, this would be 7.0 mL, or 7% of their total blood volume. Approximately 60% of preterm infants will require a blood transfusion during their hospitalization and this rate is directly associated with iatrogenic blood loss. The direct cost of a blood transfusion at UCSF Mission Bay is ~$750 per unit. With even a minimal reduction in blood transfusions with TcB use (~5%), we have the potential to save ~10 transfusions with a cost savings of $7,500 per year.

Other centers have shown improved outcomes and cost savings with similar QI interventions. For example, the POKE program at Dixie Regional Medical Center NICU used QI frameworks to reduce the number of POKEs (clinical experiences that cause harm without adding value). They decreased POKEs by 50% (eliminating 11,000/year) and saving $940,000/year. Additionally, they decreased length of stay by 21% (reducing by 2 weeks).¹² One hospital day in our ICN has a direct variable cost of $5,500 to the healthcare system. If we reduced the length of stay by even 1 day for only 5% of infants, there would be significant cost savings of $269,500 per year.

Finally, there are also many critically important indirect savings from downstream consequences of painful procedures, such as reducing neurodevelopmental harm and in turn reducing cost of therapies and resources required to manage neurodevelopmental delays.

Based on the above, we estimate a conservative cost saving of $347,622 during FY 2025.

SUSTAINABILITY: A multidisciplinary QI team called “NEOBrain” is already established in the ICN with a primary goal of reducing noxious stimuli and promoting neuroprotective care. The team meets monthly with no end date and has already committed to leading the implementation and sustainment phases of TcBs if funding for the devices and QI support was established. Additionally, the ICN nursing and provider leadership is in complete support of this project and have committed to covering the service fees and ongoing maintenance costs of bilirubinometers if funding is obtained for the initial purchase of the equipment through the Caring Wisely Contest. This will ensure sustainability of this project.

We plan to collaborate with the BCH-Oak NICU on this project, as they are already utilizing TcB for term infants but have not yet rolled-out this intervention in preterm infants. All work we do in this area, including protocol development, Apex changes, and QI analysis may have significant cross-bay impact and cost savings for UCSF Health. Given the relatively new use of TcB in preterm infants, especially during and after phototherapy, our findings may ultimately impact protocols beyond the walls of UCSF.

BUDGET: Please see Table 2 in the Supporting File attached for our proposed line-item budget.

REFERENCES:

1.    Kemper AR, Newman TB, Slaughter JL, et al. Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022;150(3):e2022058859. doi:10.1542/peds.2022-058859

2.    Walker SM. Long-term effects of neonatal pain. Semin Fetal Neonatal Med. 2019;24(4):101005. doi:10.1016/j.siny.2019.04.005

3.    Valeri BO, Holsti L, Linhares MBM. Neonatal Pain and Developmental Outcomes in Children Born Preterm: A Systematic Review. Clin J Pain. 2015;31(4):355-362. doi:10.1097/AJP.0000000000000114

4.    Counsilman CE, Heeger LE, Tan R, et al. Iatrogenic blood loss in extreme preterm infants due to frequent laboratory tests and procedures. J Matern Fetal Neonatal Med. 2021;34(16):2660-2665. doi:10.1080/14767058.2019.1670800

5.    Sankar MeeraN, Ramanathan R, Joe P, et al. Transcutaneous bilirubin levels in extremely preterm infants less than 30 weeks gestation. J Perinatol. 2023;43(2):220-225. doi:10.1038/s41372-022-01477-4

6.    Bhatt DR, Kristensen-Cabrera AI, Lee HC, et al. Transcutaneous bilirubinometer use and practices surrounding jaundice in 150 California newborn intensive care units. J Perinatol. 2018;38(11):1532-1535. doi:10.1038/s41372-018-0154-3

7.    Ng Y, Maul T, Viswanathan S, Chua C. The Accuracy of Transcutaneous Bilirubin as a Screening Test in Preterm Infants. Cureus. 15(8):e42793. doi:10.7759/cureus.42793

8.    Weber J, Vadasz-Chates N, Wade C, Micetic B, Gerkin R, Rao S. Transcutaneous Bilirubin Monitoring in Preterm Infants of 23 to 34 Weeks’ Gestation. Am J Perinatol. 2023;40(07):788-792. doi:10.1055/s-0041-1731277

9.    Van Den Esker-Jonker B, Den Boer L, Pepping RMC, Bekhof J. Transcutaneous Bilirubinometry in Jaundiced Neonates: A Randomized Controlled Trial. Pediatrics. 2016;138(6):e20162414. doi:10.1542/peds.2016-2414

10.  Klunk CJ, Barrett RE, Peterec SM, et al. An Initiative to Decrease Laboratory Testing in a NICU. Pediatrics. 2021;148(1):e2020000570. doi:10.1542/peds.2020-000570

11.  McClean S, Baerg K, Smith-Fehr J, Szafron M. Cost savings with transcutaneous screening versus total serum bilirubin measurement for newborn jaundice in hospital and community settings: a cost-minimization analysis. CMAJ Open. 2018;6(3):E285-E291. doi:10.9778/cmajo.20170158

12.  Ridout E, Kane T. Deploying POKE Within Intermountain Healthcare (POKE). ClinicalTrials.gov Identifier: NCT03688607. ClinicalTrials.gov. Accessed February 29, 2024. https://classic.clinicaltrials.gov/ct2/show/NCT03688607

13.  Nagar G, Vandermeer B, Campbell S, Kumar M. Reliability of Transcutaneous Bilirubin Devices in Preterm Infants: A Systematic Review. Pediatrics. 2013;132(5):871-881. doi:10.1542/peds.2013-1713

14.  Ten Kate L, Van Oorschot T, Woolderink J, Teklenburg-Roord S, Bekhof J. Transcutaneous Bilirubin Accuracy Before, During, and After Phototherapy: A Meta-Analysis. Pediatrics. 2023;152(6):e2023062335. doi:10.1542/peds.2023-062335

15.  Brown J, Chang X, Matson A, et al. Health disparities in preterm births. Front Public Health. 2023;11:1275776. doi:10.3389/fpubh.2023.1275776

16.  Konana OS, Bahr TM, Strike HR, Coleman J, Snow GL, Christensen RD. Decision Accuracy and Safety of Transcutaneous Bilirubin Screening at Intermountain Healthcare. J Pediatr. 2021;228:53-57. doi:10.1016/j.jpeds.2020.08.079

PROJECT LEAD(S): Jaqueline Simpsons RN MSN

                                  Mackenzie Clark PharmD co-lead

                                  Sherry Chen Rph  co-lead

EXECUTIVE SPONSOR(S): Dr.Karen Chee MD Medical Director of Hematology San Mateo

ABSTRACT 

Chemotherapy education is fundamental for increased patient engagement in shared decision making, higher levels of satisfaction, improved medication adherence, and better clinical outcomes. Although interpersonal teach via telephone or zoom is the most common modality in delivery of this information to patients in the oncology setting, patients are often not able to process large amount of new medical information in a short amount of time making education less effective. Additionally, labor cost remains a significant portion of hospital expenditures and traditional face-to-face chemotherapy education has been a big part of nursing and pharmacy workload. At UCSF, over 7000 chemotherapy plans (both IV and oral) are initiated each year. Nevertheless, there is no standardization in education content leading to variability. On average, chemo education takes about 30-60 minutes. That’s equivalent to 3500-7000 hours of non-billable service performed by nurses and pharmacists. Currently, oncology digital education resources are lacking at UCSF. We propose to develop and implement therapy specific digital education videos as primary method of teaching to fill the unmet gap in this growing telehealth era. By utilizing Mytonomy, which is an existing video-based patient engagement platform that USCF already has partnership with, this project will streamline patient education, increase patient accessibility, reduce costs and provide opportunities to reallocate resources to billable services.

TEAM 

Edna Miao PharmD, Carlo Legasto PharmD, Craig Thompson RN, Jaime Fornesca RN, Anna Re RN, Michelle Louie RN, Norma Jones, RN, Maritza Zavaleta RN

(Special thanks to Jennifer Wild MS, RN , OCN, Kara Merski RN, OCN, NPD-BC and Alan Huang PharmD for mentoring this project! )

PROBLEM 

• Chemotherapy education empowers patients and improve health status during and after cancer treatment
• Currently, patient education in the UCSF oncology clinics is performed by nurses and pharmacists at an in-person, telephone or video visit and is considered as non-billable service. Altogether, UCSF initiate over 7000 chemotherapy plans per year. With each chemo teach averaging about 45 minutes, this would result in more than 5250 of non-billable hours
• Lack of standardization in both content and delivery of information across different clinics and sites means there is no consistency in the quality of education
• Ineffective patient education may lead to increased stress, suboptimal retention, decreased treatment compliance and poorer clinical outcome
• A number of studies have demonstrated that digital educational videos can be successfully incorporated into the oncology setting to improve patient knowledge recall, reduce anxiety and standardize practice[1,2,5,6,7]
• Oncology digital education resources are lacking at UCSF
• The future continues to trend toward a digital world. Addressing the gaps and barriers of digital and telehealth equity now will foster better health outcomes in our communities

TARGET 

The goal is to develop and implement a standardized chemotherapy educational program that utilizes regimen specific digital videos as the primary form of teaching.

 Targeted ROI :

• Significant return of productive nursing and pharmacist time that can be reallocated to billable services such as infusion
• An estimate of 5250 hours saved per year assuming average chemo teaching is 45 minutes ( previous survey indicate most new start education sessions are 30-60 minutes)

The main advantages of digital education tools for patients are accessibility and consistency. Patients can watch videos anywhere, anytime. Patients can adjust the speed and repeat viewing as often as they like to gain better understanding. Videos can be shared with family members or friends who are unable to attend teach sessions. Moreover, the need for note-taking during teach is eliminated since these resources are available 24/7. The language and information given will always be consistent. In one study, a group of breast cancer patients who received videotaped education prior to consultation visits reported higher satisfaction, lower stress levels, higher quality of life and increased preparedness8. Another study identified that patients who received chemotherapy education through traditional method plus addition of a video had a higher retention of information and higher likelihood to report side effects when compared to standard in-person teaching group13.

From the hospital’s perspective, the benefits of utilizing digital resources include increased circulation and distribution (potential to scale beyond UCSF), reduction of expenses(i.e decreased OT hours or reallocation of pharmacist and nurse FTEs to other tasks), reduce variability in practice and low ongoing maintenance cost(i.e UCSF already has partnership with Mytonomy which will be explained further below).

Wiscosin’s largest cancer program, Aurora Cancer Care started implementing video teaching in 2018 and reported that digital video teaching saved an average of 30 minutes per patient which results in a week of saved nursing time for every 80 new chemotherapy starts⁹.

GAPS 

• No regimen specific chemotherapy educational videos available currently at UCSF, all teaching done by nursing or pharmacy staff via in person, zoom or telephone encounter
• Lack of consistency in content and quality of teaching across multiple ambulatory clinic and infusion sites
• Teaching sessions often go over scheduled time which can lead to incomplete tasks and burnouts in nursing and pharmacy
• Patients not able to process large amount of new information in a short period of time making education session ineffective
• With traditional teaching, patients often have to commit to a time during business hour and place for chemo teaching and therefore, potential miss works and extra financial toxicity

INTERVENTION 

Due to the large scale of this project, development of teaching videos can be done in multiple phases in order for real-time evaluation and improvement. Phase 1 will be the pilot phase and will focus on non-complex regimens such as immunotherapy, monoclonal antibodies and targeted therapy in the adult oncology outpatient setting. These regimens are well standardized across many disease sites making them ideal for exploratory purposes and data collection. The second phase will be a soft launch phase where one disease site will be selected to be site champion. The importance of having a site champion is that it would help drive necessary practice change and facilitate smooth launching of this program. During the final phase, the goal would be to expand to other disease sites and roll out 5-10 regimens at a time to allow adequate time for review and revisions and ensure quality control. A team of multi-disciplinary in-house champions with oncology background including nurses, pharmacists, oncologists, certified medical translators, and social workers will be invited to form an oncology digital health literacy committee and responsible for content development to ensure accuracy and validity. Videos will also be submitted to the UCSF education committee for final approval. 

Example of Phase 1 pilot regimens

• Pembrolizumab
• Avelumab
• Ipilimumab/Nivolumab
• Nivolumab
• Bevacizumab
• Encorafenib/cetuximab
• Encorafenib/panitutumab
• Durvalumab
• Atezolizumab
• Enfortumab
• Rituximab
• Daratumumab

Step 1 : Literature search

The first step is to conduct broad literature search on content development. Each standardized video will include a section on chemotherapy regimen specifics, take-home medications, side effects and management, frequently asked questions, and when to call clinic.

Step 2 : Video production

Previous studies have shown that animated videos under 16 minutes with voice over seem to be the most ideal for knowledge recall and retention³. This step can potentially be simplified by utilizing existing resource such as Mytonomy, which is a video-based patient engagement platform which allows patients to stream 3000+ digital videos on different topics of disease from cardiovascular to infectious disease. UCSF already has a partnership with Mytonomy and the main advantage of using this platform is that it offers the flexibility to develop content and microlearning videos tailored and customized to each organization’s needs. The award-winning platform leverages epic MyChart Bedside and Cerner and provides Netflix-like experience for patients that allows them to conveniently learn and prepare at home on any Smart TV and tablets.  

Step 3: Implementation and Feedback

The third step is implementation and feedback gathering which includes patient survey pre and post intervention. It is also necessary to use metrics to demonstrate the value of the program on patient experience and clinical outcome. Data collection will include viewing percentage per month and average view duration, stress level, satisfaction rate, adverse event reporting and hospitalization rate.

The main challenge in implementing digital literacy is health inequity among the non-digitally literate population. There is the assumption that digital tools may be a potential barrier for older patients. In reality, tech users in the age group of 65 and up have grown in the past decade. In a study of uro-oncological patients, older adults were reported to be more willing to engage with digital technologies as part of clinical trials than younger adults. Currently at UCSF, mychart usage is greater than 84% in the 65 and older group( see table below), demonstrating the elderly population is not as digital illiterate as we believe.

For those who lack internet access, videos can easily be transcribed into text/print material through converter application or the audio version of the videos can be played via phone. Another way to overcome health disparities is by offering digital videos with subtitles in different languages to address language barrier. Medical assistants can also identify patients with low digital health literacy at visits by asking simple questions, such as the following:

• Do you have internet access and reliable connectivity?
• Do you have a device that meets appropriate telehealth system requirements?
• Do you use emails?
• Can you download a mobile app?
• Do you want to receive your education via a video or traditional teach?

Once identified, an in person or telephone education session can be offered using the same print materials transcribed from videos to ensure consistency and quality of teach. Digital health literacy workshops can also be offered to increase patients digital skills. Offering in person digital health navigators might be another educational strategy. 

 Mytonomy is also committed to promote health equity and decrease health disparities.  Their contents are designed to deliver the highest possible patient engagement rates including reaching the most vulnerable and underrepresented populations. Some key features include a diverse range of clinicians and patients portrayed throughout a topic , utilization of plain language and multi-language subtitling,  adoption of visual models and diagrams, different playlists for different cultures and Spanish clinical library. In an IRB study with Duke health and Columbia University, it was found that Black patients watched Mytonomy’s videos at double the rate of their non-hispanic white patient counterparts. Hispanic patients also performed higher than non-hispanic white participants.

 Another potential barrier to implementation is compliance enforcement. Given the responsibilities to watch these videos are now shifted to patients, there needs to be proactive workarounds in place as safety measures. One strategy may be to have medical assistants check in with patient on first day of infusion at check-in and offer patients a tablet device (i.e clinic phone, clinic desktop/laptop) to watch these education videos in waiting area. Another solution would be to implement follow up phone calls or Mychart messages 48 hours prior to scheduled infusion appointment to assess comprehension of videos and answer questions.

PROPOSED EHR MODIFICATIONS

 None

RETURN ON INVESTMENT (ROI) 

Clinical Nurse and pharmacist salary range from $84.78 to $109.85 hourly. With the projected 5250 hours saved, the projected direct cost savings is estimated to be $445,095 - $576,712.50 annually. This does not take into account indirect cost savings such as reduction in preparation time for chemo teach, cutback in printing materials, time to schedule chemo teach appointments , and additional revenue generated if saved time is converted to billable services (Explained below).

Additional Revenue per year (Ideal Scenario)

In the most ideal scenario, assuming ALL of the saved nursing hours are converted to chemotherapy infusion services across all  sites, the current average net income from infusion operations at UCSF Cancer Center San Mateo for example, is approximately $450,000 per week. The average nursing hours needed to staff 1 day of infusion with 12 infusion chairs is about 57 hours. 5 day infusion week is equivalent to 285 hours.

Out of the 5250 hours saved from this proposal, 3265 hours are nursing hours and remaining is pharmacy hours. This translates into 3265/ 285 hours =  11.5 weeks of potential nursing hours to staff infusion. Assuming chair availabilities and patient volume are not limiting factors, the estimated maximum revenue generation in a year from all sites would be:

11.5 weeks of infusion x $450,000 income generated per week = $5,175,000.00

Since there will be cases where traditional face-to-face teach is necessary and beneficial , assuming 50% conversion, the potential revenue in a year would be :

0.5 x 11.5 weeks x $450,000 per week = $2,587,500.00

Chair availability is unlikely to be a limiting factor as our current chair utilization capacity is not yet maximized. In the last 6 months, San Mateo averages at about 67.8% chair capacity and mission bay averages only at 24%, meaning there is plenty of room for growth.

Whilereallocating staff to infusion services is possible at San Mateo , we recognize that other sites such as mission bay maybe using a different practice model. At San Mateo, our practice nurses doing the chemo teaches are also crossed trained in infusion. Practice nurses at mission bay do not staff infusion currently and 99% of what they do is non billable work. For these sites, the financial benefit is tied to nursing time saved to do other clinical work like symptom management or reduced need for more FTE as our organization grow. For example,  the Parnassus heme onc group recently hired 3 additional nurses to help with chemo teaches which approximate to $508,680-$659,100 in payroll expenses.

SUSTAINABILITY 

Since UCSF is already subscribed to services from Mytonomy, this program is anticipated to sustain beyond the funding year. Key process owners will be the same stakeholders in the oncology digital health literacy and education committee. These stakeholders will be responsible for reviewing contents and language of the videos for clinical accuracy and ensuring they meet UCSF standards.

BUDGET 

We are asking for $50,000 in funding to support the infrastructure for program development, data analysis and evaluation.

REFERENCE

1. Bouton ME, Shirah GR, Nodora J, et al.: Implementation of educational video improves patient understanding of basic breast cancer concepts in an undereducated county hospital population: Video Breast Cancer Concepts. J Surg Oncol 105:48-54, 2012
2. Dawdy K, Bonin K, Russell S, et al.: Developing and evaluating multimedia patient education tools to better            prepare prostate-cancer patients for radiotherapy treatment (randomized study). J Cancer Educ 33:551-556, 2018
3. Feeley TH, Keller M, Kayler L. Using Animated Videos to Increase Patient Knowledge: A Meta-Analytic Review. Health Education & Behavior. 2023;50(2):240-249
4. Frentsos J: Use of videos as supplemental education tools across the cancer trajectory. Clin J Oncol Nurs 19:E126-E130, 2015
5. Kinnane N, Stuart E, Thompson L, et al.: Evaluation of the addition of video-based education for patients receiving standard pre-chemotherapy education. Eur J Cancer Care (Engl) 17:328-339, 2008
6. Matsuyama RK, Lyckholm LJ, Molisani A, et al.: The value of an educational video before consultation with a radiation oncologist. J Cancer Educ 28:306-313, 2013
7. Sulakvelidze N, Burdick B, Kaklamani V, et al.: Evaluating the effect of a video education curriculum for first time breast cancer patients: A prospective RCT feasibility study. J Cancer Educ 34:1234-1240, 2019
8. Walker MS, Podbilewicz-Schuller Y. Video preparation for breast cancer treatment planning: results of a randomized clinical trial. Psychooncology. 2005 May;14(5):408–420. doi: 10.1002/pon.858
9. Weese, J. et al.: Drug specific videos for patient chemotherapy education. Acc-cancer. May-June 2018. https://www.accc-cancer.org/docs/documents/oncology-issues/articles/2018...

PROPOSAL TITLE: Establishing a Lab Stewardship Program to Reduce Lab Overutilization

PROJECT LEAD(S): Parul Bhargava, MD, Anoop Muniyappa, MD, MS, Teddy Peng, MD

EXECUTIVE SPONSOR(S): Amy Lu, MD, MPH, Andrew Auerbach­­­, MD

ABSTRACT 

When compared to peer academic medical centers, UCSF orders significantly more lab tests per inpatient hospitalization. Many lab tests are overutilized. To date, there is no Lab Stewardship Program at UCSF to assess lab utilization, review evidence, perform gap analyses, drive initiatives for safe and responsible lab stewardship, and engage in continuous improvement. Unnecessary labs contribute to unnecessary cost and wasted laboratory staff time, and can lead to excess venipuncture, iatrogenic anemia, prolonged length of stay, and increased mortality in hospitalized patients. Through analyzing UCSF lab tests by volume and cost, value-based care guidelines, and potential for successful clinical decision support-based interventions, our team has identified three lab tests as opportunities (CBC with differential, prealbumin, and free T4) for improvement with a high chance of success. We propose development of a Lab Stewardship Program led by the Medical Director of UCSF Labs to safely reduce unnecessary lab testing at UCSF starting with these 3 pilot tests. We aim to establish processes and protocols to implement and monitor improvement efforts, further refine our framework to identify opportunities to reduce unnecessary lab testing, and replicate these improvement processes for additional lab tests in the future. By focusing on EHR-based interventions and developing tools for real-time monitoring, we hope to create effective and sustainable lab reduction efforts.

TEAM 

• Parul Bhargava, MD (Senior Medical Director of UCSF Labs; project lead)
• Anoop Muniyappa, MD, MS (Hospital Medicine Faculty; informatics project co-lead)
• Theodore Peng, MD (Hospital Medicine Faculty; operations project co-lead)
• Janelle Lee, PhD (Senior Quality Improvement Programmer; project analyst)
• Brandon Scott, MD, MBA (Hospital Medicine Director of Value Improvement, UCSF Health Associate Medical Director for Value Improvement; project mentor)
• Sajan Patel, MD (Hospital Medicine Director of Quality Improvement; project mentor)
• Armond Esmaili, MD (Neurological Surgery Medical Director of Quality and Safety; project mentor)
• Andrew Auerbach, MD (Hospital Medicine Professor; executive sponsor)
• Amy Lu, MD, MPH (Chief Quality Officer; executive sponsor)

PROBLEM 

• Overall: Compared to peer academic medical centers (AMCs), UCSF orders significantly greater lab tests per inpatient hospitalization. Many lab tests are overutilized, leading to excess cost, staff time, and phlebotomy. See Appendix 1 for more details. UCSF currently does not have a comprehensive lab stewardship program to identify unnecessary lab testing. Through an analysis of UCSF lab tests by volume and cost, value-based care guidelines, and potential for successful clinical decision support (CDS)-based interventions, our team has identified three lab tests as opportunities for improvement with a high chance of success. Our goal is for the approach presented below to serve as the scaffolding for a comprehensive lab stewardship program at UCSF that will yield additional cost savings beyond this initial year.
• CBC with differential, prealbumin, and free T4 (thyroxine) are overutilized inpatient lab tests at UCSF that contribute to unnecessary cost, wasted laboratory staff time, and potentially excess venipuncture, and often do not align with clinical and value-based care guidelines. Guidelines and prior evidence suggest that many inpatient CBCs with differential (CBCD) can be converted to CBCs without differential (CBC), prealbumin ordering can be reduced, and free T4 testing can be done as a reflex to abnormal TSH without affecting patient quality or safety. In addition to provider education, these lab tests are well-suited for simple electronic health record (EHR) modifications, behavioral nudges, and CDS to effectively reduce unnecessary testing.
• Unnecessary lab tests also have negative effects on patients and lead to unnecessary additional costs. Studies show that routinely ordered lab tests can lead to iatrogenic anemia, increased need for blood transfusions, prolonged length of stay, and increased mortality in hospitalized patients.^1,2
• CBC with differential is one of the most frequently ordered inpatient lab tests, and is uniquely resource, time, and labor intensive. The UCSF clinical laboratory completed ~136,000 inpatient CBCDs in 2023. While the first pass of analyzing a WBC differential is automated, a significant proportion (~65%) require making a smear and manual counts, and a subset of these require clinicalpathologist review. As a result, there is a significant increase in reagent used, laboratory technologist time, and clinicalpathologist time to complete a CBCD when compared to a CBC. Additionally, a CBCD can take up to 4 times longer to complete and costs approximately $10 more in direct cost, which does not include the significant indirect costs mentioned above. See Appendix 2 for calculations.
• Many WBC differentials are unnecessary, and a significant proportion of CBC with differential can be safely converted to CBC alone. UCSF data shows that 6-7% of all CBCDs are repeated within 24 hours, and CBCDs are repeated even when the prior differentials are normal, both of which contribute to likely unnecessary testing. Published expert opinions recommenda time interval of 1.5 to up to 4 days for stable patients (excluding those on chemotherapy and being assessed for neutropenia).^3,4 Choosing Wisely also recommends against performing repetitive tests like CBCs at regular intervals in the face of clinical and lab stability.⁵
• Prealbumin is commonly ordered in the inpatient setting as a marker for poor nutrition, but this is not supported by clinical practice guidelines. The American Society for Parenteral and Enteral nutrition guidelines and the Choosing Wisely campaign recommend against using prealbumin as a marker for nutritional status or to screen or diagnose malnutrition.^6,7 The UCSF Clinical Laboratory completed nearly 3,000 inpatient prealbumin tests in 2023, many of which can be eliminated based on current guidelines.
• Free T4 is commonly co-ordered with TSH, which is not recommended by value-based care guidelines and results in unnecessary free T4 testing. The Choosing Wisely campaign recommends only a TSH for initial testing in suspected non-neoplastic thyroidal disease with follow up free T4 in only those with an abnormal TSH.^8,9 The UCSF Clinical Laboratory completed over 7,000 inpatient TSH tests in 2023. Approximately 80% of all inpatient TSH tests result in a normal TSH value and do not require a free T4, but over half of all TSH tests are initially co-ordered with a free T4 (~3,500). This means that approximately 60% (or 2,100) of free T4 tests could be avoided with a TSH that reflexes to a free T4 only when abnormal.
• Prior smaller-scale initiatives to measure and reduce unnecessary lab testing have been effective, but not sustained on a larger scale at UCSF and other AMCs. In the 2010s, UCSF saw several quality improvement initiatives to reduce unnecessary iCa, CBC, and electrolyte lab draws.^10,11 While successful, these were done prior to the implementation of an EHR. Now, with the EHR in place, this is a timely opportunity to make larger-scale, sustainable changes to improve lab stewardship. Additionally, the residents in the Neurosurgical Department at UCSF are currently participating in a REFLECT project dedicated to safely reducing unnecessary CBCs with differential, whether through conversion to CBC or through mindful cessation of excess lab draws. As Neurosurgery has the second largest patient volume at UCSF, this is a unique opportunity to collaborate for greater impact.

TARGET 

• Key Target Goal: Our goal is to establish a UCSF Lab Stewardship program, an evidence-based framework to identify overutilized lab tests, and a replicable process to safely reduce unnecessary lab testing at UCSF.
  • Our initial targets are to reduce inpatient WBC differential lab testing by 10-30% (~13,600-40,800), inpatient prealbumin lab testing by 60-80% (~1,800-2,400), and inpatient free T4 lab testing by 60% (~2,100) within 1 academic year.
  • We plan to measure the following inpatient key performance indicators over time: overall volume of CBCD, ratio of CBCD to CBC, volume of prealbumin, volume of free T4, number of each of these tests per inpatient admission, total lab tests per inpatient admission (which can be compared to benchmarks for similar AMCs), and estimated cost savings per admission.
  • We will also explore ways to measure the following additional areas where we anticipate reductions (reagent use, laboratory staff time, pathologist time, phlebotomy requests, iatrogenic anemia, clinical time reviewing lab tests) and improvements (patient experience scores).
  • Key Counterbalance Measures: Our aim is to ensure there is no increase in adverse events on involved service lines by reviewing key markers of safety related to our interventions. We also aim to quantify any disparities in ordering of the specified lab tests and ensure that disparities are not created or exacerbated by our intervention.

GAPS 

• System Issues:
• There is no comprehensive lab stewardship program at UCSF to assess lab utilization, review evidence, perform gap analyses, drive initiatives for safe and responsible lab stewardship, and engage in continuous improvement.
• Technological Gaps:
• Certain ordersets (including admission ordersets) are in place for different services that default to CBCD instead of CBC when a differential may not be indicated.
• There is no measure in place to prevent providers from ordering repeat CBCD daily or even more frequently when this is often not indicated.
• There is no backend automation or CDS to guide providers on appropriate CBCD ordering or when to decrease frequency of CBCD ordering.
• There is no CDS to guide providers away from inpatient prealbumin ordering.
• There is no reflex testing to perform a free T4 lab test only if the TSH is abnormal (which is present for other lab studies, such as Urinalysis with reflex to Urine Culture).
• There is no reporting tool that enables high-level stakeholders or individual service lines to understand volumes of lab tests ordered, identify opportunities for improvement, and to monitor the impact of these improvement efforts over time.
• Educational Gaps:
• There are no established criteria at UCSF (whether as EHR-based CDS or hospital wide resources) to help guide providers on clinically appropriate ordering intervals for CBCD, inpatient prealbumin testing, and testing free T4 only if TSH levels are abnormal.
• Providers are not aware of the additional resources consumed when performing a CBCD vs. CBC, the additional cost and time required, and how this can lead to lab delays.
• Service lines and providers are unaware of their own individual performance and where they may be opportunity for improved lab stewardship.

INTERVENTION 

• Pre-Intervention Data Collection and Analytics We will stratify ordering of the selected lab tests by inpatient service to understand the services that will be most impacted by our interventions. Additionally, we will review the volume and results from a subset of cases with a normal WBC to determine the potential utility and safety of a CBC with reflex to differential if the WBC is abnormal. We will review volume and results from a subset of cases with 2 consecutive normal differentials to determine the potential utility and safety of building CDS to suggest discontinuing daily differential orders after the second normal differential. Lastly, we will perform a manual chart review over 2 weeks of patients admitted to the Hospital Medicine and Neurosurgery services to determine what proportion of CBCD are appropriate for conversion to CBC to better predict the impact of this initiative.
• Stakeholder Engagement We plan to meet with key stakeholders (i.e., inpatient service directors) from Hematology, Nutritional Services, and Endocrinology to better understand lab recommendations and safety concerns, share our understanding of current evidence and best practices, and ensure alignment with how best to move forward together with a focus on reducing unnecessary lab testing. We will also briefly survey providers from different services (focusing on high-volume services and the above services given specific needs) on current practices for the ordering and use of CBCD, prealbumin, and TSH and free T4, and the potential impact of efforts to reduce ordering of these labs. We anticipate building carveouts for services like Hematology/Oncology, where more frequent differential ordering may be desired/indicated.  
• EHR Modification (see further below) We will submit multiple modification requests to the APeX Clinical Context Committee (AC3) to: remove CBCD from ordersets where clinically appropriate, limit the frequency of CBCD ordering to no more than q24h, build a BPA to suggest conversion of a daily CBCD order to a CBC after 2 consecutive normal WBC and differential results, build clinical guidance into the prealbumin order to reduce ordering, and build a TSH with reflex to free T4 order. We have already begun building order specifications and gathering additional data to guide these changes, and plan to have all proposed modifications submitited to AC3 prior to the start of FY25. 
• Education and Dissemination We will create a graphical abstract to circulate in the UCSF newsletter to provide evidence-based guidance and support to reduce CBCD, prealbumin, and free T4 ordering. Additionally, we will circulate clinical guidance and order modification summaries to service directors and division chiefs to distribute to inpatient providers. Lastly, we will do targeted presentations and education with divisions/services, including residents, identified as frequent utilizers of CBCD, prealbumin, and free T4.
• Monitoring We will develop a dashboard to track ordering of lab tests stratified by clinical service over time to identify opportunities for improvement, assess the impact of the proposed interventions, measure performance, and provide real-time feedback to clinical service lines.
• Launch System Wide Our goal is to create sustainable, system-wide changes to improve lab stewardship. In collaboration with our informatics experts, we have determined that making EHR changes for a single service line or by context would likely be technically challenging and overly complicated. We will focus our efforts on ensuring strong education and awareness across services, thorough pretesting of the proposed changes with our APeX colleagues, gathering feedback from patient safety leaders, ensuring appropriate measurement of counterbalance/safety measures, and continuous feedback from departmental stakeholders.
• Extensive Safety Review We will manually review charts for a subset of patients that would be affected by our proposed EHR modifications to assess for any potential adverse impacts on patient safety, quality, delays in diagnosis. Additionally, we will verify with inpatient Safety Directors that there has not been an increase in adverse events due to order reduction.
• Health Equity We will assess ordering of the specified lab tests by preferred language, sex, race-ethnicity, and payor to evaluate any systematic differences in ordering by these health equity-related variables. We will reassess this after deployment of our interventions to ensure that they do not create or exacerbate disparities.

PROPOSED EHR MODIFICATIONS 

• We will modify ordersets that currently default to CBCD to CBC (with option for differential) where clinically appropriate.
• We will modify the CBCD order to prevent ordering more frequently than q24h, with exceptions for certain services where clinically appropriate (e.g. Hematology/Oncology)
• We will build of a BPA to suggest ordering a CBC after 2 consecutive CBCDs.
• We will build an alert into the prealbumin order to recommend against ordering in the inpatient setting as a marker of nutritional status with supporting evidence/educational links.
• We will collaborate with Lab Medicine to build a TSH with reflex to free T4 order and set this as the default/highest on the list for free T4 and related search terms.

RETURN ON INVESTMENT (ROI) 

• Our estimated ROI from this initiative ranges from $161,104.00 - $439,974.00 per year in saved direct costs from these initial 3 lab tests alone. This does not take into account significant indirect cost savings for phlebotomy (including nursing support), pathologist time to review a subset of differentials, and clinician time to review results. It also does not account for additional future lab tests that would be identified and reduced through the creation of the Lab Stewardship Program. Of note, as reimbursement for inpatient laboratory testing is typically DRG-based for the entire admission, reduction in testing does not result in reduction of revenue. See Appendix 2 below for additional details.

SUSTAINABILITY 

• This initiative to reduce inappropriately ordered lab tests, including CBC with differential, prealbumin, and free T4 will be sustained through clinical decision support and order changes in APeX, educational campaigns, visible data tracking, and the establishment of a Lab Stewardship program.
  • The multiple APeX order changes and embedded CDS will persist beyond the funding year and be maintained through existing APeX infrastructure.
  • Widespread educational campaigns will help to inform and engage stakeholders across departments about the importance and relevance of these APeX changes. With the rollout of these proposed APeX changes and these dissemination efforts, we expect that the proposed changes will be accepted and become standard ordering practice within the project year. The Lab Stewardship program will continue to monitor the ordering of these tests and can provide additional feedback, education, and support as needed in future.
  • The reporting tools developed through this project will continue to be accessible and enable providers and floor units to monitor their performance beyond the project year.
  • If our efforts are successful in reducing unnecessary testing for the aforementioned labs, this can be applied to inpatient pediatrics, obstetrics, and certain outpatient labs. Most excitingly, these interventions can also be applied to countless other inappropriately order lab tests in the hospital, leading to future cost savings.
  • As described above, these operational changes to ordering labs for hospitalized patients would be long-term and sustainable.

BUDGET 

• Salary support for project co-leads for project implementation: $40,000-$45,000
• Development of educational materials, data analytics, and IT support: $5,000-$10,000

PROPOSAL TITLE: UCSF Advanced Heart Failure Comprehensive Care Center (AHF CCC) Ambulatory IV Diuretic Clinic to reduce heart failure admissions, readmissions and improve patient outcomes and  throughput at UCSF Health

PROJECT LEAD(S): Amanda Browne, NP, MBA & Nimi Tarango, NP

EXECUTIVE SPONSOR:  Liviu Klein, MD

ABSTRACT – Currently at UCSF Health, heart failure (HF) patients who are volume overloaded and resistant to oral diuretics only have the option to be admitted to the hospital for medical management of their decompensated heart failure. Hospital admissions and readmissions are costly and moreover, increase patient morbidity and mortality (Verma et al., 2021).  UCSF Medical Center’s patient census is persistently at maximum capacity and has daily challenges accommodating patients. Multiple studies have shown cost savings and admission prevention with the use of IV diuretic clinics. Given the high census at UCSF and need for acute care beds, we propose the creation of an Advanced Heart Failure IV diuretic clinic: to reduce hospital admissions for patients with acute heart failure associated with volume overload; to reduce costs associated with HF hospitalizations by preventing index, as well as HF readmissions; to reduce morbidity and mortality; and improve overall care and management of HF patients.

Proposed initiative: The Advanced Heart Failure Comprehensive Care Center (AHF CCC) proposes the creation of an Advanced Heart Failure IV diuretic clinic. The clinic will be located at 400 Parnassus Avenue, 5th floor Heart & Vascular Center expansion clinic.  The clinic is already licensed for medication administration. There exists a treatment Room with 2 treatment beds-already embedded in the clinic (previously used for allergy testing). Supported by Administrative Director, Brenda Mar, who has allocated these beds for purposes of an IV Diuretic clinic.  Referring providers from across the health system will have a direct phone # for seamless scheduling with next day appointments available. The clinic will service patients with heart failure and volume overload (VOL) from the following settings: (1) Outpatient: All patients with a diagnosis of heart failure who are failing oral diuretics despite increasing doses. Patients can be referred to the IV Diuretic clinic for diuretic resistant heart failure; (2) Emergency Room & Clinical Decision Unit (CDU): Patients in the Emergency Room presenting with HF and volume overload who are hemodynamically stable. Patients may receive IV diuretic dosing in the ER and /or CDU with a discharge plan to be seen in the IV Diuretic clinic the following day for additional diuretic dosing. Of note: “The most common reason for rehospitalization following an ED encounter for IV diuresis was recurrent HF” (Jiang et al., 2024) (3) Acute Care: Patients who are hospitalized with HF and are nearing euvolemia can be discharged 1-2 days early and can be scheduled for appt with the IV Diuretic clinic the day following discharge for additional diuretic administration and plan to transition to PO diuretics under the care and management of AHF APP and MD team.

TEAM:

AHF Administrative Leadership: Amanda Browne MBA, NP, Administrative Director & Nimi Tarango, NP, Associate Administrative Director

AHF Attending MDs: Mandar Aras, Richard Cheng, Teresa De Marco, Liviu Klein, Shweta Motiwala, & Marc Simon, as needed for APP consults.

AHF Pharmacists: Brandon Martinez & Jose Lazo

AHF APPs: Robin Fischer, Simran Grewal, & Yuri Nam

AHF RN coordinators: Maddy Cole, Jamie Lee, & Ceile Valerio

AHF Patient coordinators: Jailah Hawkes, Camille Hill, & Breeana Hill

ACC 5 Heart and Vascular clinic medical assistants

PROBLEM: Heart failure (HF) is a highly prevalent medical condition in the United States, currently affecting 6.2 million patients with an estimated increase to 8.5 million by 2030. HF is the number one discharge diagnosis for patients over the age of 65. A Medicare analysis estimated that annual costs for worsening chronic HF is between $9.3 billion and $17 billion. Furthermore, HF was the most common reason for rehospitalization, accounting for up to 8.6% of all 30-day hospital readmissions. (Jiang et al., 2024). 

Readmissions /Cost Savings with IV Diuretic clinic: There are several studies that show the benefit of ambulatory IV diuretic clinics impacting readmission rates and show financial benefit to hospitals.

• A recent retrospective metanalysis study published in Journal of Cardiac Failure looking at Medicare patients (requiring IV diuretics) from 2011 – 2018 found that patients treated in observation and outpatient settings had lower 30-day mortality rates and decreased 30-day total cost compared to patients treated in inpatient settings for IV diuresis. (Jiang et al., 2024).
• Outpatient and observation management of acute decompensated HF, when available, is a safe and cost-effective strategy in certain populations of patients with HF.
• It also noted that patients treated in the emergency room and discharged had higher mortality rates, thus emphasizing the need to treat these patients in an outpatient setting. 
• Patients who received IV diuresis in the outpatient setting had a 47% decreased 30-day mortality rate, as compared to those treated in the inpatient setting. (Jiang et al., 2024
• Amand et al. showed that ambulatory IV diuretic clinic was associated with a decreased risk of all cause rehospitalization, heart failure hospitalization or death over 180 days of follow up when compared to patients who had a 48-hour observational hospitalization during the 6-months post index heart failure admission (St Amand et al., 2020).
• In another study, when comparing inpatient diuresis to outpatient IV diuretic clinic there was no significant difference in amount of diuresis per day, adverse outcomes, 30-90-day readmissions or deaths; however, there was a significantly lower cost for the outpatient diuresis group compared to the inpatient group ($839.4 vs $9,895.7, p=<0.001) (Halatchev et al., 2021)
• Finally, Nair et al. did a retrospective analysis that showed 30-day readmission rates of 6-9% in the group receiving IV diuretics in an ambulatory setting compared to the national average of 25%. They also showed an average cost savings of $681,986 per year to the hospital
• Both index and readmission HF Hospitalizations at UCSF are costly for UCSF, resulting in lost revenue.  An outpatient IV diuretic clinic at UCSF Parnassus could offer patients close follow up and continued outpatient treatment for their heart failure symptoms helping to reduce readmission rates.
  • The financial burden for heart failure admission in fiscal year 2023 at UCSF was $16,719 direct cost per patient for the index hospitalization.
  • In FY 23 an index HF hospitalization for non-ICU admission at UCSF Health cost the health system $16,719 and a HF readmission costs the health system $26,030 with an average LOS of 8.1 days. Net income for these hospitalizations is ($3254) and ($8373) respectively.
  • Furthermore, the Medicare readmission reduction program implemented in 2012 penalizes hospitals for readmission within 30 days for conditions including HF, which results in a 3% penalty for HF readmissions that occur within 30 days of discharge, providing additional incentives.

• At UCSF Health, approximately 60% of all admissions on the Cardiology Service are those patients with a primary diagnosis of HF.
• In FY ’23 average LOS for a non-ICU HF admission is 5.3 days and readmission is 8.1 days.
• In FY ’23, there were 61 HF readmissions, resulting in a cost to the health system of  $1,587, 829.
• As shown in the literature, an IV Diuretic clinic has been shown to prevent both index and HF readmissions. 
• A 20% reduction in readmissions with IV diuretic clinic at UCSF would result in a savings to the health system of $317,565. 
• Preventing HF admissions and readmissions from the outpatient setting; preventing ER and CDU patients from hospitalization; as well as facilitating early discharges for suitable inpatients with the newly proposed AHF CCC IV Diuretic Clinic, will result in reduced costs, increased bed capacity, improved throughput, and reduced morbidity and mortality in this population.
• Optimal Timing for this initiative: The growth and expansion of the AHF CCC since 2021 has allowed for increased patient capacity with increased staffing to accommodate the tremendous growth of the HF patient population.  Furthermore, with the expansion space of the HVC clinic at 400 Parnassus ACC 5 available, with a pre-existing treatment room and licensing for medication administration, the timing, and conditions to safely operate an IV Diuretic clinic with specially trained HF clinical staff could not be more optimal.

TARGET: An IV diuretic clinic at UCSF Parnassus ACC 5 clinic will result in avoidable admissions and readmissions for HF, as well as allow for ER and CDU pending admission to be diverted to the outpatient IV Diuretic clinic for management of acute heart failure in hemodynamically stable patients. The expected opening of the IV Diuretic Clinic will coincide with the approval by the California Department of Public Health (CDPH) of the expanded ACC 5, 400 Parnassus HVC clinic, expected mid-2024. A conservative estimate for a goal that the IV diuretic clinic would achieve within 1 year of operation would be prevention of approximately 20% of HF readmissions-this would result in a savings to the health system of $317,565. Furthermore, preventing index admissions from the outpatient setting; preventing ER and CDU patients from hospitalization; as well as facilitating early discharges for suitable inpatients with the newly proposed AHF CCC IV Diuretic Clinic, will result in reduced costs, increased bed capacity, improved throughput, and reduced morbidity and mortality in this population. Currently patients are referred to the AHF CCC by provider referral. However, the IV Diuretic clinic will Improve access to specialized AHF CCC care, by expanding the reach and care to a broader population of patients that are currently not serviced by the AHF CCC. This will increase access for vulnerable populations by expedited referrals through ER, CDU, inpatient, as well as outpatient referrals from no-AHF providers.

GAPS:  Heart failure (HF) is a highly prevalent medical condition in the United States, currently affecting 6.2 million patients with an estimated increase to 8.5 million by 2030. HF is the number one discharge diagnosis for patients over the age of 65. A Medicare analysis estimated that annual costs for worsening chronic HF is between $9.3 billion and $17 billion. Furthermore, HF was the most common reason for rehospitalization, accounting for up to 8.6% of 30-day hospital readmissions. (Jiang et al., 2024)

Many large academic quaternary health systems across the United States have ambulatory IV Diuretic clinics.  The absence of such a clinic at UCSF is a major gap in the otherwise comprehensive heart failure care that we provide to this patient population, and sorely needed. Prior to the creation of the AHF CCC in late 2021, resources, staffing, and administrative oversight for HF patients was spread thin across multiple service lines, making this endeavor a challenge to launch and provide dedicated management and support for. With the creation of the AHF CCC, HF patient care is now housed under one umbrella within the AHF CCC with dedicated staff and administrative leadership. The AHF CCC treats patients from initial HF diagnosis to the time that advanced therapies, including heart transplant and left ventricular assist device (LVAD) may be needed, as well through palliative and end of life care.

INTERVENTION:

• The IV Diuretic Clinic will operate at 400 Parnassus, ACC 5 Cardiology expansion clinic. 5 days a week M-F, from 8am to 5pm.
• The clinic will operate 2 beds within the treatment room and accommodate up to 4 patients per day, over four 4-hour clinic appointments daily, or allow for 8-hour appointments as needed, based on patient condition. The clinic is already licensed for medication administration. There exists a treatment Room with 2 treatment beds-already embedded in the clinic (previously used for allergy testing). Supported by Administrative Director of Ambulatory Cardiology, Brenda Mar, who has allocated these beds for purposes of an IV Diuretic clinic. 
• The room will need to have scales and blood pressure monitoring equipment
• There will need to be a pyxis or locked cabinet to house IV diuretics (furosemide and bumetanide) as well as oral electrolyte supplements.
• There will need to be IV access equipment
• IV Fluids in case needed for over diuresis
• Sensible Medial RedS Vest (these are technology that allow for assessment of VOL in patients with HF in a non-invasive way). These items are already approved for the AHF CCC budget and will not incur additional costs.
• It will be staffed by experienced HF APPs, RNs, and PharmDs. These are existing staff within he AHF CCC. No additional staff are needed for this initiative.
• Referring providers from across the health system will have a direct phone # for seamless scheduling with next day appointments available.
• The clinic will service patients with heart failure and volume overload (VOL) from the following settings:
  • (1) Outpatient: All patients with a diagnosis of heart failure who are failing oral diuretics despite increasing doses. Patients can be referred to the IV Diuretic clinic for diuretic resistant heart failure
  • (2) Emergency Room & Clinical Decision Unit (CDU): Patients in the Emergency Room presenting with HF and volume overload who are hemodynamically stable. Patients may receive IV diuretic dosing in the ER and /or CDU with a discharge plan to be seen in the IV Diuretic clinic the following day for additional diuretic dosing.
  • (3) Acute Care: Patients who are hospitalized with HF and are nearing euvolemia can be discharged 1-2 days early and can be scheduled for appt with the IV Diuretic clinic the day following discharge for additional diuretic administration and plan to transition to PO diuretics under the care and management of AHF APP and MD team.
  • The day prior to the patient’s appt, the AHF APP will review the referral, review the chart and patient’s medical history and current HF status.
  • The morning of the appt the AHF APP will clinically assess the patient and order the appropriate IV diuretic dose.
  • In collaboration with the APP, the AHF RN would monitor the patient during treatment and following treatment for 1-3 hours post diuretic administration and perform heart failure education as needed and then discharge the patient home.
  • AHF PharmDs to monitor medication inventory. AHF CCC Patient Coordinator to assist with securing follow up appts with AHF CCC if needed, or PCP or cardiologist for patients to optimize transition from AHF CCC IV diuretic clinic.
  • We anticipate there may be a need for ambulatory SW or case manager to assist with transportation to /from clinic, and other psychosocial needs as they arise.
  • In collaboration with the AHF CCC IT data analyst and the UCSF finance department, we will observe admission, readmission and LOS data for HF patients following launch of the IV diuretic clinic to observe for changes in admissions, readmissions, and LOS.  
    • We will also conduct qualitative surveys of the Emergency Department provider staff, as well as and General Cardiology providers at baseline and again at 6 and 12 months following the opening of the IV diuretic clinic to evaluate access, ease of referral, efficacy of treatment, transitions from IV diuretic clinic back to primary care provider or primary cardiologist or other service provider. 
    • Adverse outcomes that could occur as a results of IV diuretic clinic may be electrolyte disturbances and changes in renal function within patients following diuresis. There may be alterations in blood pressure (hypotension) with associated diuresis.  Close monitoring for 1-4 hours (or more if needed) will be provided to each patient following treatment to observe for any untoward side effects. 
    • Repeat STAT labs will be performed on the first floor lab at 400 Parnassus with anticipated results in 1 hour to allow IV diuretic clinical nursing and APP staff time to review results and make recommendations to patients on the same day of treatment.

PROPOSED EHR MODIFICATIONS: (1) Flowsheet for ambulatory Apex to document initial weight, daily weight during treatment period, and goal dry weight, dose of diuretic, BP (2) Outpatient SmartSet for IV diuretic order and monitoring (3) creation of reports to track outcomes data i.e. volumes, weight loss, adverse events, readmissions (4) Establish billing capabilities

UPFRONT COSTS:

• Baseline Costs
  • Pyxis MedStation ES 2-Draw        $22,999.00
  • GE Critikon Dinamap V100  x 2    $2500.00
  • Initial IV Supplies (including IV starter kit, tubing, fluids etc)           $2000.00
  • Medication Costs: Total $10,800.00
    • IV Furosemide
    • IV Bumetanide
    • PO Potassium
    • PO Magnesium
    • Metolazone
    • Midodrine          
    • Total Start up Costs $38,299

RETURN ON INVESTMENT (ROI)

• A recent retrospective study published in Journal of Cardiac Failure looking at Medicare patients (requiring IV diuretics) from 2011 – 2018 found that patients treated in observation and outpatient settings had lower 30-day mortality rates and decreased 30-day total cost compared to patients treated in inpatient settings for IV diuresis. (Jiang et al., 2024)
• Metanalysis Results by Jiang, et al. 2024 demonstrated that the average estimated for outpatient IV diuretic clinic cost for Index Clinic Visit Cost was $734; Estimated outpatient index clinic visit and total 30 day followup was $5977.
• Estimated Savings of IV Diuretic Clinic VS. Acute care hospitalization $7005 per patient
• At UCSF Health, in FY ’23, readmission rates were 18% with an average LOS of 8,1 hospital days
  • In FY ’23, there were 61 HF readmissions, resulting in a cost to the health system of  $1,587, 829.  As shown in the literature, an IV Diuretic clinic has been shown to prevent both index and HF readmissions. 
  • A 20% reduction in readmissions with IV diuretic clinic at UCSF would result in a savings to the health system of $317,565. 
  • Furthermore, preventing HF admissions and readmissions from the outpatient setting; preventing ER and CDU patients from hospitalization; as well as facilitating early discharges for suitable inpatients with the newly proposed AHF CCC IV Diuretic Clinic, will result in:
    • reduced costs overall. Total 30 day costs were lowest with treatment in the outpatient and observation settings, at $5977 and $7123, respectively, compared to the average cost of $10,312 in the ED setting (Jiang et al., 2024)
    • increased bed capacity for other patients that require acute care
    • improved throughput with the ability to discharge appropriate HF patients early to the IV diuretic clinic
    •  reduced morbidity and mortality in this population. Patients who received IV diuresis in the outpatient setting had a 47% decreased 30-day mortality rate, respectively, as compared to those treated in the inpatient setting. (Jiang et al., 2024). It also noted that patients treated in the emergency room and discharged had higher mortality rates, thus emphasizing the need to treat these patients in an outpatient setting. 
    • Added Benefit: increased adherence to Guideline Directed Medical Management
      • Guideline directed medical therapy (GDMT) is shown to reduce morbidity, mortality, hospitalization and re-hospitalization for HF. There is a significant lack of usage of GDMT among HF patients. Quadruple medical GDMT therapy for HFrEF is estimated to reduce the risk of death by 73% over 2 years. (Patolia et al., 2023)
      • The IV Diuretic clinic staffed by an AHF specialized team will help to increase prescribing of GDMT these life-saving therapies, thereby further reducing rehospitalization and reducing morbidity and mortality. (Heidenreich et al., 2022)

SUSTAINABILITY:  

• If successful, this intervention will be sustained beyond the funding year as the upfront costs for equipment will be the primary initiation costs.
• Staffing for the clinic will be provided by current AHF CCC APPs, RNs, PharmDs, PCs, and HVC medical assistants. No new staff are required to sustain this clinic. Additional labor resources will be requested as needed based on the ambulatory IV diuretic clinic success  and need to expand services. If successful, future consideration can be given to replicate an IV diuretic clinic at Mission Bay Cardiovascular Care Center to serve a larger number of patients across San Francisco.
• We anticipate we will be able to bill insurance
• Budget:
• Monthly Order
  • IV Lasix  $2368.00
  • IV Bumex             $1165.00
  • Quarterly Order
    • IV Supplies          $2000.00
    • PO Potassium (20MEq & 40MEq) Solution             $3624.00
    • PO Magnesium $26.40
    • PO Metolazone $280.00
    • PO Midodrine    $777.60

• PROJECT LEAD(S): Lan Vu, MD, MAS; Doruk Ozgediz, MD, MSc
• EXECUTIVE SPONSOR(S): Atsuko Baba, MD; Hanmin Lee, MD
• ABSTRACT - One paragraph summary of your proposed initiative – Limit 1500 characters (with spaces)

There is growing literature on the importance of social determinants of health (SDoH) on surgical quality outcomes in the pediatric population.  Patient navigator programs have been shown to address and minimize the impact of SDoH at multiple levels.  In addition, these risk factors have been shown to be associated with surgery same day cancellations, which impacts access to equitable health care for children.  We propose to develop community-based patient navigator program as an intervention to provide resources for high risk patients, identified by individual and neighborhood-level SDoH screening.

TEAM - 
Matt Pantell, MD, MS (Pediatric Hospitalist whose research and clinical areas of interest include interventional programs to address health equity): Mentor
The nurse practitioners who will performing the individual-level SDoH screening (Amanda Parker, NP, Anne Hagbom, NP, Mellany Aquino, NP, Bianca Juarez, NP, Megan Drombroski, NP, Jessica Pascual, NP)

• PROBLEM – Surgical quality outcomes is strongly tied to social determinants of health (SDoH) in the pediatric population.  Recent literature highlights the impact of race and ethnicity on postoperative mortality in healthy children. Compared with being white, African-American children had 3.43 times the odds of dying within 30 days after surgery, 18% relative greater odds of developing postoperative complications, and 7% relative higher odds of developing serious adverse events. (Nafiu et al, JAMA Surg, 2020).  Looking specifically at our institution’s pediatric cohort, 12% of the NSQIP-P population had high Social Vulnerability Index (SVI) and this was associated with postoperative complications. (Yap et al, Am J Surg, 2023).  Currently, there is variability in SDoH assessment of the surgical population and limited resources to address these risks when they are identified (Sokol et al, Pediatrics, 2019).  Patient-navigator programs have led to improved processes of care, patient experience, clinical outcomes and costs for children with chronic conditions (McBrien et al, PLoS One 2018). Surgery same day cancellations is an important metric to assess the success of the Pre-Surgery clinic at UCSF.  There has been a recent uptrend in the reasons for same day cancellations of late arrivals and no shows, which may be secondary to modifiable SDoH risk factors.  The mechanism to screen for SDoH (financial resource strain, food insecurity, housing stability, and transportation needs) currently exist in the UCSF Epic system.  However, there is minimal social worker resource in the Pediatric Pre-surgery clinic to address these needs when identified. 
• TARGET -  

Outcome metrics:

1. Distribution of individual-level and neighborhood-level SDoH in our current surgical patient population
2. Successful contact with families by the patient navigator
3. Surgery same day cancellations rates before and after implementation of patient navigator program
4. Comparing individual-level SDoH with neighborhood level-level SDoH (SVI) and their impact in on the surgical outcomes in the NSQIP-P database.
5. Results of satisfaction survey

 The expected benefits include decline in of the number of same day cancellations based on modifiable reasons (ie no shows and late arrivals), improved patient experience and patient/families satisfaction in the immediate study period. In the long term, we expect improvement in surgical quality outcomes as assessed through the NSQIP-P database which may allow us to determine the role/impact of individual versus neighborhood-level SDoH. 

• GAPS - Why does the problem exist?  Describe system issues; technological gaps; educational gaps

The mechanism to screen for SDoH (financial resource strain, food insecurity, housing stability, and transportation needs) currently exist in the UCSF Epic system.  However, there is minimal social worker resource in the Pediatric Pre-surgery clinic to address these needs when identified. In addition, social worker does not address the barriers at the community level which would be the focus of the patient navigator program.   

• INTERVENTION 

Study Design:
Phase 1: Patient Navigator training program: URM medical students or post-baccalaureate students from the community (trained by professional Patient Navigator at ZSFG)

Phase 2: Intervention
1. SDoH screening at Prepare clinic appointment:

• 8 screening questions on Epic: financial resource strain, housing stability, food insecurity, transportation needs, utilities to assess individual-level SDoH
• Automated geocoding of addresses in Epic into SVI to identify neighborhood-level SDoH
• Patients/families identified as high risk for any of the categories will be given access to resources in local community (https://www.findhelp.org/) and asked to participate in Patient Navigator program.
• SDoH risk assessment entered into NSQIP-P database by SCR (surgical clinical reviewer)

2. Intervention Phase:

• 1^st call: provide local community resources before procedure date
• 2^nd call: follow-up one week after procedure
• 3^rd call: follow-up one month after procedure
• 4^th call: follow-up two months after procedure (satisfaction survey)

Study Duration: one year

Patient Population:

All children who will be evaluated at Pediatric Prepare clinic before scheduled procedure at BCH SF, plan to expand to BCH-Oakland after pilot period of 3 months at BCH-SF

Sample size: total 7,000 surgical procedures (1500 anesthesia nonsurgical procedures), about 50% of cases are scheduled outpatient cases

Current proportion of cohort considered high risk for SDoH: estimated 12% (based in NSQIP-P data)

Estimated N=420 patients (high risk)

• PROPOSED EHR MODIFICATIONS Individual-level SDoH screening questions already exist as part of the storyboard on Epic. We are requesting the addition of neighborhood-level SDoH assessment be included into Epic by geocoding the home addresses and converting into SVI percentile (1-100, higher percentile notates higher level of social vulnerability).  The algorithm has already been developed (Yap et al, J Am Surg, 2023).

• RETURN ON INVESTMENT (ROI) Estimated direct cost savings to the health care system cannot easily be calculated. However, decrease in surgery same day cancellations will allow for better OR block time utilization, leading to improved revenue.  Decrease postoperative complications would impact health care costs as documented in the NSQIP-P database (include postop ED visits, hospital readmissions, and hospital length of stay). 

• SUSTAINABILITY -If successful, the patient navigator program will be sustained by hiring one full-time patient navigator to train and coordinate the program.  Medical Director of Pediatric Perioperative Services (Dr. Atsuko Baba) and Surgeon in Chief for the UCSF Benioff Children’s Hospital in San Francisco (Dr. Hanmin Lee) are both executive sponsors for this proposal and are committed to providing operational resources and funding after the project year.

• 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
  0.5FTE Patient Navigator: train volunteer patient navigators:           $30,000-40,000 (based on annual salary of $60,000-80,000)
  0.1FTE RN or MD director                                                                 $10,000-20,000

Center for Health Equity in Surgery and Anesthesia (CHESA) and the Division of Pediatric Surgery have expressed commitment to providing additional funding if needed to support this program.

PROJECT LEAD(S):

• Monisha Bhatia, MD – Assistant Professor, Division of Hospital Medicine
• Prashant Patel, DO – Assistant Professor, Division of Hospital Medicine

EXECUTIVE SPONSOR(S):

• Bradley Monash, MD – Vice Chief of Clinical Affairs, Hospital Medicine

ABSTRACT:

Securing on-time discharges improves hospital throughput and optimizes patient flow and capacity. This is especially important during times of high census and ED boarding, which have significant patient experience and safety implications. The Hospital Medicine Service (HMS) cares for the largest volume of patients at UCSF Health, but often faces challenges in securing on-time discharges. Estimated discharge date accuracy for the service was as low as 62% in 2023 while length of stay averaged 8.1 days. Obstruction in on-time discharges often results from (1) variability in discharge planning practice patterns, (2) inadequate alignment among care team members on which patients are expected to discharge, (3) insufficient communication of discharge barriers, and (4) lack of coordination on which team member will complete discharge tasks. Since October 2023, the HMS has piloted the interprofessional “Accelerated Discharge Program,” designed to enhance communication of anticipated discharge and streamline coordination on discharge tasks for patients most likely to discharge. Through the Caring Wisely program, our interprofessional team seeks to expand and sustain several priming, enabling, and reinforcing interventions that will directly target the key root causes of later-than-ideal discharges on the HMS. We ultimately aim to increase the number of on-time discharges, improve EDD accuracy, reduce LOS, and support UCSF’s global capacity optimization efforts.

TEAM:

• Brandon Scott, MD – Director of Value Improvement, Division of Hospital Medicine (DHM), Primary Project Mentor
• Rachel White, MHSA – Quality Improvement Program Manager, DHM, Program Manager
• Connie Li – Clinical Assistant, Goldman Medical Service (DHM), Team Member
• Sarah Apgar, MD – Director, Goldman Medical Service (DHM), Core Advisor
• Ethel Wu, MD – Assistant Director, Goldman Medical Service (DHM), Core Advisor
• Faye Chan, MD – Interim Director, Goldman Medical Service (DHM), Core Advisor
• Lourdes Moldre, RN – Patient Care Director, Interdisciplinary Partner
• James Darby, RN – Parnassus Medicine Unit Director (14L/15L), Interdisciplinary Partner
• Ongoing discussions with Medicine Case Management Leadership and Patient Capacity Management Center leadership on partnership and integration
• Bradley Monash, MD – Vice Chief of Clinical Affairs, DHM, Executive Sponsor

PROBLEM:

UCSF’s Parnassus campus frequently experiences challenges with high capacity necessitating focused efforts to optimize on-time discharges within inpatient care teams.  The quality, safety, and financial consequences of a lower than predicted number of on-time discharges and include but are not limited to:

• Suboptimal patient satisfaction due to prolonged ED and PACU boarding
• Suboptimal care quality and risk of patient safety events, as the number of admitted patients “boarding” in the ED and post-procedural patients boarding in the post-anesthesia care unit (PACU) increases  
• Significant provider burnout and moral distress due to caring for patients in the “wrong care location”
• Limitations in outside hospital transfers, interservice transfers within UCSF, and direct admissions of patients needing UCSF tertiary/quaternary care
• Prolonged length of stay for admitted patients (e.g. discharge barriers not addressed earlier in the admission, thus adding a subsequent day to the patient’s hospitalization for care coordination)

For patients on the HMS, UCSF’s largest service by volume with over 7,000 Parnassus discharges in 2023, many delays in on-time discharge stem from deficiencies in the care team coordination and communication processes. For example:

• HMS multidisciplinary discharge rounds (MDR) is intended to raise awareness of anticipated discharge and discharge coordination needs structurally lack participation from key team members from nursing and rehabilitation colleagues
• On HMS’s Goldman Medical Service (“GMS,” the direct care service) a solo hospitalist must prioritize urgent clinical needs over non-urgent discharge tasks, resulting in later discharges. There is no clear standard work nor guidelines on which interprofessional care team member could or should take on shared discharge tasks which leads to suboptimal discharge task coordination.

TARGET:

• We seek to increase the number of on-time discharges of HMS patients by increasing their Estimated Discharge Date accuracy (“EDD accuracy”) from a baseline of 65% to 70% by supporting primary teams with interprofessional coordination on discharge task management. Specific targets include:
• Early identification of which  patients are discharging and consistent dissemination to multidisciplinary team members
• Streamlined communication about patients most likely to discharge
• Define and assign discharge tasks: identify tasks that delay on-time discharges and help our care team with task management to facilitate smoother discharges, while optimizing role clarity and infrastructure
• Through these interventions we hope to achieve Reduction in Length of Stay (LOS): We anticipate expedited discharge barrier resolution resulting in earlier discharges that will lead in an average length of stay reduction of 0.2 days

GAPS

System issues and technological gaps include:

• Lack of interprofessional identification and consistent messaging of HMS patients who are expected to discharge the following day. Care team members use different platforms to message about discharge barriers, and the Voalte messaging platform does pose challenges to rapid identification of the correct individual to reach.
• Lack of standardized work or interdisciplinary role delineation on discharge task management. There is lack of consensus on which disciplines are responsible for which discharge tasks which risk both diffusion of responsibility as well as inefficient coordination discharge task completion
• Inconsistent use of existing EHR-based tools that can identify accelerated discharge candidates and proactively mobilize resources to support earlier discharges. Multiple EHR tools (like Estimated Discharge Date, Discharge Milestones, and Discharge Comments) exist to promote visibility around discharge planning, but they are inconsistently utilized by care team members.
• High workload for HMS teams in the morning can limit bandwidth for accelerated, earlier discharges. Multiple morning care activities – patient handoffs of overnight admissions, MDR, and rounding on acutely ill patients – can significantly limit the bandwidth of HMS teams to discharge medically stable patients earlier in the day unless proactive support is offered

Educational gaps include:

• Suboptimal HMS team and provider awareness of existing systems that can be proactively mobilized to support accelerated discharges.

INTERVENTION:

In October 2023 we initiated our Accelerated Discharge Program (ADP) pilot on the GMS which involved streamlining outreach to identify likely next day discharges, discharge barriers, and delegate task completion with our Clinical Assistant. Moving forward we will deploy multiple interventions that identify and implement opportunities to connect physicians with additional support to identify, delegate, and address discharge barriers. Our proposed multi-modal interventions will incorporate priming, enabling, and reinforcing tactics to yield sustained improvement.Specifically:

• Development of interprofessional standard work to proactively identify the ADP HMS patients to address discharge barrier prior to EDD. This would include using afternoon tee time (case manager – hospitalist meeting to discuss discharging patients) and the clinical assistant’s recruitment of the “Accelerated Discharge Program” patient(s) to add to a shared, visible APeX list
• Feasible EHR enhancements to existing discharge-focused EHR tools. We have laid the groundwork for cross-disciplinary communication using a radio button or order set to identify early discharges.
• Improve provider education about discharge-focused tools which can be leveraged to confirm and document barriers to discharge/discharge needs
• Augmenting physician-level discharge task completion by supporting hospitalists. This is currently in pilot phase. Multiple DHM hospitalist roles have bandwidth and expertise to assist the primary hospitalists with specific discharge tasks if delegated in an appropriate, timely, and clear fashion
• Data analysis to identify common discharge barriers for ADP patients, documenting which tasks are completed by which interprofessional team member.
• Enhanced provider- and service-line feedback about accelerated discharge efforts
• Development of interprofessional “discharge team.” Recently published literature by Falcetta et al. (Journal of Hospital Medicine, January 2024) saw improvement in length of stay (1.8 days post intervention) attributed to the development of a multiprofessional discharge team dedicated to proactively identifying and intervening on discharge barriers and addressing discharge tasks. Our ADP program is currently integrating HMS’s discharge team with a new Medicine Nursing discharge champion and will expand this scope to other disciplines (e.g., Case Management, Flow Team) to adopt a similar discharge team model proven to reduce length of stay, rates of morning discharges, and bed turnover

PROPOSED EHR MODIFICATIONS:

We will explore the following modifications which may impact EDD accuracy and LOS.

• Addition of “radio buttons” to identify/flag accelerated discharge candidates
• A case management-facing best practice alert to identify accelerated discharge candidates
• Possible modification of standard inpatient progress notes to include discharge barriers
• Reduce redundant areas for interdisciplinary discharge communication (e.g. Discharge Comments, Case Management Discharge Sticky Note)
• Addition of an Accelerated Discharge Order Set

RETURN ON INVESTMENT:

We anticipate the ADP producing cost savings through reduction of length of stay in HMS patients. In the latest analyzed data from our current pilot, we found that from December 2023-January 2024, 64% of the 160 GMS patients identified as possible next day discharged through the ADP actually discharged next day and these next day discharges had an average length of stay of 7.5. This was a 0.2 reduction from the average length of stay of all patients treated by the GMS hospitalists in that same time period (7.7). We identify this 0.2 day reduction in length of stay as a conservative estimate of length of stay reduction opportunity given that these results were based on current ongoing interventions that predate any future support from Caring Wisely.

With Caring Wisely’s support, we anticipate the ability to expand the impact of our efforts as described in our proposal, highlighted by the development of an multiprofessional discharge team and expansion of these efforts to serve the Wards teaching service in addition to GMS. Extrapolating the impact of this work from recent literature, we estimate that an optimistic estimate of reduction in length of stay could be 1.8 days, again as shown by Falcetta et. al.

Collectively, we anticipate direct cost savings to the health system attributed from reduction in HMS length of stay leading to decreased direct variable costs from bed days saved over one year’s time to range from $814,514 (0.2 reduction in length of stay for GMS service) to $13,363,219 (1.8 reduction in length of stay for GMS and Wards teaching service) as outlined in Tables 1 and 2 (see attached documents). True financial impact  expected to exceed these figures as these estimates do not consider savings from additional cost of care delivery beyond direct variable cost of a bed nor increase in revenue/contribution margin arising from backfill as UCSF Health Parnassus Heights’ hospital capacity increases as a direct result from the accelerated discharge program.

SUSTAINABILITY:

• We aim to intentionally implement interventions that integrate into existing resources/processes and care team members (e.g. Case Management MDR and tee time, Flow Control Team rounding, GMS clinical assistant, EDD and Discharge Report APeX tools, CARTBoard and enterprise throughput dashboards) to ensure long-term sustainability . The Caring Wisely funding year will be utilized to establish successful standard work that can be feasibly adopted by current process owners for hospital discharges and throughput and once adopted will not require ongoing support for maintenance. We anticipate success in this project to lead to adoption of ADP core features by other service lines.
• We believe our interventions will be able to achieve sustained cost-savings without the need to hire additional care team members. Our goal is to better leverage, connect, and streamline our existing processes to produce faster, safer, and higher quality discharges for patients and care providers alike through communication practices, establishing norms, and APeX enhancements as described above.

BUDGET:

• $40,000 – effort for project lead(s)
• $5,000 – reserved for as-needed clinical informatics support (e.g. data analysis, EHR modifications
  
• $5,000 – reserved for as-needed pilot financial incentives that award early discharges

Plasma metagenomic sequencing (pmNGS) is an infectious disease diagnostic tool that detects microbial DNA from patient plasma¹. Due to its unbiased nature, pmNGS can identify bacteria, fungi, parasites and DNA viruses, including those clinicians may have not considered in their differential diagnosis or that are difficult to identify via standard testing². The diagnostic power of pmNGS can circumvent invasive and expensive diagnostic procedures³ and, potentially, shorten patient stays. However, the per-syndrome utility of pmNGS is not well established, and its cost is relatively high compared to other infectious disease diagnostics. Absent institutional or national guidelines for test use, UCSF has seen skyrocketing volumes of pmNGS, with an increase from 18 tests in 2018 to 616 tests in 2024, with an estimated annual cost of ~$1 million. Here we propose a multipronged approach to define the clinical indications for which pmNGS has highest impact, reduce costs of unnecessary testing, analyze hospital days saved, avoid costs related to procedures, and promote equity and excellence. We have created an Infectious Disease/Clinical Microbiology Consensus Molecular Testing Guidance to guide use of pmNGS testing at UCSF (Appendices 1-2). We will update the APeX lab order for pmNGS to align with this guidance. Next, we will estimate pmNGS effects on patient antimicrobial management, length of stay, and need for procedures, stratified by clinical syndrome (Appendix 3). This approach will enable assessment of pmNGS utility, improve care, and reduce waste.

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