UCSF Open Proposals

Caring Wisely FY26 Project Contest

Enhancing Clinical Access to Pediatric Celiac Disease Care at UCSF Health using a Human-Centered Design Framework

Submitted by Telly Cheung on January 24, 2025 - 9:03am Last revised by Rasmyah Hammoudeh on March 11, 2025 - 1:59pm.

Proposal Status:

PROPOSAL TITLE: Enhancing Clinical Access to Pediatric Celiac Disease Care at UCSF Health using a Human-Centered Design Framework

PROJECT LEAD(S): Telly Cheung, MD; Mala Setty, MD; Patrika Tsai, MD, MPH

EXECUTIVE SPONSOR(S): Sue Rhee, MD; Amy Lu, MD

ABSTRACT

Clinical access to pediatric celiac care at UCSF remains inadequate, as >90% of kids are estimated to be undiagnosed or unknown to the institution. This represents a significant missed opportunity to screen, diagnose, and manage a growing population of children with celiac disease. No qualitative initiatives to date have engaged caregivers and practitioners to 1) identify these barriers to patient access and 2) co-design patient-centered interventions to enhance care delivery. As therapeutics rapidly emerge, we need to improve care gaps that are limiting individuals from seeking celiac expertise. We propose a novel human-centered design project to increase access to celiac care by streamlining scheduling workflows, engaging in patient-centered outreach, standardizing nutritional resources, and developing practitioner-driven modifications to the electronic health records. Using structured design methods, we will pilot this work in the Type 1 diabetes clinics at UCSF. We aim to boost referral volumes and improve care efficiency by 25% at UCSF. A 3% increase in patient volume during FY2026 would generate an estimated return of investment of $353,478 from initial evaluation, screening, and diagnostic endoscopies, and up to $4.6 million from endoscopies if we evaluated all missing cases.

TEAM

Telly Cheung, MD (Project Lead), 3^rd Year Pediatric GI Fellow, Rising Assistant Professor of Pediatrics
Mala Setty, MD (Project Co-Lead), Professor of Pediatrics
Patrika Tsai, MD, MPH (Project Co-Lead), Professor of Pediatrics
Sharad Wadhwani, MD, MPH (Project Mentor), Assistant Professor of Pediatrics
Namrata Patel-Sanchez, MD, MPH (Quality Improvement Mentor), Assistant Professor of Pediatrics
UCSF School of Medicine Technology team (Project Collaborator), Human-Centered Designers
Jennifer Olson, MD (Project Collaborator), Professor of Pediatrics
Sharon Chui, MPH (Project Collaborator), Digestive Disease Administrative Director
Sue Rhee, MD (Executive Sponsor), Division Chief of Pediatric Gastroenterology
Amy Lu, MD (Executive Sponsor), Chief Quality Officer, UCSF Health

PROBLEM

Celiac disease is a chronic, small-intestinal immune-mediated enteropathy estimated to affect over 100 million individuals worldwide.^1,2 Among the 7.7 million people living across 9 counties in the Bay Area, an estimated 22,000 children likely have celiac disease. This estimate is based on the 1.4% global prevalence of celiac disease and approximation that 20% of the Bay Area population is under 18 years old.^2,3 From 2013-2023, about 2,000 children screened for celiac seropositivity at UCSF, which accounts for <10% of potential cases. Thus, >90% of kids remain undiagnosed or unknown to UCSF, leading to missed opportunities for early diagnosis, timely intervention, and effective reduction of morbidity and mortality in a growing celiac population.⁴

Celiac disease imposes a burden on children, society, and the healthcare system through high dietary costs, nutritional deficits, barriers to reimbursement, loss in school performance, and greater healthcare utilization.⁵ These challenges disproportionately affect low-income families with limited access to care, and may worsen existing health inequities.^6,7 No quality improvement initiatives to date have engaged caregivers and practitioners in designing targeted interventions to bridge these care gaps. Across studies, models for improvement in chronic pediatric illnesses have leveraged patient-centered strategies to transform healthcare systems.^8–15 They lay the groundwork for advancing celiac care by underscoring the value of accessibility.

Despite these critical gaps, therapeutics are rapidly emerging with >20 celiac drugs currently under investigation, and Phase 3 trials for adults beginning in early 2025.^16–18 Building a model of care at UCSF that integrates the needs of caregivers and practitioners will be essential to serving the millions anticipated to seek gastroenterology expertise over time.¹⁹ By utilizing human-centered design methods, we will directly engage stakeholders in developing best-practices tailored to their needs. Piloting structured design work in type 1 diabetes, a high-risk condition with >5-fold higher prevalence of celiac disease, will inform decision-making and enable a strategic, scalable approach to improve clinical access for pediatrics and adults.^20–22

The UCSF Division of Pediatric Gastroenterology is committed to advancing quality initiatives that address gaps, meet rising demand, and enhance celiac care. This project builds upon our Division’s investment in the professional growth of the celiac team. Support from Caring Wisely would accelerate key milestones needed to develop stakeholder-driven improvements, positioning UCSF to offer high-quality and accessible celiac care.

TARGET

Our target goal is to use human-centered design methods to establish an integrated care model for celiac disease that improves clinical access to screen, diagnose, and manage all children with concomitant type 1 diabetes by 25% across UCSF Health centers between 2025-2026. We will use structured design incorporating stakeholder values and preferences to achieve these qualitative and quantitative benefits:

Qualitative		Quantitative
Improve clinical access for children with celiac disease	→	Increase celiac referral volume by 25%
Design educational material for caregivers and pediatricians that manage chronic conditions associated with celiac disease	→	Increase celiac serology testing by 25%
Develop standardized gluten-free diet resources	→	Reduce time to dietician education by 25%
Establish an APeX-based Smartform to streamline celiac screening, diagnosis, and management	→	Improve standardized documentation by 25%
Enhance framework to transition children to adult care	→	Increase transition-of-care for patients ≥21 years old to Adult Gastroenterology by 25%

GAPS

Several gaps at UCSF detract from screening, diagnosing, and managing the >90% of potential diagnoses.

System issues:

Lack of systematic infrastructure to efficiently identify at-risk individuals from primary care and subspecialties, refer to Pediatric Gastroenterology, and timely schedule with the celiac team
Fragmented care prohibits multi-disciplinary and team-based management of celiac disease

Educational gaps:

Inadequate outreach to engage with caregivers and educate pediatricians on the referral of at-risk kids
Non-standardized dietary education reduces the effectiveness and quality of dietary counseling

Technological gaps:

Lack of standardized documentation to chart the disease course of celiac disease
Gaps in clinical documentation limit effective transition-of-care from Pediatric to Adult Gastroenterology

INTERVENTION

Human-centered design is a novel participatory-based approach used in public health, medicine, and industry to solve problems.²³ This structured process elicits the perspectives and values of stakeholders, allowing for the co-design of interventions specific to the end-users’ needs. By integrating inclusive and equitable strategies, human-centered design is ideal for addressing the systematic, educational, and technological disparities in celiac care. We will apply human-centered design principles to inform the following interventions aimed to improve clinical access to celiac care:

	Intervention	Description	Rationale	Equity-Driven
System	Re-design efficient referral and appointment scheduling workflows	Understand the barriers patients face in accessing celiac care and identify practitioner needs for improving scheduling	Streamlining referrals will enhance accessibility, reduce delays, and improve care transition from teens to adult care	Enroll caregivers who screen positive for ≥1 social need(s) (i.e., financial strain, food insecurity, housing instability, and/or transportation issues)
Education	Develop a patient-centered outreach campaign	Raise awareness among the community and referring pediatricians	Minimizing educational gaps among caregivers and practitioners will improve recruitment	Create an outreach intervention in multiple languages
Education	Create standardized gluten-free diet nutritional resources for dissemination	Define high-value gluten-free diet resources and preferred modality to disseminate education	Decreasing inconsistency in dietary counseling will improve adherence and disease control	Provide culturally appropriate gluten-free education that aligns with the diverse dietary practices of families
Technology	Practitioner-driven modifications to the electronic health records	Incorporate practitioner-driven modifications to the electronic health records to enhance documentation of celiac disease courses	Standardized documentation will facilitate more efficient monitoring of at-risk kids, resource allocation for refractory cases, and support transition-of-care	Ensure the values and preferences of all team members (i.e., clinicians, dieticians, social workers, and medical staff) are recognized

Practice Setting: We will focus on outpatient clinics for celiac disease and type 1 diabetes through the Department of Pediatrics that spans UCSF Mission Bay and Benioff Children’s Hospital Oakland.

Target Population: We will assemble a team of caregivers (N=12) and practitioners (N=8). To ensure equity, we will enroll caregivers with ≥1 social need(s) (i.e., financial strain, food insecurity, housing instability, and/or transportation issues) based on UCSF’s Social Determinants of Health tracker. We will recruit racially and ethnically minoritized caregivers to promote diverse representation. Practitioner teams will include: 2 gastroenterologists, 2 pediatricians, 1 advanced practice provider, 1 dietician, 1 social worker, and 1 practice administrator.

Approach: We will use design tools (e.g., brainstorming, sorting, categorizing, sketching, theming, synthesis, ideation, role-playing, storyboarding, and prototyping) to identify the high-value barriers to accessing and improving celiac care. The Double-Diamond model for human-centered design provides a framework to first broaden our understanding of the problems in the current celiac model of care (Discovery), distill these problems into design principles (Define), again expand on potential solutions (Develop), and finally narrow design solutions (Deliver) based on iterative feedback from stakeholders. We will achieve these aims by engaging stakeholders in a series of 8 virtual focus groups.

	Focus Group #	Focus Group Agenda
Discover	1 – Caregivers 2 – Practitioners	Identify gaps in care Brainstorming
Define	3 – Caregivers 4 – All	Define design principles Problem sorting and categorizing
Develop	5 – Caregivers 6 – Practitioners 7 – Caregivers 8 – All	Ideation and role-playing Visual storyboarding Prototype iterations

Focus Group Content: In focus groups 1-2 (Discovery), we will ask caregivers and practitioners to share their experiences in receiving and providing care, respectively. In semi-structured interviews, we will ask about their experiences managing celiac disease, barriers to dietary adherence, scheduling and APeX workflow issues, and challenges accessing or providing care. In focus groups 3-4 (Define), we will design concept maps using data captured in Discovery. We will sort and prioritize problems as elicited by stakeholders (e.g., ranking and voting). We will map the path that children and their caregivers go from symptom onset to diagnosis and treatment (i.e., obtaining referrals, getting blood work, identifying gluten-free options, and scheduling follow-up). For practitioners, we will map their experience scheduling, evaluating patients, helping caregivers navigate dietary changes, and documenting clinical data. We will distill the findings into design principles to guide our interventions to address these problems. In focus groups 5-6 (Develop), we will evoke ideation and role-playing among caregivers and practitioners to develop patient-centered healthcare interventions. We will facilitate ideation and storyboarding to allow stakeholders to react, respond, and discuss their ideas. By brainstorming and sorting solutions with stakeholders, we will prioritize the most important interventions in our celiac model of care. In focus groups 7-8, we will develop a prototype iteration for these ideal targets. We will support structured feedback to ensure that storyboards reflect stakeholders’ perspectives.

Potential barriers to implementation: We may have insufficient representation of diverse social needs from caregivers. We will purposely enroll caregivers with social adversities screened at UCSF to ensure equitable inclusion. We may also have difficulty scheduling focus groups with stakeholders. We will budget extra time to schedule focus groups up to every 2-4 weeks. Moreover, we bring our: (1) experience applying human-centered design methods to now published work, (2) formal training in human-centered design through UCSF’s Department of Epidemiology and Statistics, (3) existing relationships with design team consultants who will directly support this proposal, (4) success in recruiting diverse participants, and (5) planned advanced training in the Improvement Science Series at Cincinnati Children’s that lines up with the start-up of this award period.^24,25 Together, this ensures our proposal can feasibly be conducted within the 1-year award period.

Potential adverse outcomes of proposed interventions: Practice changes (i.e., standardization of gluten-free resources and documentation) may initially be challenging to adopt. Our human-centered design approach will integrate the values and preferences of stakeholders into interventions, thus helping to streamline implementation. As clinical access increases, we expect that higher patient volumes will require adjustments in practitioners’ schedules. Our focus on optimizing scheduling workflow will preemptively address these issues.

PROPOSED EHR MODIFICATIONS

Due to gaps in standardizing the identification of all at-risk individuals, we will implement an APeX Smartform initiative to improve documentation. Currently, our non-standardized approach to documenting disease courses detracts from monitoring the most at-risk individuals. By building a celiac-focused Smartform into patients’ “Problem List”, this unified documentation will facilitate quality improvement efforts and strengthen future research opportunities. We will develop a template to track disease severity, symptom profile, diagnostic criteria, associated conditions, serologic and nutritional markers, anthropometrics, and dietary adherence.

RETURN ON INVESTMENT (ROI)

By establishing a systematic, educational, and technological framework to improve our screening of celiac disease among high-risk children with type 1 diabetes, we will increase clinical access and reduce the widening gap in equitable care. By conservative estimates using Medi-Cal reimbursement rates, if we increased our screening to capture even 3% of the 20,000 children with potential celiac disease in the Bay Area, a comprehensive evaluation (i.e., laboratory screening, diagnostic endoscopies, and referrals) would generate an estimated return of investment of $353,478 in revenue.²⁶ Moreover, the billing of outpatient follow-up and celiac screening required for 1^st degree family members would further enhance revenue.^1,27,28 Our estimates would represent the recruitment of approximately 40% of children with type 1 diabetes currently followed at UCSF. The market share for the estimated 20,000 and growing number of children in the Bay Area with celiac disease remains substantial. These initiatives lay the groundwork for generating up to $4.6million from diagnostic endoscopies alone of all undiagnosed children, with adult cases bringing an additional $20 million.^2,3,26 Investing to improve the model of care for celiac disease will capture the projected >$10 billion market for gluten-free products and services (by 2032), leveraging near limitless growth potential for UCSF.²⁹

Tests and Referrals	Procedural Code (CPT)	Cost (Medi-Cal rates)²⁶
Complete blood count with differential	85025	$6.75
Complete metabolic panel	80053	$9.19
Tissue transglutaminase IgA	86364	$11.53
Deamidated gliadin peptides IgA and IgG	86258	$11.53
Endomysial antibody	86231	$12.09
Total serum IgA	82784	$6.08
Total serum IgG	82784	$6.08
Thyroid stimulating hormone	84443	$14.76
Free thyroxine (T4)	84439	$7.91
Iron panel	83540	$5.72
Ferritin	82728	$12.07
Vitamin D	82306	$20.72
HLA celiac typing	81382	$109.94
Upper endoscopy with biopsies	43239	$234.18
Complex new outpatient visit	99205	$90.23
Dietician referral	97802	$30.35

SUSTAINABILITY

If successful, this foundational work will identify gaps to accessing celiac care and help develop patient-centered solutions, setting the stage for a Cross-Bay Celiac Disease Program at UCSF. Once implemented, our interventions (i.e., scheduling workflow updates, nutritional resources, and APeX modifications) should require minimal maintenance from personnel. Moreover, by creating a robust referral network, generating revenue, and gaining recognition as a world-renown institution, we position UCSF to garner support from the Department of Pediatrics, Division of Pediatric Gastroenterology, and philanthropy from donors. Philanthropy remains a key driver of success in other Celiac Disease Centers nationally. Philanthropic efforts will be one instrumental component to ensure the Center's long-term impact and outreach. Ultimately, implementation of our quality initiatives will inform a scalable model that may advance health equity in other chronic diseases.

BUDGET

Budget Item	Description	Amount
UCSF SOM Tech Team	The UCSF SOM Tech team provides expertise in human-centered design and will be responsible for facilitating semi-structured interviews, focus groups, and applying human-centered design principles for this project.	$19,800 ($132 hourly rate, 150 hours of effort)
Salary Support for Dr. Cheung	Lead all aspects of project ideation, design, development, management, implementation, and analysis.	$20,000 (0.15 FTE)
Participant Incentives	We will give participants $50 for each focus group that they participate in.	$8000
Transcription Services	We will transcribe recorded focus groups using a professional transcription service (TranscriptionWing).	$1500
Data Network and IT Support	We will budget for data networking and IT support (i.e., for data storage, software, hardware, and/or internet security).	$500

REFERENCES

1. Hill ID, Fasano A, Guandalini S, et al. NASPGHAN Clinical Report on the Diagnosis and Treatment of Gluten-related Disorders. J Pediatr Gastroenterol Nutr. 2016;63(1):156-165. doi:10.1097/MPG.0000000000001216

2. Singh P, Arora A, Strand TA, et al. Global Prevalence of Celiac Disease: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2018;16(6):823-836.e2. doi:10.1016/j.cgh.2017.06.037

3. Bay Area Census -- Bay Area Data. Accessed September 24, 2024. http://www.bayareacensus.ca.gov/bayarea.htm

4. Zingone F, Bai JC, Cellier C, Ludvigsson JF. Celiac Disease–Related Conditions: Who to Test? Gastroenterology. 2024;167(1):64-78. doi:10.1053/j.gastro.2024.02.044

5. Bozorg SR, Lee A, Mårild K, Murray J. The Economic Iceberg of Celiac Disease: More Than the Cost of Gluten-Free Food. Gastroenterology. Published online April 24, 2024:S0016-5085(24)00480-3. doi:10.1053/j.gastro.2024.02.051

6. Oza SS, Akbari M, Kelly CP, et al. Socioeconomic Risk Factors for Celiac Disease Burden and Symptoms. J Clin Gastroenterol. 2016;50(4):307-312. doi:10.1097/MCG.0000000000000366

7. Cheung T, McDonald C, Setty M, Tsai P, Wadhwani SI. Social Adversities Associate with Worse Disease Control in Pediatric Celiac Disease. J Pediatr. 2025;276. doi:10.1016/j.jpeds.2024.114305

8. Egberg MD, Gulati AS, Gellad ZF, Melmed GY, Kappelman MD. Improving Quality in the Care of Patients with Inflammatory Bowel Diseases. Inflamm Bowel Dis. 2018;24(8):1660-1669. doi:10.1093/ibd/izy030

9. Heisler C, Rohatinsky N, Mirza RM, et al. Patient-Centered Access to IBD Care: A Qualitative Study. Crohns Colitis 360. 2023;5(1):otac045. doi:10.1093/crocol/otac045

10. Schwartz SP, Rehder KJ. Quality improvement in pediatrics: past, present, and future. Pediatr Res. 2017;81(1):156-161. doi:10.1038/pr.2016.192

11. Bravata DM, Gienger AL, Holty JEC, et al. Quality Improvement Strategies for Children With Asthma: A Systematic Review. Arch Pediatr Adolesc Med. 2009;163(6):572-581. doi:10.1001/archpediatrics.2009.63

12. Flood K, Nour M, Holt T, Cattell V, Krochak C, Inman M. Implementation and Evaluation of a Diabetic Ketoacidosis Order Set in Pediatric Type 1 Diabetes at a Tertiary Care Hospital: A Quality-Improvement Initiative. Can J Diabetes. 2019;43(5):297-303. doi:10.1016/j.jcjd.2018.12.005

13. Freedman JL, Reilly AF, Powell SC, Bailey LC. Quality Improvement Initiative to Increase Influenza Vaccination in Pediatric Cancer Patients. Pediatrics. 2015;135(2):e540-e546. doi:10.1542/peds.2014-0943

14. Choi SW, Chang L, Hanauer DA, et al. Rapid reduction of central line infections in hospitalized pediatric oncology patients through simple quality improvement methods. Pediatr Blood Cancer. 2013;60(2):262-269. doi:10.1002/pbc.24187

15. Fiorino G, Allocca M, Chaparro M, et al. ‘Quality of Care’ Standards in Inflammatory Bowel Disease: A Systematic Review. J Crohns Colitis. 2019;13(1):127-137. doi:10.1093/ecco-jcc/jjy140

16. Schuppan D, Junker Y, Barisani D. Celiac Disease: From Pathogenesis to Novel Therapies. Gastroenterology. 2009;137(6):1912-1933. doi:10.1053/j.gastro.2009.09.008

17. Buriánek F, Gege C, Marinković P. New developments in celiac disease treatments. Drug Discov Today. 2024;29(9):104113. doi:10.1016/j.drudis.2024.104113

18. Discepolo V, Kelly CP, Koning F, Schuppan D. How Future Pharmacologic Therapies for Celiac Disease Will Complement the Gluten-Free Diet. Gastroenterology. 2024;167(1):90-103. doi:10.1053/j.gastro.2024.02.050

19. Anderson RP, Verma R, Schumann M. A Look Into the Future: Are We Ready for an Approved Therapy in Celiac Disease? Gastroenterology. 2024;167(1):183-193. doi:10.1053/j.gastro.2024.02.005

20. Elfström P, Sundström J, Ludvigsson JF. Systematic review with meta-analysis: associations between coeliac disease and type 1 diabetes. Aliment Pharmacol Ther. 2014;40(10):1123-1132. doi:10.1111/apt.12973

21. Pham-Short A, Donaghue KC, Ambler G, Phelan H, Twigg S, Craig ME. Screening for Celiac Disease in Type 1 Diabetes: A Systematic Review. Pediatrics. 2015;136(1):e170-176. doi:10.1542/peds.2014-2883

22. Karimzadhagh S, Abbaspour E, Shahriarinamin M, et al. Meta-Analysis: Global Prevalence of Coeliac Disease in Type 1 Diabetes. Aliment Pharmacol Ther. 2025;61(1):8-31. doi:10.1111/apt.18373

23. Melles M, Albayrak A, Goossens R. Innovating health care: key characteristics of human-centered design. Int J Qual Health Care. 2021;33(Supplement_1):37-44. doi:10.1093/intqhc/mzaa127

24. Cheung T, Squires J, Bautista B, et al. Co-producing a health advocate intervention for pediatric liver transplant recipients using human-centered design. Liver Transpl. (In press).

25. Intermediate Improvement Science Series | Anderson Center. Accessed September 28, 2024. https://www.cincinnatichildrens.org/research/divisions/j/anderson-center...

26. Medi-Cal Rates | Medi-Cal Providers. Accessed January 23, 2025. https://mcweb.apps.prd.cammis.medi-cal.ca.gov/rates

27. Rubio-Tapia A, Hill ID, Semrad C, et al. American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. Off J Am Coll Gastroenterol ACG. 2023;118(1):59. doi:10.14309/ajg.0000000000002075

28. Husby S, Koletzko S, Korponay-Szabó I, et al. European Society Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for Diagnosing Coeliac Disease 2020. J Pediatr Gastroenterol Nutr. 2020;70(1):141-156. doi:10.1097/MPG.0000000000002497

29. Gluten Free Food Market Size, Share & Growth | Forecast [2032]. Accessed January 23, 2025. https://www.fortunebusinessinsights.com/industry-reports/gluten-free-foo...

WatchMe: Utilizing Digital Tools to Improve Patient Education, Satisfaction, and Attendance in the Echo Stress Laboratory

Submitted by Aimee Camano on February 25, 2025 - 3:53pm Last revised by Rasmyah Hammoudeh on March 11, 2025 - 2:00pm.

Proposal Status:

Review Complete

WatchMe: Utilizing Digital Tools to Improve Patient Education, Satisfaction and Attendance in the Echo Stress Laboratory

PROJECT LEAD(S):

Aimee Camano MSN FNP-C

William Bradley DNP

EXECUTIVE SPONSOR(S):

Isaac Kwan - Cardiac Sonographer, Supervisor

Dr. Kirsten Fleischmann - Associate Chief of Cardiology, Ambulatory Operations

Monet Strachan - Technical and Quality Director, Adult Echocardiography

Dr. Mike Salerno – Echo Laboratory Chief Medical Director, Cardiology

ABSTRACT

Heart disease remains the leading cause of mortality in the United States affecting both men and women (Centers for Disease Control and Prevention, 2024). At UCSF, a range of cardiac stress tests – including Treadmill Stress Echo, Stress EKG Test, Supine Bicycle Stress Echo, Dobutamine Stress Test and Tilt Table Testing – are essential diagnostic tools for preventing heart attack and progression of cardiovascular diseases. However, these tests currently face a scheduling wait time of 1-2 weeks, with daily patient cancellations, reschedules and no-shows at 10.2% contributing to an estimated annual revenue loss of $1,861,779.

The primary causes of missed appointments leading to revenue loss include patient refusal, inability to follow instructions when holding beta blockers due to limited understanding of the tests, inappropriately ordered test due to acute disease conditions such as musculoskeletal limitations and uncontrolled hypertension. To address these challenges, developing a digital education tool partnering with Mytonomy, a contracted media company, tailored specifically for UCSF echo procedures and digitally updating our stress laboratories by placing television sets in the waiting room and individual stress rooms will improve patient education, satisfaction, and reduce missed appointments. This tool will be integrated in the Echo Lab website and embedded within the Epic system, allowing providers and patient care teams to shared decision making by providing real-time educational resources with patients at the point of care. This informative and collaborative approach to ordering tests, encourages patients engagement thereby increasing the chance of patients showing up for the appointment. In the primary setting, a systematic review by Coronado-Vasquez et al., shows strong evidence supporting use of decision aids in improving knowledge, risk and patient satisfaction in their plan of care (2020).

Following implementation, a targeted campaign: WatchMe is designed to raise awareness about the digital platform available to the UCSF community. The impact will be measured by analyzing Epic data and Press Ganey Patient Satisfaction scores in six months post-intervention. By enhancing patient education and provider support, WatchMe aims to improve clinical accessibility, reduce delays in critical cardiac testing necessary for early diagnosis and treatment of heart disease, and mitigate revenue loss- ultimately advancing patient care and operational efficiency at UCSF.

TEAM

Aimee Camano MSN FNP-C- Nurse Practitioner

William Bradley DNP, ACNP Nurse Practitioner

PROBLEM

Over the past six months, the UCSF Parnassus Echocardiography (Echo) Lab has experienced a 10.2% daily average patient cancellations, reschedules, or no-shows. This trend has adversely affected scheduling efficiency, revenue, and patient satisfaction. As of February 14, 2025, the average wait time for stress testing appointments is 1-2 weeks. In a similar internal study done at the UCSF Radiology Unit by Anthony et al. (2022), the initial no show rate was at 18.1%, after calling patients two- to four days prior to scheduled appointment, the rate decreased to 4.3%. Currently, the echo lab is sending calls and text messages prior to appointment and the no show rate from August 19, 2024 to February 14, 2025, a total of 122 working days remains at 10.2%.

A significant contributor to these missed appointments includes orders that do not correlate to patient’s physical condition prior to testing such as mobility limitations, uncontrolled hypertension and receiving beta blocker treatment. Moreover, patients' limited understanding of procedures, leading to unmet expectations and test changes, is reflected in the 2025 PressGaney score of 94.3% for staff's explanations. Consequently, more time is needed to describe the procedures leading to increased waiting time in registration,shown at 92.91% (PressGaney, 2025). These factors lead to delays, rescheduling, or cancellations, thereby impacting future scheduling availability and revenue. Overall, the likelihood to recommend stress testing is at 55th percentile with a decrease in trend since 2021 (PressGaney, 2025).

TARGET

The primary beneficiaries of this project are patients aged 18 to 90 scheduled for cardiology stress testing. Our goal is to reduce missed testing opportunities from 10.2% to less than 5% within six months by improving access to educational resources while fostering collaborative decision making when test ordering. Data will be collected by tracking no-shows, cancellations, and rescheduled tests, aiming to enhance outpatient and inpatient access to cardiac stress testing. Furthermore, the echo lab team seeks to improve patient satisfaction by decreasing the wait time in registration and improve likelihood to recommend.

Table 1. Collected Data from 8/19/24- 02/14/25

Total number of missed opportunities (no show, cancellations, reschedule)	162
Total number of cases booked	1592
Daily Percentage of missed opportunity	10.2%
Average scheduled daily cases	12.72
Total work days	122

Table 2. Cost of Studies 2025 - Average Cost of Procedures Billed $5,881

Billed amount for the following services:
Treadmill Only	3,041
Treadmill Stress Echo	6,082
Dobutamine Stress Echo	9,407 with contrast 10,203
Supine Bicycle Echo	9,407 with contrast 10,203
Cardiopulmonary Exercise Test (CPET)	5,638
Tilt Table Testing	1,716

Table 3. RETURN ON INVESTMENT (ROI) – $857,879

STEP	Process	Calculation	Result
1	Average cost of billed procedures X Average scheduled daily cases	$5,881 X 12.72	$74,806.32 (Projected daily revenue)
2	Projected daily revenue X Daily percentage of missed opportunity	$74,806.32 X 10.2%	$7,630 (Lost daily revenue)
3	Lost daily revenue X Total work days	$7,630 x 122	$930,889 (Total revenue lost biannually)
4	Total revenue lost biannually x annual	$930,889 X 2	$1,861,779 (Annual Lost Revenue)
5	Projected daily revenue x projected goal of missed opportunity with this project (goal decrease is <5% with this project)	$74,806.32 X 5.5%	$4,114.43 (Projected captured opportunity)
6	Projected captured opportunity x Total work days	$4,114.43 X 122	$501,950 (biannual savings in missed opportunity)
7	Biannual savings in missed opportunity x annual	$501,950 x 2	$1,003,900 (Projected annual Savings if missed opportunity improves)
8.	Annual lost revenue – Annual savings if missed opportunity improves	$1,861,779 – $1,003,900	$857,879 Return On Investment

GAPS

Due to time constraints during clinic visits, patients often struggle to comprehend and visualize the procedures. The current age for stress testing is over 65 years old, with diverse educational backgrounds and language proficiencies. Providing educational videos in multiple languages with clear visual demonstrations will enhance equity and accessibility for all patients.

INTERVENTION

Developing a digital educational tool by partnering with Mytonomy focusing on UCSF-specific echo procedures such as Treadmill Stress Echo, Treadmill Only, Supine Bicycle Stress Echo, Dobutamine Stress Test, and Tilt Table Testing. Existing educational guidelines and protocols will enhance accuracy in creating videos available in the following platforms: Epic system (while ordering), MyChart for patient access, and UCSF Echocardiology website. Once the videos are produced, a robust campaign (WatchMe) emphasizing ease of access to multiple clinic sites within UCSF will start and continue until the 6^th month. Utilizing a multi-channel communication through emails, intranet, posters and creating events in major outpatient clinics in UCSF to hold Q&A sessions while showing videos of our stress laboratory. A digital upgrade to install television and other electronic devices (IPAD) will then be utilized at the exercise lab to show the video to patients. At this stage data collection will commence to document missed opportunities and patient satisfaction for comparison.

PROPOSED EHR MODIFICATIONS

Integration of Video Links: Incorporate video links into stress testing order forms within the Epic system which will then be available in MyChart for patients to view.
Enhanced Ordering Process: Add prompts to provide real-time information to providers and patients regarding the ordered tests.
Updated Online Resources: Revise the UCSF Echo Lab website to include access to frequently asked questions and educational materials.
Update the digital tools at the echo lab with television sets and other digital tools (IPAD).

SUSTAINABILITY and SCALING

The videos wil be available to UCSF with Mytonomy licensing for two years. Since the video links will be automatically embedded in the EPIC system when orders are placed, all providers including care teams have access to this digital educational tool, strengthening shared decision making and engagement in the testing modality. The project can scale up to all exercise labs in the UCSF system including remote sites. Team meetings will be held monthly to address barriers, successes and adjust strategies to sustain momentum. The same model can be replicated in multiple procedural areas within the UCSF system to improve missed opportunities for testing. Furthermore, potential research opportunities in measuring exercise capacity with digital tools to improve exercise time will be available in the future.

Table 4. BUDGET - Projected Cost $50,000

Video Production	$10000
IPAD x 10	$5000
Television x 10	$5000
Training Cost to travel clinics in UCSF for implementation, food, transportation, staff salaries	$25000
Research data gathering and processing and future publishing	$5000

References

Anthony, R., Fleischman, K., Bradley, W., Chao, C., Lee, S., Greenway, J. (2022). Myocardial Perfusion Study No Show Rate.

Coronado-Vázquez, V., Canet-Fajas, C., Delgado-Marroquín, M. T., Magallón-Botaya, R., Romero-Martín, M., & Gómez-Salgado, J. (2020). Interventions to facilitate shared decision-making using decision aids with patients in Primary Health Care: A systematic review. Medicine, 99(32), e21389. https://doi.org/10.1097/MD.0000000000021389

Centers for Disease Control and Prevention. (2024, October 24.). Heart Disease Facts. https://www.cdc.gov/heart-disease/data-research/facts-stats/index.html

PressGaney. UCSF Echo Lab Parnassus. (2025, February 21). Breakout Scorecard.

Supporting Documents:

Anthony et al., Result

Supporting Data (no shows, calculations)

PressGaney Scores

Optimizing comfort and reducing opioid and sedative exposure – a goal-directed, nurse-implemented comfort algorithm in the Pediatric Cardiac ICU

Submitted by Minso Kim on February 27, 2025 - 1:43pm Last revised by Rasmyah Hammoudeh on March 26, 2025 - 6:23pm.

Proposal Status:

Selected for 2nd Round

PROJECT LEAD(S): Minso Kim, Sandra Staveski, Lori Fineman, Amy McCammond

EXECUTIVE SPONSOR(S): Shannon Fitzpatrick, MS, RN, CCRN, Patient Care Director, Pediatric Critical Care. University of California San Francisco (UCSF) Benioff Children’s Hospital (BCH) Mission Bay

ABSTRACT (1490 characters): Effective comfort management in children following heart surgery is crucial to successful recovery. Complex symptoms, neurodevelopmental variation, and a diverse care team can contribute to inconsistent care delivery. Further complicating care, important interactions exist among pain, agitation, delirium, and iatrogenic withdrawal syndrome (IWS) and the cardiac system function. A standard approach to pain and sedation following child heart surgery has been shown to improve outcomes, decrease total exposure to opioid and sedative medications, enhance throughput, and reduce hospital length of stay (LOS). Our interprofessional team in the Pediatric Cardiac Intensive Care Unit (PCICU) developed a unique, goal-directed, nurse-implemented pain and sedation algorithm and complementary Advancing Patient-Centered Excellence (APeX) order set, based on published and validated algorithms. Our algorithm aims to improve efficacy in achieving adequate comfort in postoperative child heart surgery patients as measured by clinical outcomes as well as by family feedback. It also aims to reduce children’s total cumulative exposure to opioid and sedative medications. Clinical and pharmacologic data for the 12-month period prior to implementation will be compared to data collected at 6- and 9-months post-implementation. Finally, measures of team communication, performance, and satisfaction related to pain and sedation management will be examined by a pre- and post-implementation survey.

TEAM: Sandra Staveski PhD, RN, CPNP-AC, FAAN; Lori D. Fineman, RN, MS, CNS; Brianna Rojo, RN, MSN, CNS; Tommy Flynn, PhD, RN, CPNP-AC; Minso Kim, MD, Assistant Professor of Pediatrics; Michael Cisco, MD, Associate Professor; Amy McCammond, MD, Associate Professor of Pediatrics; Lulu Jin, Pharm.D., BCPPS, BCPS, Pediatric Clinical Pharmacy Supervisor.

PROBLEM: Lowest effective dose of opioids and sedative agents is a strategic goal in critical care to optimize outcomes. However, ensuring adequate comfort in children with heart disease is complex process and remains elusive.¹ Valentine and colleagues revealed a lack of standardized comfort care and use of sedation protocols in PCICUs including in UCSF BCH PCICU.² There are multiple symptoms such as pain, agitation, under- and over-sedation, delirium, and IWS that overlap with each other. Teasing these symptoms out can be a subjective and challenging process. A pre-implementation survey in our PCICU team showed poor consistency among interprofessional clinicians as multiple team members had differing approaches. Moreover, practice variability among nurses based on expertise, beliefs, and clinical practice can add to the wide range of opioid and sedative use. We identified issues in the categories below:

Patients. Our patient population contains a high percentage of neonates, infants, and neurodevelopmentally divergent patients with impaired verbal communication who require developmentally appropriate approaches to pain and sedation assessment and management. This population benefits the most from evidence-based medication choice to maximize their potential brain development. Exposure to benzodiazepine in infancy is associated with impaired brain development suggested by hippocampal growth alteration implicated in memory processing.³ Use of prolonged continuous ketamine infusions may be associated with increased delirium.⁴ Children who were exposed to higher doses and longer durations of opioid and sedative medications are at a greater risk for IWS and delirium.⁵ Conversely, children exposed to lower doses and shorter durations of sedative medications are at a lower risk for sedation-related complications.⁶ We theorize that our work will not only be fiscally responsible but also add crucial information to the current medical literature. Our algorithm focuses on interprofessional goal setting as well as standardized weaning method for children exposed to opioids, benzodiazepines, and other sedative agents after heart surgery. We hypothesize that these focuses will reduce IWS, subsequently improving parental perception of the pain and sedation management.

Process. Clinical variability impacts infants, children, and adolescents differently. For example, a clinical team may be able to verbally communicate with and support a well-developed adolescent through critical illness in comparison to consoling those who lack verbal communication skills due to their age or neurodivergence. While there is a paucity of unifying practice guidance,⁶a nurse-implemented, goal-directed, child-centric strategy to improve comfort in PCICU is possible and safe to use.⁷ Similarly, another study of nurse-implemented, goal-directed sedation strategy found a reduction in LOS and cumulative exposure to benzodiazepines.⁸

Systems. Children with agitation, inadequate sedation, poor pain control, delirium or IWS have higher nursing workload and require more 1:1 staffing.⁵ Having sedative medication guidelines is associated with reduced ICU and hospital LOS, decreased occurrence of delirium, shorter length of mechanical ventilation, less exposure to opioid and sedatives, decreased occurrence of IWS, and improved communication and documentation of sedative goals.^1,5 Importantly, these positive changes were without an increase in adverse events.⁷We hypothesize that financial metrics associated with implementing CICU Comfort Algorithm will decrease total exposure to opioid and sedatives, decrease hours on ventilator, reduce LOS, and improved throughput thereby reducing financial burden and sedation-related complications.

TARGETS: We will evaluate metrics important to each of our goals detailed below, comparing our baseline PCICU data (12-month period pre-implementation) with post-implementation data at 6- and 9-month timepoints (related to 1 year study period).

Increase PCICU’s effectiveness in achieving adequate pain relief and appropriate sedation based on acuity for infants and children (0-18 years old) recovering from heart surgery as reflected by clinical outcomes and family feedback. While complex and multidimensional, we plan to evaluate several specific metrics to reflect this. We will evaluate total mechanical ventilation days, ICU LOS and total hospital LOS, aiming for an overall 5% decrease in each endpoint. At baseline, our patients recovering from heart surgery have median 3.2 mechanical ventilation days, median 11.7 ICU LOS, and median 18.0 hospital LOS. There were total 342 heart surgery cases at BCH Mission Bay PCICU in the past 12 calendar months. We will gather comfort scores from our electronic Health Record (EHR) pre- and post-implementation as balancing measures. In addition, we will evaluate post-discharge family survey data (Press Gainey Survey) regarding parental response to the questions “How well your child’s pain was controlled in the first 24 hours following surgery” and “How well your child’s pain was addressed.” We will aim for a 5% increase in families responding “Good” or “Very Good” to these questions at the 6- and 9-month time points. Currently our baseline Press Gainey scores for FY2024 are 95.3 for the question “how well my child’s pain was addressed”.
Successfully implement our comfort algorithm in > 75% of children 0-18 years old recovering from heart surgery in the PCICU (excluding those who have undergone ventricular assist device (VAD) placement, heart transplant and/or palliative/comfort care), with equitable application of algorithm in children across all racial and ethnic backgrounds. This will be assessed by auditing utilization of the associated comfort algorithm APeX order set in comparison to unit admission and demographic data. We will further audit compliance with specific components of our algorithm using our audit tool developed in conjunction with UCSF Health regulatory team for appropriateness and sustainability. We will perform subgroup analysis to ensure that our algorithm is being applied equitably to children from all racial and ethnic backgrounds.
Reduce total cumulative exposure (both exposure and duration) to opioid and sedation medications by 10% for each medication class. We will collect both pre- and post-implementation data regarding total cumulative exposure and total duration of treatment for all opioid and sedative medications for postoperative children while in our PCICU. Additionally, we will collect data on number of patients continuing to wean from opioid and sedative medications at hospital discharge.
Demonstrate a 10 % improvement in our PCICU team’s assessment of our effectiveness, consistency, and communication surrounding pain and sedation management. We have previously conducted an interprofessional survey to assess each team member’s satisfaction with communication and team function related to the assessment and treatment of pain and agitation in children recovering from heart surgery. We will re-administer this survey at 6- and 9-month time points post-implementation.

GAPS: Analgesia and sedation are important parts of effective postoperative recovery in children after heart surgery ages 0-18 years old. Various system issues, technological boundaries, and educational gaps make the selection and titration of analgesic and sedating agents challenging. Children requiring heart surgery consists of a wide range of ages, developmental, and genetic variations. Their clinical acuities complicate the differentiation between the symptoms of impaired organ function and pain, agitation, delirium, and IWS. Variable clinical staff education, experience, and resource availability create inconsistencies in both the assessment and treatment of comfort from day to day. The lack of a standard approach to guide clinical processes related to ordering and administering analgesics and sedatives is a key gap that, when bridged, has been shown to facilitate improved outcomes as described above.

INTERVENTION:

1. Our interprofessional working group has developed an algorithm to standardize analgesia and sedation in our PCICU. Our algorithm was based upon published analgesia and sedation algorhithms,^7,9 which was modified to reflect local practices and preferences. Briefly, our algorithm provides preferred medication choices, starting dosages, and instructions for increasing or decreasing medication dose as needed based on level of sedation or pain agreed upon during daily rounds. Our algorithm specifies the method of assessing level of sedation to improve consistency; a goal sedation level is set by our medical team, and the medication doses are titrated by our clinical nurses to achieve and maintain that specified comfort level. Additionally, our algorithm includes a standardized approach to weaning from analgesic and sedative medications to prevent IWS. Our algorithm will be applied uniformly to all PCICU surgical patients (0-18 years old) except for VAD placement, heart transplant, or comfort care patients. To ensure there are no equity gaps, we will measure adherence to our algorithm and compare rates among different subgroups.

2. Our algorithm will be implemented in our PCICU at BCH Mission Bay for children between 0-18 years of age. We care for approximately 500 patients per year, ranging in age from newborn to adult. All patients having surgery will be managed with our algorithm. Our medical staff consists of 12 attending physicians, 8 Nurse Practitioners, and fellows from our Pediatric Cardiology and Critical Care fellowship training programs. Approximately 120 nurses staff our unit.

3. We anticipate our largest barrier to implementation will be faculty, trainee, and staff education that are sustained over time. We will approach this using multiple strategies, including electronic dissemination of our algorithm, reviewing our algorithm in person at staff meetings, online training modules, and utilizing staff champions to provide in person assistance.

4. Potential adverse outcomes that we will track include unplanned extubation and hemodynamic instability due to suboptimal sedation or analgesia. Patient/caregiver satisfaction is also tracked in post-discharge surveys. Similar algorithms have been studied in pediatric critical care units, and these studies suggest that an algorithm can provide clinical benefits without significant adverse outcomes.

PROPOSED EHR MODIFICATIONS: Effective and efficient application of technological resources is key to progressive quality improvement projects. Utilizing existing tools and workflows from UCSF Health’s EHR record system (APeX), this project proposal includes development of an algorithm-based order set and an algorithm-specific APeX report. Providers use order sets in APeX to place interdependent orders efficiently while, in this case, consistently adhering to algorithm directives. APeX reports are generated from existing data in our EHR and can be used to monitor various clinical processes and phenomena. We have been working with EHR leaders to modify orders.

RETURN ON INVESTMENT: In 2024, patients who were admitted under pediatric cardiothoracic surgical service had an average 5.5 day of ICU LOS. The direct cost portion of ICU LOS is estimated at $5,500 per day. We aim to decrease the ICU LOS by 5% (0.3 days) by implementing our project. Our estimated annual surgical volume is 300 patients excluding VAD placement or heart transplant patients. If we successfully implement CICU Comfort Algorithm in 75% of this population, this will equate to 225 patients. This will translate to direct cost savings of $371,250 per year. Additionally, this decreased ICU LOS will open up 56 ICU patient days per year to admit more patients for cardiac surgery, which will further generate revenue in return.

SUSTAINABILITY: Our algorithm will be embedded in our broader PCICU management of postoperative children and will involve ongoing annual re-education, mandatory orientation and maintenance of competencies. Longitudinal interprofessional working group will continue to monitor our project and outcomes moving forward.

BUDGET:

We request $10,000 for data extraction by Clinical Translation Science Institute (CTSI) [including medication duration, cumulative doses of opioid, benzodiazepine, dexmedetomidine, propofol, ketamine, total ventilator days, LOS, discharge home on methadone, lorazepam, or clonidine, and parent satisfaction measures.
We wish for $10,000 for our PCICU Pharmacist salary and fringe for supervising data verification and analysis by School of Pharmacy graduate research students and/or work study students.
We request $15,000 for data collection, verification, management, and cleaning by graduate pharmacy, work study students and/or nursing student researcher. Graduate PharmD students will verify 10% of data extracted by CTSI.
We wish for $5,000 for PCICU clinical nurse champions to aide in staff education and/or implementation support during our study proposal timeframe.
We request $10,000 salary and fringe support for proposal and study planning, oversight and statistical support by Dr. Staveski and statistical support from UCSF SON statistician and/or graduate research student.

REFERENCES:

Balit CR, LaRosa JM, Ong JSM, Kudchadkar SR. Sedation protocols in the pediatric intensive care unit: fact or fiction? Transl Pediatr. 2021 Oct;10(10):2814-2824.
Valentine K, Cisco MJ, Lasa JJ, Achuff BJ, Kudchadkar SR, Staveski SL. A survey of current practices in sedation, analgesia, withdrawal, and delirium management in paediatric cardiac ICUs. Cardiol Young. 2023 Nov;33(11):2209-2214.
Duerden EG, Guo T, Chau C, Chau V, Synnes A, Grunau RE, Miller SP. Association of Neonatal Midazolam Exposure with Hippocampal Growth and Working Memory Performance in Children Born Preterm. Neurology. 2023 Nov 7;101(19):e1863-e1872.
Da Silva PSL, Kubo EY, da Motta Ramos Siqueira R, Fonseca MCM. Impact of Prolonged Continuous Ketamine Infusions in Critically Ill Children: A Prospective Cohort Study. Paediatr Drugs. 2024 Sep;26(5):597-607.
Best KM, Asaro LA, Franck LS, Wypij D, Curley MA; Randomized Evaluation of Sedation Titration for Respiratory Failure Baseline Study Investigators. Patterns of Sedation Weaning in Critically Ill Children Recovering from Acute Respiratory Failure. Pediatr Crit Care Med. 2016 Jan;17(1):19-29.
Poh YN, Poh PF, Buang SN, Lee JH. Sedation guidelines, protocols, and algorithms in PICUs: a systematic review. Pediatr Crit Care Med. 2014 Nov;15(9):885-92.
Lincoln PA, Whelan K, Hartwell LP, Gauvreau K, Dodsen BL, LaRovere JM, Thiagarajan RR, Hickey PA, Curley MAQ. Nurse-Implemented Goal-Directed Strategy to Improve Pain and Sedation Management in a Pediatric Cardiac ICU. Pediatr Crit Care Med. 2020 Dec;21(12):1064-1070. Erratum in: Pediatr Crit Care Med. 2021 Feb 1;22(2):e164.
Hanser A, Neunhoeffer F, Hayer T, Hofbeck M, Schlensak C, Mustafi M, Kumpf M, Michel J. A nurse-driven analgesia and sedation protocol reduces length of PICU stay and cumulative dose of benzodiazepines after corrective surgery for tetralogy of Fallot. J Spec Pediatr Nurs. 2020 Jul;25(3):e12291.
Curley MAQ, Gedeit RG, Dodson BL, Amling JK, Soetenga DJ, Corriveau CO, Asario LA, Wypij D; RESTORE Investigative Team. Methods in the design and implementation of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial. Trials. 2018 Dec 17;19(1):687. Erratum in: Trials. 2019 Jan 7;20(1):17. Asaro, Lisa A [corrected to Asario, Lisa A].

Supporting Documents:

cicu_comfort_algorithm.pdf

cicu_comfort_algorithm_2025updated_3.20.25.docx

order_set_cicu_comfort_algorithm_2.13.25.docx

Targeting Plasma Metagenomic Sequencing to Improve Patient Care and Reduce Waste

Submitted by Natasha Spottiswoode on February 27, 2025 - 3:27pm Last revised by Rasmyah Hammoudeh on March 11, 2025 - 2:06pm.

Proposal Status:

Selected for 2nd Round

PROPOSAL TITLE: Targeting Plasma Metagenomic Sequencing to Improve Patient Care and Reduce Waste

PROJECT LEAD(S): Natasha Spottiswoode, Monica Fung, Rama Yakubu

EXECUTIVE SPONSOR(S): Charles Chiu (UCSF Microbiology Director)

ABSTRACT. 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 have not considered in their differential diagnosis or that are difficult to identify². The diagnostic power of pmNGS can circumvent invasive, expensive diagnostic procedures³ and potentially shorten patient stays. However, the per-syndrome utility of pmNGS is not well established, and its cost is high compared to other infectious disease diagnostics. Absent institutional or national guidelines for use, UCSF has seen skyrocketing volumes of pmNGS, with an increase from 18 tests in 2018 to 616 in 2024, with an estimated annual cost >$1 million. Here we propose a multipronged approach to define clinical indications for which pmNGS has highest impact, reduce unnecessary testing costs, analyze hospital days saved, avoid costs related to preventable procedures, and promote equity and excellence. We have created an Infectious Disease/Clinical Microbiology Consensus guidance statement to structure use of pmNGS testing (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.

TEAM

Project Lead: Natasha Spottiswoode MD DPhil (Assistant Professor of Infectious Disease) Project Lead: Monica Fung MD MPH (Associate Professor of Infectious Disease, Clinical Director of Transplant/Immunocompromised ID, Director of ID Inpatient Services)

Project Lead: Rama Yakubu MD PhD (Co-Director, UCSF Microbiology)

Antimicrobial Stewardship: William Simmons MD (Assistant Professor of Infectious Disease, Director of Antimicrobial Stewardship)

Scientific Guidance: Charles Langelier MD PhD (Associate Professor of Infectious Diseases)

Infectious Disease Fellow: Emily Lydon MD Infectious Disease Fellow: Julieta Rodriguez MD Infectious Disease Fellow: Nathan Radakovich MD Clinical Research Coordinator: Hannah Teal

Executive Sponsor: Charles Chiu MD PhD (Professor of Laboratory Medicine, Co-Director, UCSF Microbiology)

PROBLEM: The use of pmNGS has dramatically increased at UCSF over the last few years. Yet, studies of its effectiveness in diagnosis are limited. Single-center retrospective analyses of pmNGS have been small (all <200 patients) and have had extremely disparate estimations of clinical utility, ranging from 7%⁴, to 30.4%⁵, to 46%⁶. This variability is explained at least in part by the fact that pmNGS is ordered on different patient populations and for different clinical syndromes. The few clinical indications which have been studied for pmNGS utility are lower respiratory infection (LRTI) in immunocompromised patients⁷, febrile neutropenia (FN)^8,9 and sepsis¹⁰. Prospective, real-time assessment of pmNGS impact by clinical syndrome is needed to

understand clinical utility and promote appropriate use. UCSF is poised to lead the nation in this area. Much of the foundational mNGS basic research was performed by UCSF-affiliated scientists, leading to deep scientific and clinical expertise in our institution^11-13. Moreover, UCSF is a marked outlier in use of pmNGS compared to peer institutions, which order this test far less frequently (West Coast Transplant Infectious Disease Society; 10/2/24). Lacking more robust data, it is unclear if practice patterns

at UCSF represent an over-use of laboratory resources and significant extra cost outlay; or, conversely, we are under-using this test and creating an equity gap between patients who receive this test, and those who do not.

This is a logical moment to pursue by-syndrome clinical effectiveness analyses. Firstly, the UCSF health center usage, already higher than comparator institutions, is increasing markedly. 164 pmNGS

tests were sent in 2022, 255 in 2023, and 614 in 2024 (Figure 1), leading to a total cost in 2024 estimated >$1 million at approximately $2,200/test (Figure 1; Appendix 3). 34 tests have been

Figure 1. pmNGS volume and cost at UCSF are increasing sharply. Left panel: Volume of pmNGS tests sent at UCSF since the test introduction (black line), % of tests with at least one microbe detected (blue line) and % of tests with high-pathogenicity organisms detected (green). Right panel: estimated cost of pmNGS testing per year. 2025 is projected by # tests sent from 1/1/25-1/17/25 and 2024 per-test cost.

sent in just the first two weeks of 2025, a rate triple that of the equivalent period in 2024. This increase in use suggests increasing clinician awareness of this diagnostic technique, but likely also some percent of overuse. Finally, there is active consideration of implementing pmNGS for diagnosis in common critical illness syndromes, such as sepsis¹⁰. Assessing utility of current clinical use for pmNGS is essential before extending the scope of its use.

TARGET: The overarching goal of this proposal is (1) define the proportion of pmNGS tests that change length of stay and/or procedure need when sent for assessment of each of the syndromes in Appendix 1, and (2) leverage that information to standardize diagnostic use; promote early deployment of test in high-impact scenarios; and reduce use in the clinical scenarios expected to have lowest impact. We specifically aim to attenuate the rising rate of testing per year, by avoiding 10-15% of inappropriate tests from 2024 testing levels (5-6 tests per month). Secondly, we aim to ensure that all patients with a given syndrome receive the same guideline-directed care, rather than the current testing landscape in which test use is highly dependent on specific provider practices rather than policy. These efforts are measurable by means of clinician surveys coupled with retrospective review (Appendices 2-3). Given high test volume and faculty enthusiasm and engagement, especially from highest-utilizing groups, we expect our goals to be eminently achievable. This work is exceptionally relevant from a patient care and cost control perspective, given the dramatic yearly increase in pmNGS testing and associated direct costs, as well as the potential anticipated benefit to patient care and cost decrease if this test is deployed to its fullest promise (Appendix 4). This is a timebound project, with tracking of outcomes for 1 year, after which the pmNGS use guidelines and APeX order will be iterated to promote care, equity, and cost control. Finally, this project is equitable and inclusive in its goals, as it seeks to standardize care and ensure all patients are getting timely diagnostic care, while avoiding resource over-use.

GAPS:

Gap 1: Disconnect between stakeholders. The growing capacity for novel diagnostics such as pmNGS is outstripping the robust evaluation of how they should be deployed. Traditional research funds do not support quality improvement/stewardship projects, and personnel with clinical and scientific expertise are siloed from teams focusing on quality improvement and cost control.

Gap 2: Overuse. At UCSF, test volume has increased 20x from 2021 to 2024, with associated increased costs. The utility of this test is not established in different scenarios, with other centers estimating ~50-90% of tests do not change management^4-6. Overuse is a gap.

Gap 3. No tracking of current use. At the moment, there is not robust assessment of what pmNGS is used for at UCSF. Therefore, we do not know which services and indications are driving the uptick in test volume and associated costs.

Gap 4: No coordinated guidance. Absent coordinated guidance on when to use this test, test use at UCSF is dependent on the diagnostic familiarity or particular prior experiences of an individual provider, leading to inequities and inconsistencies in which patients receive this test and at what points in their diagnostic journey.

INTERVENTIONS

Alter the order format for pmNGS to integrate the indication options in the APeX order with the Infectious Disease/Clinical Microbiology Consensus Molecular Testing Guidance (Appendix 1) such that clinicians must indicate the guideline-concordant reason they are ordering this test.
Leverage the daily Micro Reports of pmNGS and survey clinicians about patient outcomes (antimicrobial changes, days of stay changes, and procedures avoided or pursued) by clinical syndrome.
- Publish internal quarterly reports summarizing results by syndrome and ordering service, and disseminate to key stakeholders.
  - Promote effective test use by:
    - Iterating test order format in APeX to restrict to higher-yield clinical scenarios.
- Establish and maintain a weekly clinical microbial sequencing board¹² to review pmNGS cases in real time between microbiologists and clinicians, and promote effective use by regular discussions with high-use clinical services.

PRACTICE SETTING AND TARGET POPULATION: This project will focus specifically on the inpatient use of pmNGS testing with a focus on the infectious disease and immunocompromised transplant services that guide either the use or interpretation of the majority of pmNGS tests at this time. However, we anticipate that lessons learned will be applicable to all clinicians using pmNGS within UCSF, and will also directly impact practices of other peer institutions.

BARRIERS: Key to this project is the iterative assessment of test utility by the ordering or recommending clinicians. This requires short-term follow up of results, which in the first year of this project will be labor-intensive. Thus, we have requested dedicated time for a clinical research coordinator (Hannah Teal) and for a supervising clinician (Dr. Spottiswoode).

ADVERSE EVENTS: pmNGS results have the potential to drastically improve patient care, but false negatives or false positives have the potential to cause harm by causing under- or over- treatment. The iterative nature of this project, in which indications for future years will be based on this funded year, will help to minimize these potential unwanted consequences. Moreover, the identification of low-yield clinical scenarios for which pmNGS should be avoided will not only help to reduce overall costs, but also reduce adverse events.

RETURN ON INVESTMENT (ROI) – We estimated the ROI of this proposed project as between $172,074-245,385. Appendix 4 contains all baseline costs and per-month estimations.

· Estimated costs saved by avoiding testing in low-yield scenarios (est: $132,000-

$158,400) Other centers have estimated 54-94% pmNGS tests did not change management.

Conservatively, we extrapolated that 10-15% of UCSF tests in lowest-yield clinical scenarios could be avoided. Projected ROI for the next year is therefore based on costs from 10-15% of tests sent in 2024 (Figure 2, L panel, burgundy lines).

· Costs saved by avoiding invasive procedures (est: $40,074-$160,296). Early studies have suggested that in hematological malignancy patients who underwent bronchoscopies for diagnosis of LRTI, 25% might have avoided bronchoscopy if pmNGS results were available³. At UCSF, experience supports bronchoscopies avoided if non- culturable organisms are detected (Pneumocystis jirovecii;

Figure 2. Panel A shows the estimated costs saved by reducing unnecessary testing (burgundy lines; solid is estimated saved costs while dotted lines are upper and lower bounds) and the costs saved by avoiding unneeded bronchoscopies (purple lines; dotted lines are upper and lower bounds). Panel B shows the estimated total cost saved over the next year, with upper and lower bounds shown in dotted lines.

Toxoplasmagondii,etc.) or if pre- test probability of an infectious LRTI was low. We will prospectively ask clinicians to fill out a survey stating if any procedures were obviated as a

result of pmNGS testing. We estimated ROI by conservatively estimating 0.5-2 additional bronchoscopies and associated diagnostic testing might be avoided per month, and omitted other procedures (biopsies, etc.) (Figure 2, L panel, red lines).

Total costs saved. We only included cost savings from reducing unnecessary test use and specifically preventing bronchoscopies, though we will also assess effects of these tests on length of stay by clinician estimation (Appendix 3). Estimated savings are shown in Figure 2.
Other considerations. pmNGS results may revolutionize a patient’s care, change therapeutic management, and/or lead to epidemiologic investigations. These hard-to-predict benefits are not included in our ROI estimations, but should be considered as part of the global consequences of standardizing test uptake. Two recent examples:
- Example 1: Heart transplant patient with cavitary pneumonia receives pmNGS that reveals Rhizopus, leading to lobectomy performed same day.
- Example 2: Bone marrow transplant patient with fevers and lymphadenopathy receives pmNGS that shows Mycobacterium tuberculosis, leading to isolation and public health investigation.
SUSTAINABILITY – After this year, we will be able to iterate the Infectious Disease/Clinical Microbiology Consensus Molecular Testing Guidance to promote highest-yield testing and avoid of pmNGS test ordering in low -impact clinical scenarios. We will integrate new testing guidelines into the APeX ordering system workflow. In parallel, we will actively communicate our findings to Infectious Disease groups and other major users of this diagnostic test.

BUDGET

NAME	ROLE ON PROJECT	Cal. Mnths	INST.BASE SALARY	SALARY REQUESTED	FRINGE BENEFITS	TOTAL
Natasha Spottiswoode	Project Lead	1.2	232,063	23,063 (10%)	NA	23,206
Hannah Teal	Clinical Research Coordinator	4	77,552	26,794 (34.5%)	NA	26,794
Monica Fung	Project Lead	As-needed
Rama Yakubu	Project Lead	As-needed
Total Estimated Budget						50,000

Sources Cited

Chiu CY, Miller SA. Clinical metagenomics. Nat Rev Genet 2019;20(6):341-355. DOI: 10.1038/s41576-019-0113-7.
Wilson MR, Shanbhag NM, Reid MJ, et al. Diagnosing Balamuthia mandrillaris Encephalitis With Metagenomic Deep Sequencing. Ann Neurol 2015;78(5):722-30. DOI: 10.1002/ana.24499.
Madut DB, Chemaly RF, Dadwal SS, et al. Clinical Utility of Plasma Microbial Cell-Free DNA Sequencing Among Immunocompromised Patients With Pneumonia. Open Forum Infect Dis 2024;11(8):ofae425. DOI: 10.1093/ofid/ofae425.
Hogan CA, Yang S, Garner OB, et al. Clinical Impact of Metagenomic Next-Generation Sequencing of Plasma Cell-Free DNA for the Diagnosis of Infectious Diseases: A Multicenter Retrospective Cohort Study. Clin Infect Dis 2021;72(2):239-245. DOI: 10.1093/cid/ciaa035.
Vinh Dong H, Saleh T, Kaur I, Yang S. Elucidating the Clinical Interpretation and Impact of a Positive Plasma Cell-Free DNA Metagenomics Test Result-A Single Center Retrospective Study. J Appl Lab Med 2024;9(1):14-27. DOI: 10.1093/jalm/jfad083.
Shishido AA, Noe M, Saharia K, Luethy P. Clinical impact of a metagenomic microbial plasma cell-free DNA next-generation sequencing assay on treatment decisions: a single-center retrospective study. BMC Infect Dis 2022;22(1):372. DOI: 10.1186/s12879- 022-07357-8.
Bergin SP, Chemaly RF, Dadwal SS, et al. Plasma Microbial Cell-Free DNA Sequencing in Immunocompromised Patients with Pneumonia: A Prospective Observational Study. Clin Infect Dis 2023. DOI: 10.1093/cid/ciad599.
Benamu E, Gajurel K, Anderson JN, et al. Plasma Microbial Cell-free DNA Next- generation Sequencing in the Diagnosis and Management of Febrile Neutropenia. Clin Infect Dis 2022;74(9):1659-1668. DOI: 10.1093/cid/ciab324.
Schulz E, Grumaz S, Hatzl S, et al. Pathogen Detection by Metagenomic Next- Generation Sequencing During Neutropenic Fever in Patients With Hematological Malignancies. Open Forum Infect Dis 2022;9(8):ofac393. DOI: 10.1093/ofid/ofac393.
Kalantar KL, Neyton L, Abdelghany M, et al. Integrated host-microbe plasma metagenomics for sepsis diagnosis in a prospective cohort of critically ill adults. Nat Microbiol 2022. DOI: 10.1038/s41564-022-01237-2.
Langelier C, Kalantar KL, Moazed F, et al. Integrating host response and unbiased microbe detection for lower respiratory tract infection diagnosis in critically ill adults. Proc Natl Acad Sci U S A 2018;115(52):E12353-E12362. DOI: 10.1073/pnas.1809700115.
Wilson MR, Sample HA, Zorn KC, et al. Clinical Metagenomic Sequencing for Diagnosis of Meningitis and Encephalitis. N Engl J Med 2019;380(24):2327-2340. DOI: 10.1056/NEJMoa1803396.
Gu W, Deng X, Lee M, et al. Rapid pathogen detection by metagenomic next-generation sequencing of infected body fluids. Nat Med 2021;27(1):115-124. DOI: 10.1038/s41591- 020-1105-z.

Supporting Documents:

Joint Microbiology/Infectious Disease Molecular Diagnostic Guidelines

Major Use Cases of pmNGS

Clinical Impact Questionnaire

Estimated Costs

Caring Wisely Proposal

An Evidence-Based Same-Day Discharge Pathway for Urologic Oncology Patients Undergoing Radical Prostatectomy

Submitted by Amy Showen on February 28, 2025 - 11:40am Last revised by Amy Showen on March 27, 2025 - 6:36pm.

Proposal Status:

Selected for 2nd Round

PROPOSAL TITLE: An Evidence-Based Same-Day Discharge Pathway for Urologic Oncology Patients Undergoing Radical Prostatectomy  

PROJECT LEAD(S): Amy Showen, MD, MSc; Max Bowman, MD

EXECUTIVE SPONSOR(S): Max Meng, MD; Benjamin Breyer, MD, MAS, FACS  

ABSTRACT 

Prostate cancer is the most common urologic malignancy in the United States. Robot-assisted laparoscopic prostatectomy (RALP) is the gold standard surgical treatment for localized prostate cancer, and is frequently performed by urologic oncologists at UCSF, typically with a one-night hospital stay. As it stands, our prostate cancer program is highly rated and has a longstanding history of clinical leadership and innovation. Over the past 15 years, there has been increased interest from the urologic community at large in performing radical prostatectomy in the outpatient setting with same-day discharge (SDD). There is now ample evidence that RALP with SDD can reduce health care costs (by 19%) and increase surgical efficiency, while maintaining both patient safety and satisfaction. Indeed, SDD is no longer a novelty, with high-volume surgeons and institutions performing up to 59% of their RALP cases with SDD.  This mounting evidence, in combination with UCSF’s expanding ambulatory surgical capacity at the Bayfront and Burlingame outpatient surgery centers, presents a unique opportunity to maximize healthcare value by developing a RALP SDD pathway within our department. We propose development of an evidence-based RALP SDD pathway within the UCSF Department of Urology, with a goal of increasing the proportion of RALP procedures performed with SDD to 30%.  

TEAM: Amy Showen, MD, MSc (Urology Resident; project co-lead); Max Bowman, MD (Urology Faculty; project co-lead); Max Meng, MD (Chief of Urologic Oncology; executive sponsor); Benjamin Breyer, MD, MAS, FACS (Chair of Urology; executive sponsor); Peter Carroll, MD, MPH (Urology Faculty; project mentor); Matthew Cooperberg, MD, MPH (Urology Faculty; project mentor); Hao Nguyen, MD, PhD (Urology Faculty; project mentor); Sam Washington, MD, MAS (Urology Faculty; project mentor); Carissa Chu, MD (Urology Faculty; project mentor); Anobel Odisho, MD (Urology Faculty; project mentor) ; Sharon Gleeson, RN (Director of Perioperative Services at Mission Bay; project partner); Lina Bandera, RN (Director of Perioperative Services at Bayfront; project partner)

PROBLEM  

Prostate cancer is the most common cancer diagnosed in men in the United States.[1] Robot-assisted laparoscopic prostatectomy (RALP) is the gold standard surgical treatment for localized prostate cancer, and is frequently performed by urologic oncologists at UCSF, with over 300 cases performed annually.[2]

Typically, patients undergoing RALP are admitted postoperatively for one night for monitoring and postoperative education. Over the past 15 years, there has been increased interest from the urologic community in performing RALP with same-day discharge (SDD).[3] The COVID-19 pandemic accelerated uptake of RALP SDD, as surgeons and hospitals attempted to conserve critically needed hospital beds and minimize hospital-acquired infections. Indeed, SDD is no longer a novelty, with high-volume surgeons and institutions performing up to 59% of their RALP cases with SDD.[4]

The argument for RALP with SDD from a healthcare value perspective is simple: RALP with SDD can reduce health care costs and increase surgical efficiency. Two studies to date have estimated the cost savings associated with SDD in the United States. Cheng et al. demonstrated a $2,106 (19%) overall cost reduction per patient who underwent SDD versus inpatient RALP at two academic medical centers.[5] Abaza et al. estimated the cost of an overnight admission at $2,109 per patient in a community setting.[6] Of note, neither of these studies were performed at outpatient surgery centers, and do not account for additional potential cost-savings associated with performing RALP with SDD at an outpatient center. Similarly, neither study accounted for additional indirect cost savings derived from freeing the use of inpatient beds and personnel for other patients, which has previously been estimated to be $1,652 per patient at our institution.

There is ample evidence that RALP with SDD can be performed safely. A meta-analysis by Uy et al. of 14 studies found no differences in ≥grade 3 Clavien-Dindo complications (RR: 0.4, 95% CI 0.2, 1.1, p 0.07), 90-day readmission rates (RR: 0.6, 95% CI 0.3, 1.1, p 0.10) or ED visits (RR: 1.0, 95% CI 0.3, 3.1, p 0.97) amongst patients undergoing SDD versus inpatient RALP.[7] Similarly, a recent systematic review by Najdawi et al. of 16 studies published between 2020-2024 assessing outcomes after SDD versus inpatient multi-port RALP demonstrated that complication rates, ED visits, and readmission rates were not negatively impacted by same-day discharge.[8] (To the contrary, two studies reported favorable outcomes in the SDD cohorts.)[6,9]

Patient satisfaction with RALP SDD has been shown to be high, with satisfaction rates between 87.5% and 100%.[3,5,8] Early mobilization and return to “normal” life/work are priorities amongst patients undergoing RALP, and SDD may facilitate meeting these goals.[10] Patient quality and safety will be a priority and these outcomes will be tracked during this project to ensure safe implementation.

Historically, the UCSF Department of Urology has taken a thoughtful and conservative approach towards adopting RALP SDD. The department recently performed RALP SDD for a small minority of patients in 2024. Contemporary evidence on the favorable cost-savings, safety, patient satisfaction, and feasibility of RALP SDD, combined with new SDD capacity at the Bayfront Outpatient Surgery Center, offers a unique opportunity to maximize healthcare value in our department. We propose development of an evidence-based RALP SDD pathway, with a goal of increasing the proportion of RALP procedures performed with SDD to 30%.

TARGET   

Key target: to increase the proportion of RALP procedures performed with SDD to 30% within 1 FY. This is an attainable goal based on published experiences at other institutions: at Brigham and Women’s, the proportion of SDD cases increased from 4.4% to 45% over the course of 1.75 years; amongst a single surgeon at OhioHealth Dublin Methodist Hospital, the proportion of SDD cases increased to 49.2% 21 months after introduction of a SDD pathway; amongst a French surgeon’s patient cohort the proportion of SDD was 59% one year after introduction of a SDD pathway.[11,6,4] We further aim to ensure that patient safety, equity, and satisfaction are not compromised as a result of our intervention.

To track and promote progress towards our goals, we plan to measure the following performance indicators over time for each target:

Target 1: Increase the proportion of RALP procedures performed with SDD to 30% within 1 FY.  

Percentage of all patients undergoing RALP who are eligible for SDD per our selection criteria

Percentage of patients who are eligible for SDD per our selection criteria who are offered SDD by their surgeon

Percentage of all patients undergoing RALP who elect to undergo SDD

Percentage of all patients undergoing RALP who successfully undergo SDD

For patients who are offered and elect to undergo SDD, we will track their progress through each phase of the SDD pathway, thereby identifying any roadblocks to success.

We will explore patient motivations for electing SDD versus inpatient RALP

Target 2: Maintain patient safety.  

Rates of Clavien-Dindo complications amongst patients undergoing SDD versus inpatient RALP

Rates of 30-day readmissions amongst patients undergoing SDD versus inpatient RALP

Rates of emergency department visits amongst patients undergoing SDD versus inpatient RALP

Amongst patients who “fail” the SDD pathway (elect to undergo SDD but ultimately are admitted), we will examine the reasons for failure to ensure that there are no major safety events and use this as a feedback mechanism to refine the pathway.

Target 3: Maintain patient equity.  

Rates of SDD versus inpatient RALP, by race/ethnicity, language, and insurance

Target 4: Maintain patient satisfaction.  

We will explore patient satisfaction with SDD with a patient experience questionnaire.

GAPS  

Cultural gaps: Historically, a barrier to implementation of a RALP SDD pathway was surgeon concerns regarding patient selection and safety of SDD. As described above, since RALP SDD was introduced 15 years ago, studies have repeatedly demonstrated that SDD is safe, and does not negatively impact rates of complications, readmissions, or ED visits. We have partnered with surgeons performing RALP in our department to design a safe and feasible SDD pathway, based on existing successful protocols from peer institutions/surgeons. We will partner with surgeons performing RALP in our department over the course of the project to further refine and finalize our pathway.

Educational gaps: Another historical barrier to RALP SDD involves developing the resources needed to ensure timely and safe discharge. We will modify our existing high-quality preoperative educational materials for patients (written and audiovisual) to include information about the RALP SDD pathway and postoperative care topics (i.e., foley catheter management) typically covered during the inpatient stay.

Systems gaps: The Mission Bay PACU has the capacity to recover patients who undergo RALP SDD, but there are challenges, including pressure to clear beds and staffing shortages as evening hours approach. These challenges can be addressed, for example, by scheduling patients undergoing RALP SDD as the first case of the day and including patients who live nearby. The new Bayfront Outpatient Surgery Center offers additional SDD capacity for appropriate patients. We may also be able to temporarily admit patients for observation prior to SDD.

Technological gaps: Development of a RALP SDD pathway has the potential to significantly change our practice at UCSF. Technological support with EHR innovations through the Caring Wisely program will allow us to track numerous performance and safety metrics (described in “Target” section), empowering us to make iterative improvements to our pathway and outcomes over the project year and into the future.

INTERVENTION 

We aim to design and implement an evidence-based RALP SDD pathway based on existing successful protocols from peer institutions, and expert input from our own urologic oncologists.

Stakeholder engagement: We will meet with key stakeholders (including faculty in the Departments of Urology and Anesthesia, and PACU directors at Mission Bay and Bayfront) to solicit input, ensure that all parties are aligned on the proposed SDD RALP pathway, and anticipate/troubleshoot roadblocks to successful implementation. We are excited to have secured the enthusiastic support of Sharon Gleeson and Lina Bandera, Directors of Perioperative Services at Mission Bay and Bayfront, respectively. The support of the Caring Wisely Core Leadership Team and Executive Committee will further empower us to address any barriers that arise and successfully reach our targets.

Practice setting: The RALP SDD pathway will be implemented at Mission Bay and Bayfront (for appropriate patients). Both sites offer 23-hour observation in the event that a planned SDD cannot occur.

Target population: All patients undergoing RALP who meet the selection criteria will be eligible for the SDD pathway. We would like to highlight that the surgeon remains the ultimate decision-maker with regard to whether to offer SDD to patients who otherwise meet selection criteria. Eligible patients will then receive education regarding the SDD pathway, and can elect to aim for SDD or next day discharge.

RALP SDD pathway elements: Review of the literature underscores the importance of SDD programs that incorporate patient selection, preoperative preparation for SDD, intraoperative measures to prevent postoperative pain and nausea/vomiting, and enhanced recovery protocols.[7,8] We have incorporated these elements into our RALP SDD pathway (Appendix 1). This pathway will be fine-tuned over the coming months with feedback from our key stakeholders prior to implementation.

PROPOSED EHR MODIFICATIONS   

We will build a RALP SDD dashboard that tracks patient candidacy for and progress through the pathway. This will allow surgeons to easily evaluate patient candidacy for SDD, and if enrolled in the pathway, their readiness for SDD from a clinical perspective. We will also track applicable outcome metrics (per “Target” section) to allow for iterative improvement through PDSA cycles and ensure patient safety is maintained.

We will build smart order sets for the RALP SDD pathway.

We will build a smart data element that populates preoperative SDD counseling materials into the AVS.  
To work towards our goal implementation date of July 1, we are currently reviewing our Apex builds with our project mentor Dr. Anobel Odisho, who is a member of the urology faculty and AC3 team. We look forward to an upcoming scheduled meeting with the Apex Enabled Research team to further discuss feasibility and timeline for our builds.

RETURN ON INVESTMENT (ROI) 

(Mean cost of RALP staying 1 night) – (Mean cost of RALP SDD) = Mean cost savings per RALP SDD

$22,341 – $19,137 = $3,204

(Total annual RALP volume) * (RALP SDD target) * (Average cost savings per RALP SDD) = Annual cost savings

310 * 0.3 * $3,204 = $297,972

*Of note, the above estimates do not include the indirect contribution margin (additional money made by freeing up an inpatient bed for other patients), which has previously been estimated to be $1,652 per instance at UCSF, leading to an annual cost savings estimate of $451,608.

SUSTAINABILITY 

Sustainability: Once developed, implemented, and refined during the funding year, sustaining the RALP SDD pathway will require minimal effort/resources. Project co-lead and Department of Urology faculty Max Bowman will provide longitudinal oversight of the pathway.The urologic oncology faculty at UCSF is a relatively small group, and as they will be involved in development of the pathway, we expect that maintaining adherence to the pathway in future years will be straightforward. The patient education resources developed will continue to be utilized and can be easily refined as needed in the future. The APeX infrastructure including order sets, counseling materials, and dashboard to monitor performance will continue to be available to providers.

Scalability: There are numerous other urologic procedures (for example, robot-assisted partial nephrectomy, laparoscopic nephrectomy) that are currently performed with an overnight stay, but are potentially well-suited for SDD in the appropriate patient. Thus, the intervention developed and lessons learned from this project can be applied in the future to other surgeries, leading to future cost savings.

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

REFERENCES 

1.Salami S, Borza T, Isharwal S, Packiam VT, Sharma V. Prostate Cancer Screening, Diagnosis and Risk Stratification. 

2.Eastham JA, Boorjian SA, Kirkby E. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline. Journal of Urology. 2022;208(3):505-507. doi:10.1097/JU.0000000000002854 

3.Martin AD, Nunez RN, Andrews JR, Martin GL, Andrews PE, Castle EP. Outpatient prostatectomy: too much too soon or just what the patient ordered. Urology. 2010;75(2):421-424. doi:10.1016/j.urology.2009.08.085 

4.Ploussard G, Almeras C, Beauval JB, et al. Same-day discharge surgery for robot-assisted radical prostatectomy in the era of ERAS and prehabilitation pathways: a contemporary, comparative, feasibility  study. World J Urol. 2022;40(6):1359-1365. doi:10.1007/s00345-020-03119-w 

5.Cheng E, Gereta S, Zhang TR, et al. Same-Day Discharge vs Inpatient Robotic-Assisted Radical Prostatectomy: Complications, Time-Driven Activity-Based Costing, and Patient Satisfaction. J Urol. 2023;210(6):856-864. doi:10.1097/JU.0000000000003678 

6.Abaza R, Martinez O, Ferroni MC, Bsatee A, Gerhard RS. Same Day Discharge after Robotic Radical Prostatectomy. Journal of Urology. 2019;202(5):959-963. doi:10.1097/JU.0000000000000353 

7.Uy M, Millan B, Jones C, et al. Successful Same-Day Discharge for Robot-Assisted Radical Prostatectomy: A Systematic Review and Meta-Analysis. UrolPract. 2022;9(4):294-305. doi:10.1097/UPJ.0000000000000305 

8.Najdawi F, Alcantar J, Lee DI, Shahait M, Dobbs RW. Same Day Discharge After Robotic Radical Prostatectomy. Curr Urol Rep. 2025;26(1):27. doi:10.1007/s11934-025-01254-8 

9.Siron N, Assad A, Ouirzanne M, et al. Performing urological inpatient procedures as same-day procedures during the COVID pandemic: A retrospective feasibility study. CUAJ. 2023;17(10). doi:10.5489/cuaj.8324 

10.Reynolds BR, Bulsara C, Zeps N, et al. Exploring pathways towards improving patient experience of robot‐assisted radical prostatectomy (RARP): assessing patient satisfaction and attitudes. BJU International. 2018;121(S3):33-39. doi:10.1111/bju.14226 

11.Labban M, Frego N, Qian ZJ, et al. Institutional trends and safety profile of same-day discharge for robot-assisted laparoscopic radical prostatectomy: A retrospective analysis. Urol Oncol. 2023;41(8):354.e19-354.e26. doi:10.1016/j.urolonc.2023.05.013 

12.Millan B, Cassim R, Uy M, Bay B, Shayegan B. First Canadian experience with same-day discharge after robot-assisted radical prostatectomy. CUAJ. 2022;17(2). doi:10.5489/cuaj.7914 

13.Liem SS, Jivanji D, Brown S, et al. Feasibility of same-day discharge of robotic-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection. World J Urol. 2024;42(1):72. doi:10.1007/s00345-023-04764-7 

Supporting Documents:

APPENDIX 1. UCSF RALP SDD PATHWAY

Improving Health and Tech Literacy by Optimizing MyChart Usage through a Student Patient Navigator Program

Submitted by Helen Lau on February 28, 2025 - 11:43am Last revised by Rasmyah Hammoudeh on March 11, 2025 - 2:05pm.

Proposal Status:

Review Complete

PROPOSAL TITLE: Improving Health and Tech Literacy by Optimizing MyChart usage through a Student Patient Navigator Program

PROJECT LEADS:
Helen Lau RN CPNP – Craniofacial Pediatric Nurse Practitioner
Jaclyn Kukoff SLP – Speech Pathologist

EXECUTIVE SPONSORS: Jason Selinger, MBA – Vice President, Ambulatory Services, UCSF Benioff Children’s Hospitals

ABSTRACT MyChart is a healthcare application that can be a critical part of a patient or family’s experience at UCSF, with the potential to make their healthcare more organized, accessible, and engaging. It provides an easy way to view medical records, upcoming appointments, and communicate with providers.We are committed to expanding access and usage of MyChart, by providing personalized and culturally appropriate training to patients and families in the waiting room. We plan to do this by partnering with the Volunteering Office to identify student volunteers who have already been onboarded to UCSF Benioff Children’s Hospitals. We plan to train student volunteers to encourage downloading and use of the MyChart App, showing families how to add their child as a proxy, demonstrating how to locate appointments, messaging providers, and uploading insurance information with a demonstration.

TEAM

Helen Lau RN CPNP- Craniofacial Pediatric Nurse Practitioner

Jaclyn Kukoff SLP- Speech Pathologist

Noah Macey BA - Research Fellow

Carole Reilly RN - Craniofacial Nurse Coordinator

Leticia MonroyMSW - Medical Social Worker

PROBLEM

Background and Equity Gaps

Underutilization of health application: Currently, usage of MyChart for Craniofacial patients is underutilized. Of our patients with craniofacial differences seen in the last 5 years, 67% have signed up for MyChart, and 10% have logged on. For those identifying as English speaking, 71% downloaded MyChart and only 10% logged in. For our Spanish speaking families, 59% downloaded the app and only 9% logged in. For our Arabic speaking families, 61% signed up for the app but only 8% logged in. Information on additional language utilization is available upon request.
Multidisciplinary care: For our patients with craniofacial differences, multiple specialties are often involved in their care including speech, neurosurgery, social work, nursing, plastic, ophthalmology etc. among other specialists. MyChart can be an organizational tool to track appointments, communicate with the care team and can increase access to medical care through efficient care coordination.

What are some financial and operational metrics?

Operational and financial metrics include MyChart enrollment, MyChart usage, no show rates, and visit volumes.

Why address this problem now?

This is a particularly salient problem in our ever-changingtechnological world. We plan to leverage technology to help improve patient autonomy and care. We also serve a diverse population and would like to decrease disparities in health and tech literacy.

TARGET

MEASURABLE PROGRAMMATIC GOALS

Student volunteers will increase MyChart enrollment in the craniofacial department by 5 %after 3 months
Student volunteers will increase MyChart usagein in the craniofacial department by 5 % after 3 months
Student volunteers will increase family/patient self-reported comfort in using MyChart by 10 % measured by pre and post intervention surveys after 3 months

GAPS

SYSTEMIC ISSUES

We suspect these gaps may be present due to lack of tech literacy, language support, and education provided by our team.

Our visits in the Craniofacial Center can last anywhere from 15 min for a post op appointment to 60 min for a new patient with complex needs. Frequently, there is not enough time to review how to download or use MyChart during the visit or the parents are in a rush to leave the hospital/clinic.

Although there is a handout that details how to download MyChart which may be given to the family at the registration desk, parents continue to have difficulty following the instructions on how to get started with MyChart especially with parent identification as a proxy. Within our center, we do try to review how to download the app as much as we can however, the decreased number of families who log in compared to downloading the app show that parents are not effectively utilizing MyChart.

Additionally, it is possible that our team needs to more effectively demonstrate how MyChart can help to organize and increase access to the patient’s treatment plan to garner interest in logging into the app.

INTERVENTION

Practice setting and target population: Outpatient Craniofacial department, Medical subspecialities 5th floor, waiting room. We see patients with congenital and acquired craniofacial differences. This includes facial trauma, cleft palate, and craniosynostosis.

On any given day, 1-2 providers see between 8-16 patients over a period of 3-5 hours. We have anywhere from 1 room to 3 exam rooms during this time.
The ability to be roomed on time may be dependent not only on room availability but also staffing
While in the waiting room, we are proposing that Student Volunteers can offer a brief training to familiarize families on MyChart usage
Staff: Partner with high school and college student volunteers (already onboarded, completed Immunizations, background check, training and HIPAA) and offer a stipend per quarter of work. Preferably bilingual/bicultural volunteers
Timing: ~10 minutes

Process

Short survey: Families will fill out a short survey asking the initial reason they downloaded the app (if applicable) and what the biggest barrier is to logging in.
MyChart Training: Volunteers review how to use MyChart in the waiting room. We anticipate this tutorial to take less than 10 minutes.
Incentive: Families will receive a coupon for food or drink from the cafe after they complete the surveys and training.
Follow up: If the families have further questions, they can see the volunteer after completion of their appt. We will also have additional MyChart handouts available so that if parents have questions after they leave their appointment.
Data: We will measure gaps using pre and post intervention MyChart use data. We may also consider a survey pre and post intervention measuring family’s confidence in using the application.

Potential Barriers

Because it is a shared waiting room with other subspecialties, we may encounter patients who are present to see other medical subspecialties and not just craniofacial.

Possible adverse outcomes

Traffic in clinic space
Germ precautions
Possibility that families use MyChart incorrectly

PROPOSED EHR MODIFICATIONS N/A

RETURN ON INVESTMENT (ROI)

Estimated direct cost savings and/or revenue enhancement to the health system from the proposed project e.g. decreased no show rates, increased engagement between the team and family, increased transparency on treatment plan between the specialty team and PCP, and increased access to imaging results/medical records.

Previous work suggests that increased MyChart usage would improve the efficiency of patient care. According to Winstanley et al, two-thirds of patients report that MyChart usage helps them communicate better with their nurses, and half said the same for their physicians. A full 90% reported that being able to use MyChart helped them with their medications. In a similar vein, a survey by Kachroo et al found that MyChart users made fewer telephone calls after medical procedures.

The findings together suggest that increasing MyChart uptake would increase patient satisfaction and understanding with relatively low investment. As for whether the program would be successful, research by Vanderhout et al found that lack of awareness and difficulty registering together made up 2/3 of the reason for MyChart non-adoption in their sample. Our program would directly address both these issues. Additionally, Ramsey et al conducted a trial program of concierges to help young patients sign up for MyChart, and found that 80% of participants reported satisfaction—a positive finding given similarities with our program.

SUSTAINABILITY

This intervention will remain sustainable past the funding year as this work can be accomplished through the volunteer department to recruit new student navigators. We also believe that once we equip families with the knowledge on how to navigate MyChart, they will continue to use it independently.

Key UCSF leaders/process owners

Helen Lau, RN CPNP

Jackie Kukoff, SLP

BUDGET

Remote Blood Pressure Monitoring Among High-Risk Obstetric Patients to Decrease Unnecessary Inpatient Utilization

Submitted by Christine Blauvelt on February 28, 2025 - 12:49pm Last revised by Christine Blauvelt on March 25, 2025 - 9:29am.

Proposal Status:

Selected for 2nd Round

PROJECT LEADS: Christine Blauvelt MD, Neda Ghaffari MD, Roxanna Irani MD PhD

EXECUTIVE SPONSOR: Nerys Benfield MD MPH

ABSTRACT: Hypertensive disorders of pregnancy (HDP) are increasingly prevalent, posing significant risks to maternal health, including stroke and renal failure. At UCSF, one quarter of deliveries involve HDP, far exceeding the national average. Postpartum hypertension remains a leading cause of readmission, with about half of postpartum readmissions at UCSF due to hypertension-related issues. This proposal aims to implement a structured remote blood pressure (BP) monitoring program for high-risk patients, utilizing Bluetooth-enabled devices, an integrated APeX dashboard, and nurse-driven protocols for timely intervention. The program aims to improve BP self-monitoring, reduce postpartum length of stay, readmissions and emergency visits, and enhance patient confidence in managing their health. Preliminary data from our pilot program has shown promising results, with enrollees demonstrating high engagement, high patient satisfaction, and a 0% readmission rate for hypertension among postpartum participants. Our pilot has proven the feasibility and clinical importance of this work, and our Caring Wisely proposal aims to further build infrastructure and sustainability into our program so it can ultimately be expanded to all high-risk pregnant and postpartum patients at UCSF.

TEAM:

Christine Blauvelt, MD (Clinical Fellow, Maternal-Fetal Medicine)

Roxanna Irani, MD PhD (Associate Professor, Maternal-Fetal Medicine; Ambulatory Executive Director for Women’s Health)

Neda Ghaffari, MD (Associate Professor, Maternal-Fetal Medicine and Clinical Informatics)

Martha Tesfalul, MD (Assistant Professor, Maternal-Fetal Medicine)

Esther Hsiang, MD MBA (Assistant Professor, Department of Medicine; Interim Director of Care Delivery Transformation, Office of Population Health)

Timothy Judson, MD MPH (Associate Professor, Department of Medicine; Interim Chief Population Health Officer)

Michael Helle, MBA, MHA (Vice President for Population Health)

Tasha Toliver (Manager, Office of Population Health)

Henrietta Tran, MSHE (Manager, Office of Population Health)

Kristin Gagliardi (Innovation Implementation Specialist, Office of Population Health)

PROBLEM:

Hypertensive disorders of pregnancy (HDP) are increasing in prevalence and pose significant risks to maternal health. These conditions, which include gestational hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia, can lead to severe complications such as stroke, renal failure, hepatic dysfunction, and cardiovascular disease.¹ In 2019 at UCSF, 24.7% of 2,832 delivering patients were diagnosed with a HDP, which is well above the national average of 5-8%.

The definitive management of HDP is delivery of the pregnant person. However, delivery does not always resolve hypertension, and postpartum hypertension (PP HTN) can persist or even worsen in the early postpartum period. Worsening or de novo PP HTN remains the most common reason for acute postpartum evaluation. In 2019, 1.8% of all patients delivering at UCSF were readmitted for PP HTN (data derived from UCSF deidentified clinical data warehouse). The trajectory of postpartum blood pressure (BP) typically peaks between three to six days after delivery, often after hospital discharge. If elevated BP is not promptly addressed in the outpatient setting, it may reach the severe range (over 160/110 mmHg), increasing the risk of stroke due to pregnancy-related physiologic changes and necessitating urgent inpatient evaluation, treatment, and admission.

This unpredictability underscores the importance of empowering patients with knowledge and tools for BP self-monitoring. Previous studies have shown that when patients with HDP monitor their blood pressure at home, there are reduced rates of hypertension-related hospital readmissions and ED visits.^2-5 One prospective cohort study of 780 patients demonstrated a reduction of postpartum readmissions or ED visit for hypertension from 11% to 2.8% (aOR 0.24, 95% CI 0.12–0.49, P<.001) with the implementation of a remote blood pressure monitoring program with standardized blood pressure management.² Another study of 428 women demonstrated fewer hypertension-related readmissions in postpartum patients enrolled in an intervention with telehealth and remote blood pressure monitoring compared with the controls (0.5% vs 3.7%; RR, 0.12; 95% CI, 0.01–0.96).³

Increased confidence in outpatient BP monitoring can have significant institutional and patient-level benefits. Patients who are comfortable with remote BP monitoring are more likely to engage in self-care, recognize concerning symptoms early, and seek appropriate outpatient interventions rather than relying on emergency department visits. At the institutional level, reducing unnecessary postpartum evaluations and admissions alleviates provider burden, enhances resource allocation, and improves overall patient satisfaction. The ability to safely discharge patients with an effective outpatient monitoring system may also contribute to a reduced postpartum length of stay without compromising patient safety.

Patients with HDP consistently have longer postpartum LOS than those without, likely driven by inpatient blood pressure monitoring and medication titration (Figure 1: Postpartum LOS at UCSF by Hypertension Status). Our labor and delivery unit has historically required 24 hours of observation after any medication dose adjustment. In February 2024, this protocol was revised to 6-12 hours of observation after dose adjustments, yet provider hesitation remains regarding same-day discharge after medication changes. A structured remote BP monitoring program could increase provider confidence in earlier discharge while ensuring patient safety. Over time, broader adoption of remote BP monitoring will help align inpatient protocols with these evolving care models.

Figure 1: Postpartum LOS at UCSF by Hypertension Status

In 2023, the UCSF Division of Maternal-Fetal Medicine partnered with the Office of Population Health to launch a remote BP monitoring pilot program for peripartum patients with or at high risk of developing HDP. The program infrastructure included an APeX-integrated hypertension dashboard that consolidates data from Bluetooth-enabled BP devices (Figure 2: APeX BP Display), clinical decision-support including medication titration and escalation pathways, and a centralized team to engage with and monitor patients. The goal of the program was to demonstrate proof of concept and establish feasibility for a remote monitoring program to improve BP control for peripartum patients.

The pilot has enrolled 55 patients with or at high risk of developing a HDP. The pilot program demonstrated strong engagement with remote monitoring: 94% remotely transmitted at least one BP per week 75% of the time, and 88% had a BP measurement within 10 days of delivery (ACOG best practice recommendation¹). Pilot participants had a shorter postpartum length of stay (LOS) compared to historical UCSF data (Pilot: 2.7 days overall, 2.5 days for those enrolled prior to delivery; Historical: 3.0 days for patients with HDP). Qualitative interviews highlighted high patient satisfaction, with participants valuing the ease of a technology-enabled solution, the support from the nurse monitoring team, and the structure it provided in developing consistent BP monitoring and medication adherence habits. Additionally, postpartum enrollees had a 0% readmission rate for hypertension compared to 5% among non-participants. This preliminary data suggests several potential benefits of remote BP monitoring for high-risk patients, warranting further investigation and expansion of the program.

TARGET:

By June 2026, we will expand the remote BP monitoring program to 100 additional participants who are at high-risk of HDP at UCSF. Our clinical goals are to increase patient engagement in BP self-monitoring, reduce postpartum length of stay, reduce postpartum readmissions and OB ED visits for HTN, and improve patient confidence in at-home BP management. Our program goals are to build sustainability and efficiency into the remote BP monitoring system so it can be expanded to all high-risk patients at UCSF.

Target Quantitative Outcomes:

≥95% of enrolled patients will report weekly BP at least 75% of the time

≥95% of postpartum participants will have a BP measurement within 10 days of delivery.

0.5 day reduction in postpartum length of stay for patients with HDP

50% reduction in postpartum readmissions for HTN-related complications

50% reduction in OB ED visits for HTN-related complications to improve healthcare quality and patient experience.

Target Qualitative Outcomes:

Improved patient confidence in self-monitoring and managing BP, as assessed through post-program surveys and qualitative interviews.

Enhanced provider efficiency through automated risk stratification and streamlined nurse-led interventions, reducing unnecessary emergency visits.

Greater health equity by ensuring access to BP monitoring tools and education for patients from diverse backgrounds, addressing potential barriers related to language, digital literacy, and socioeconomic status.

GAPS:

Several systemic, technological, and education gaps have historically contributed to poor outpatient BP control and delayed interventions, leading to HDP-related morbidity and costs.

System Issues:

Lack of standardized postpartum BP monitoring protocols: Many patients are discharged with minimal guidance on BP self-monitoring and follow-up care.

Limited care coordination: Patients often experience fragmented care due to unclear pathways for outpatient BP management and difficulty accessing timely follow-up appointments.

Health disparities and inequities: Social determinants of health, such as limited access to medical devices, transportation barriers, and digital literacy challenges, disproportionately affect marginalized populations.

Technological Gaps:

Limited integration of home BP monitoring into the EHR: Existing systems do not allow for seamless tracking of BP trends, limiting real-time provider intervention.

Inefficient alert systems: Current workflows do not prioritize automated notifications for high-risk BP elevations, delaying clinical action.

Educational Gaps:

Patient knowledge gaps: Many individuals do not fully understand the risks of hypertensive disorders of pregnancy or how to manage it at home.

Low patient confidence in self-management: Many postpartum individuals report anxiety about at-home BP monitoring, leading to decreased adherence and increased emergency department utilization.

INTERVENTION:

We propose a remote BP monitoring program leveraging Bluetooth-enabled devices, an EHR-integrated dashboard, and standardized nurse-driven protocols (Figure 3: Program Workflow).

Program Workflow

Technology-Enabled Remote BP Monitoring: High-risk patients will receive Bluetooth-enabled blood pressure monitors to facilitate remote tracking and improve hypertension management. An APeX-integrated dashboard displays real-time BP data, allowing clinical teams to efficiently monitor trends and identify patients requiring intervention. Additionally, an automated alert system flags severe BP elevations, enabling timely provider response and reducing delays in care.

Healthcare Navigator and Nurse-Driven Telehealth Support: Eligible patients will be contacted and enrolled by healthcare navigators, who will also assist with BP device set-up. Patients will have regular virtual check-ins with nurses trained in hypertension management to ensure ongoing support and adherence to treatment plans. Standardized protocols will guide BP management, including medication titration and care escalation based on real-time data. Direct communication pathways between nurses and obstetric providers will facilitate rapid intervention, improving patient outcomes and reducing the risk of complications.

Patient Education and Engagement: Patients will receive education on BP self-monitoring, medication adherence, and symptom recognition to enhance their confidence in managing hypertension. MyChart reminders will reinforce adherence to BP monitoring and follow-up visits, ensuring consistent engagement. Early antepartum education will introduce self-monitoring before delivery, helping patients become comfortable with the process and improving postpartum adherence.

Equity: We plan to continue a focus on populations with known health disparities in peripartum health. We will reserve at least 10% of program spots for eligible Black/African-American patients, who experience disproportionately high rates of HDP and related complications. We will continue to recruit from our Black concordant care programs for pregnant patients (Black Wellness Clinic). Multilingual support has been integrated into educational materials and telehealth visits to accommodate diverse patient populations. Digital literacy assistance will be available through one-on-one support for patients unfamiliar with technology, helping them navigate remote monitoring tools. Additionally, a tailored outreach system will proactively engage diverse patient populations, including by race/ethnicity and insurance status. This initiative aligns with UCSF’s commitment to reducing maternal health disparities and improving postpartum outcomes through innovative, patient-centered, and technology-driven care models.

PROPOSED EHR MODIFICATIONS:

Currently, we use an APeX-integrated BP monitoring dashboard that displays BP readings from Bluetooth-enabled devices and generates automated alerts for severe BP elevations. However, enhancements to our APeX integration could allow for more informed decision-making and make the program more efficient and sustainable.

Enhanced BP Monitoring Display: To support scalability and streamline clinical decision-making, we will expand the APeX hypertension dashboard to consolidate key clinical data. Proposed additions include HDP diagnosis, current medications, gestational age or weeks postpartum, and a flowsheet containing BP readings, medication adjustments, and OB ED visits/admissions (Figure 4: Hypertension Dashboard).

Hypertension Dashboard

Standardized Outpatient Order Set Addendums: Develop structured order sets to guide outpatient BP management, including recommended medication titrations based on severity.
Automated Patient Alerts for Severe Hypertension: We propose implementing an automated patient alert system to immediately notify patients when they record a dangerous BP, prompting them to seek urgent medical attention. While our care team will continue to receive alerts and conduct patient outreach, this automated system will provide an additional layer of safety within the remote BP monitoring program.

RETURN ON INVESTMENT (ROI):

Reduce postpartum hospital stay by 0.5 days

Metric	Calculation
Direct cost of 1 day postpartum LOS	$3841.82
Projected reduction in postpartum LOS	100 participants * 0.5 day reduction = 50 days
Projected cost savings	50 days * $3841.81/day = $192,091

Reduce PP HTN readmissions by 50%

Metric	Calculation
Number of PP HTN readmissions/year	7% * 100 participants = 7 readmissions
Total days of reduced PP readmissions	7 readmissions * 50% * 2 days = 7 days
Backfill volume of new incremental admissions	7 days / 4 day LOS = 1.75 admissions
Projected additional revenue from new incremental admissions	1.75 admissions * $7500 = $13,125

Increased provider capacity

Automated BP risk stratification and streamlined nurse-led interventions will reduce the need for obstetric providers to follow-up these patients, allowing them to see a higher volume of other patients.

Our nursing team currently spends approximately 0.17 hours per patient per week on BP review and management. When individual clinicians perform this task, we estimate their efficiency is lower than our nursing team, as they lack the streamlined systems developed by our team. Therefore, we estimate that clinicians would require 0.2 hours per patient per week, equating to 0.4 CPT level 3 follow-up visits per patient per week.

The projected revenue from additional visits ($165/visit) is based on UCSF reimbursement data from 2023, weighted according to the observed payor mix in the pilot.

Metric	Calculation
Additional provider visits per patient per week	0.4 visits
Average duration of program involvement per patient	12 weeks
Reimbursement from additional visit (CPT level 3 f/u)	$165
Projected additional revenue from new incremental visits	$165 * 0.4 visits * 12 weeks * 100 patients = $79,200

TOTAL COST SAVINGS / ADDITIONAL REVENUE: $284,416/year

SUSTAINABILITY:

As part of ensuring sustainability of the program, we have assembled a large team consisting of inpatient and outpatient providers and staff, as well as key leaders in the department. This team monitors outcomes at monthly and quarterly intervals and revisits protocols to improve and maintain the program. We also plan to build APeX modifications that will make the program more efficient and allow us to support future program expansion. Additionally, we are exploring reimbursement modalities for remote patient monitoring and other additional funding avenues to offset some of the costs required to sustain the program (i.e. equipment replacement). Finally, participants will be asked to return their BP device at postpartum visits and/or will be provided materials to mail the BP devices back, which will allow them to be used by other participants.

BUDGET:

Item	Cost
Bluetooth enabled BP cuff ($77) Assumes 50% equipment return rate	$77 * 100 patients * 50% = $3850
Nursing support 1.0 FTE covers 960 patients	0.10 FTE * $282,000 = $28,200
Healthcare navigator support 1.0 FTE covers 1000 patients	0.10 FTE * $126,000 = $12,600
APeX modifications Consultant time	$100/hr * 53.5 hours = $5350
TOTAL	$50,000

REFERENCES:

American College of Obstetricians and Gynecologists. "Gestational hypertension and preeclampsia: ACOG practice bulletin, number 222." Obstet Gynecol 135.6 (2020): e237-e260.

Mei JY, Corry-Saavedra K, Nguyen TA, Murphy AM. A standardized clinical assessment and management plan (SCAMP) reduces readmissions in postpartum hypertension. American Journal of Obstetrics & Gynecology. 2023;228(1):S18-S19.

Hoppe KK, Williams M, Thomas N, et al. Telehealth with remote blood pressure monitoring for postpartum hypertension: a prospective single-cohort feasibility study. Pregnancy hypertension. 2019;15:171-176.

Hauspurg A, Lemon LS, Quinn BA, et al. A postpartum remote hypertension monitoring protocol implemented at the hospital level. Obstetrics and gynecology. 2019;134(4):685.

Suresh SC, Duncan C, Kaur H, et al. Postpartum outcomes with systematic treatment and management of postpartum hypertension. Obstetrics & Gynecology. 2021;138(5):777-787.

Supporting Documents:

Figure 1: Postpartum LOS at UCSF by Hypertension Status

Figure 2: APeX BP Display

Figure 3: Program Workflow

Figure 4: Hypertension Dashboard

Enhancing Neonatal Care Through Lactation Support and Oral Milk Drops

Submitted by Rebecca Carter on February 28, 2025 - 2:27pm Last revised by Rasmyah Hammoudeh on March 11, 2025 - 2:04pm.

Proposal Status:

Review Complete

PROJECT LEADS: Rebecca Carter, MD, Vidya Pai, MD, Clare Pearson, RN, CNL

EXECUTIVE SPONSORS: James Anderson, MD, Director of Neonatology, UCSF Benioff Children’s Hospital Oakland, Leslie Lusk, MD, Medical Director, ECMO Co-Medical Director, UCSF Benioff Children’s Hospital Oakland

ABSTRACT: Mother’s own milk (MOM) is the optimal nutrition source for critically ill infants. Provision of MOM is associated with reductions in many short- and long-term neonatal morbidities. Use of MOM is associated with both direct and indirect cost savings through reduction in subsequent healthcare utilization and improved neurodevelopmental outcomes. Benioff Children’s Hospital (BCH) Oakland neonatal intensive care unit (NICU) discharges fewer infants on MOM than other safety net NICUs in California. Without regular lactation support from a dedicated NICU International Board-Certified Lactation Consultant (IBCLC), our NICU has struggled to increase rates of breastfeeding and MOM use. We propose the introduction of regular lactation support to help mothers establish and maintain milk supply, and the initiation of an oral milk drops procedure to provide MOM to all infants on day-of-life 3 until ready for oral feeding. Through this intervention, we will increase the rates of breastfeeding and MOM use at time of NICU discharge and reduce length of NICU hospitalization by ≥1 day in at least 30% of NICU admissions. Based on a variable direct cost of $3,154/day, and an average of 393 yearly admissions from 2022-2024, we estimate a direct cost savings of $369,018 for FY2026. Because the benefits of MOM feedings far exceed these measurable direct cost benefits, we expect the financial savings to the healthcare system to greatly exceed this estimate. Additional benefits include cost savings from reducing donor human milk and formula use; decrease in short- and long-term neonatal morbidities; reduction in rehospitalization rates and pediatric subspecialty visits; and improved patient and family experience through enhanced bonding. This intervention aligns with the True North Pillars of improving clinical outcomes, improving financial performance, and creating exceptional patient experiences.

TEAM: Rebecca Carter, MD, Project Lead; Vidya Pai, MD, MS Epi, Project Lead; Clare Pearson, RN, CNL, Nursing Project Lead; Manchen Hao, MPH, PMP, Quality Improvement Advisor; Taranae Mahmoodi, Neonatology Service Line Director; Phuong Huynh, RD; Vanessa Kobza, RD; Leslie Lusk, MD, Medical Director, Neonatology, UCSF Benioff Children’s Hospital Oakland

PROBLEM: Mother’s own milk (MOM) is the optimal nutrition source for critically ill and premature infants. When provided during a critical exposure period in the NICU hospitalization, MOM is associated with a reduction in many short-term neonatal morbidities including late onset sepsis, necrotizing enterocolitis, chronic lung disease, and retinopathy of prematurity.^1,2 Dose-dependent effects of human milk feeding have been demonstrated to improve cognitive and language development,⁴ and reduce healthcare utilization through fewer hospitalizations, pediatric subspecialty visits, and specialized therapy supports after NICU discharge.⁵Estimated costs of these prematurity-related complications that may be avoided with MOM use range from $27,890 for late-onset sepsis to $46,103 for necrotizing enterocolitis (in 2016 US dollars).⁶

Lactation consultants are essential resources for hospitalized newborns and their mothers. Dedicated NICU lactation support is associated with increased rates of breastfeeding and MOM use during hospitalization and at time of discharge.^7-9 Lactation support also provides direct cost savings through reduction in donor milk and formula use in addition to the previously described indirect cost savings through improved health outcomes.

The proportion of infants receiving mother’s own milk (MOM) at time of discharge from the BCH Oakland NICU is lower than comparable safety net NICUs in California, particularly in our most vulnerable population of Very Low Birth Weight (VLBW) infants. From 2018-2022, only 42% of our VLBW babies were receiving MOM at NICU discharge, compared to 67% for comparable California safety net NICUs. Black VLBW infants fare particularly poorly, with less than 30% of Black infants receiving MOM at NICU discharge. Despite interventions to promote breast pumping and address barriers to MOM use by our quality improvement team, our rates of breast milk use are poorly sustained for the duration of NICU hospitalization. Based on input from our families and staff, the inability to provide regular and frequent lactation support is one of the most significant barriers to improving rates of breastfeeding and MOM use.

Critically ill infants experience many invasive oral procedures, such as suctioning, taping, feeding tube insertion, intubation, and mask ventilation. These repetitive experiences can negatively impact oral function and the subsequent progression of oral feeding skills.⁹ Delayed oral feeding competence is a primary driver of prolonged NICU hospitalization, and mitigation of negative oral experiences during the period of critical infant brain development is essential to promoting feeding proficiency.^9,10 O’Rourke et al utilized lactation support to provide positive oral experiences through the provision of oral milk drops in infants unable to orally feed. They found that this low-cost intervention led to a 4-day reduction in hospital length of stay and an estimated cost savings of over $600,000, in addition to enhanced parental understanding of oral feeding and improved bonding.¹⁰

TARGET: Our goal is to establish regular lactation support for families in the BCH Oakland NICU. With the support of a dedicated IBCLC, we will provide early, regular, and frequent lactation support for breast pumping. We will partner with a local lactation service that currently supports the UCSF Mission Bay ICN and the BLOOM: Black Love Opportunity and Outcome Improvement in Medicine Clinic, to provide racially concordant lactation support to Black race-identifying families. We will provide education to staff and family on the benefits of human milk feedings and standardize and support the transition to non-nutritive breastfeeding (NNBF) and nutritive breastfeeding (NBF). For infants unable to feed orally, we will establish a procedure for families and staff to provide oral milk drops. We will utilize the electronic health record to automate interventions and track outcomes.

GAPS

Gap	Specific driver	Interventions
Educational	Lack of knowledge on benefits of human milk, pumping, positive oral stimulation on feeding outcomes	-Educational sessions for physicians and nurses -Monthly newsletter to nursing staff -Educational handouts to families
Systems	Mother-infant separation	Transport team brings educational materials to referring hospital
Systems	Lack of IBCLC support	Recruit IBCLC
Technological	Lack of standardized pathway for introducing NNBF and NBF	Clinical guideline dissemination

INTERVENTION

Intervention	Description	Rationale
Education	-“Milk Matters” newsletter -Staff education sessions, nursing skills day -Educational handouts brought to referral hospital by transport team -Education outreach to referral hospital staff	Lack of knowledge of MOM benefits
Colostrum collection kit delivered to referring hospital	Families will receive a cooler bag with syringes and oral swabs for colostrum collection, and educational handouts	Mothers often remain hospitalized for days after infant transfer
Lactation supply cart	Create and maintain lactation supply cart with pumping kits, pumping logs, nipple shields, galactagogues, educational materials	Ensure availability of pumping equipment at bedside
Community partners	Partner with Alameda Women Infants and Children (WIC) to obtain loaner pumps	Ensure pump available for home
Weekly lactation rounds	-Discuss maternal milk supply, barriers to MOM provision weekly at ID rounds -Review eligibility for NNBF, NBF	Multidisciplinary involvement
Clinical pathway	-Clinical procedure for oral milk drops -Standardize eligibility for NNBF, NBF	Reduce practice variability
Order modification	-Automate orders: milk drops, IBCLC consult, NNBF and NBF	Reduce practice variability
Collaboration	Partner with MB ICN, review cross-bay outcome measures and share high-impact interventions.	Share successes and challenges
Audit	Create dashboard to track outcome measures and stratify by birth weight, gestational age, race/ethnicity: - IBCLC consultation rates - % infants receiving oral milk drops - % infants breastfeeding at NICU discharge - % infants receiving MOM at NICU discharge	Provide feedback on impact of improvement efforts

Urgency: The American Academy of Pediatrics proposed standards for levels of neonatal care in 2023, indicating that an IBCLC be available on-site for weekday consultation and be accessible by phone 24/7.¹²With no dedicated NICU IBCLC, the BCH Oakland NICU does not meet this standard of care.

Barriers: Implementing an IBCLC and providing oral milk drops will require creation of new workflows, in addition to education and training of nursing staff. We aim to mitigate these challenges through educational sessions and in-unit training.

Possible adverse outcomes: Breast milk administration error rates will continue to be tracked and reviewed.

Plan to measure and close equity gaps: Rates of lactation consultation, expressed milk volumes, direct breastfeeding, and MOM use at discharge will be measured for all patients and further stratified by race and ethnicity. Any identified inequities will be communicated to clinicians, and efforts to close potential gaps will be incorporated into the interventions.

PROPOSED EHR MODIFICATIONS: APeX order sets will be revised to automate orders for IBCLC consultation, oral milk drops, and eligibility criteria for NNBF. A dashboard will be created to track outcome measures and review data with key stakeholders.

RETURN ON INVESTMENT (ROI): For FY24, the cost components for BCH Oakland NICU bed days (variable direct costs only) were $3,154 per day. The average number of NICU admissions from 2022-2024 was 393 infants. Based on a conservative estimate of length of stay reduction of 1 day in at least 30% of NICU admissions in FY2026, we estimate a direct cost savings of $3,154/day x (393 x 30%) = $369,018 for FY2026.

SUSTAINABILITY: These interventions will be sustained by the BCH Oakland NICU quality improvement team led by Drs. Pai and Carter, Clare Pearson, Phuong Huynh, and Vanessa Kobza. Outcome measures will be reviewed monthly to ensure continuous quality improvement. If the introduction of a dedicated NICU IBCLC proves to be a high-impact intervention, we will advocate to establish a permanent partnership with our local lactation services.

BUDGET: See attachment

Supporting Documents:

budget_and_references.docx

Expanding Access to Sleep Studies via Disposable WatchPATs for UCSF Sleep Clinic

Submitted by Katherine Malcolm on February 28, 2025 - 4:48pm Last revised by Rasmyah Hammoudeh on March 11, 2025 - 2:03pm.

Proposal Status:

Review Complete

Approximately 30% of UCSF Sleep Clinic patients reside outside a 5-10 mile radius, and many face transportation barriers that prevent them from accessing in-lab sleep studies or pick up at-home devices and drop them back off the next day. Additionally, patients with advanced illnesses often lack the necessary support to attend in-person studies or appointments to pick up studies. Currently, UCSF Sleep Clinic does not have a system to mail home sleep apnea testing devices. This project proposes a partnership with Itamar Medical to implement a program that mails disposable WatchPAT devices directly to patients, enabling timely diagnosis and treatment for those in rural areas and with mobility challenges. This initiative will improve access, enhance equity, and streamline operational efficiency.

Katherine Malcolm, Assistant Professor of Medicine, Pulmonary, Critical Care and Sleep Medicine Department
Jolie Chang, Professor of Otolaryngology, Head and Neck Surgery, Chief of the Division of Sleep Surgery and General Otolaryngology

PROBLEM:
Many UCSF Sleep Clinic patients travel long distances for care, with at least 30% residing outside a 5-10 mile radius. Transportation barriers, lack of caregiver support, and advanced illness prevent some from completing in-lab sleep studies, delaying diagnosis and treatment. This gap disproportionately affects rural and underserved patients, leading to increased morbidity and healthcare costs due to undiagnosed and untreated sleep apnea. Current financial and operational constraints prevent UCSF from mailing home sleep studies, limiting care access. Addressing this issue now aligns with UCSF’s commitment to health equity and improves patient outcomes by facilitating timely diagnoses.

TARGET:
Our SMARTIE goal is to:

Implement a mailed WatchPAT program within six months.
Increase access to home sleep studies for patients in rural areas or with mobility challenges by 50% in the first year.
Reduce no-show rates for sleep studies by at least 20%.
Improve equity by ensuring patients with transportation barriers receive comparable care.

Expected benefits include improved patient adherence to sleep studies, reduced delays in diagnosis, lower healthcare costs from untreated sleep apnea, and enhanced operational efficiency.

GAPS:

System Gaps: No infrastructure currently exists for mailing home sleep studies.
Technological Gaps: Limited integration of WatchPAT results with APeX (UCSF’s EHR system).
Educational Gaps: Patients may require additional instructions for at-home testing.

INTERVENTION:
The proposed intervention will establish a process for UCSF Sleep Clinic to mail disposable WatchPAT devices to eligible patients. Itamar Medical will provide training and support for logistics, ensuring efficient distribution and return of devices. We will develop patient-friendly instructions and offer remote support to minimize user errors.

Target Population:

UCSF Sleep Clinic patients residing outside the immediate area (5-10+ miles).
Patients with advanced illness or mobility restrictions preventing travel.

Potential Barriers:

Insurance coverage for mailed home sleep studies.
Ensuring timely device return and compliance with testing protocols.

Mitigation Strategies:

Partnering with UCSF billing and Itimar to navigate reimbursement.
Developing clear patient communication materials to ensure proper device use.

PROPOSED EHR MODIFICATIONS:

Current Workflow: Manual documentation and scheduling of in-lab studies.
Desired Modifications: Integration of WatchPAT test orders/results within APeX.
New Tools Needed: Automated workflows for tracking mailed devices and test completion.

RETURN ON INVESTMENT (ROI):

Reduced costs associated with missed in-lab study appointments.
Increased efficiency in diagnosing sleep apnea, leading to fewer complications and hospitalizations.
Potential revenue from increased home sleep study volume.

SUSTAINABILITY:
If successful, UCSF can integrate this service into standard sleep study protocols. Key stakeholders (sleep clinic leadership, billing, and IT) will assess long-term funding sources, such as insurance reimbursements or UCSF operational budgets, to maintain and expand the program.

BUDGET (Up to $50,000):

Devices & Supplies: Disposable WatchPAT units ($100 per unit).
Staffing: Part-time coordinator to manage logistics.
Software Integration: EHR modifications for workflow efficiency.
Patient Education Materials: Printing and digital resources.

Supporting Documents:

expanding_access_to_sleep_studies_via_disposable_watchpats_for_ucsf_sleep_clinic.docx

Salary Support for a Dedicated Mental Health Navigator for Medical/Surgical Beds Across UCSF

Submitted by Bo Hu on February 28, 2025 - 4:53pm Last revised by Rasmyah Hammoudeh on March 11, 2025 - 2:03pm.

Proposal Status:

Review Complete

PROPOSAL TITLE: Salary Support for a Dedicated Mental Health Navigator for Medical/Surgical Beds Across UCSF

PROJECT LEAD(S):

Bo Hu, MD MS. Assistant Professor of Psychiatry, UCSF Health

Misti Meador, Assistant Director of Post Acute Care

EXECUTIVE SPONSOR(S): Nerys Benfeld, MD. Chief Medical Officer, Adult Services

ABSTRACT:

Patients with psychiatric needs on the medical floor are often dispositionally and legally complex. This not only leads to longer stays on acute/transitional care beds with minimal interventions, but also provides a suboptimal environment of care for chronically underserved patients. Exacerbating the situation, recent legal and institutional changes will increase the volume of patients who fit criteria for holds and conservatorship, further placing strain on the system. Therefore, we propose a dedicated mental health navigator across the UCSF acute care system, with the goal of decreasing length of stay by coordinating legal and dispositional services in complex adult patients with mental illness. This role would also allow medical staff and social work to operate at the highest scope of practice.

UCSF TEAM

Bo Hu, Consultation Liaison Psychiatrist, Officer of Quality Improvement in Psychiatry (project lead)

Erik Levinsohn, Consultation Liaison Psychiatrist

Larry Kaplan, Service Director of Consultation Liaison Psychiatry

Ramotse Saunders, Medical Director of Acute Services, Psychiatry

Manisha Israni-Jiang, Clinical Professor, Internal Medicine and Pediatrics

Quinny Cheng, Medicine I Social Worker Medical Director

Misti Meador, Assistant Director of Post Acute Care

Kelley Ogami, Medicine I Social Worker

Nerys Benfield (Executive Sponsor)

UCSF Mental Health Navigator, Assignment TBD

PROBLEMS

The physical separation of Langley Porter Psychiatric Institute from Parnassus has led to logistical difficulties in complex patients

For example, the legal team (judge and attorney) who is overseeing probable cause legal hearings often do not have the time to physically come to Parnassus, which requires physicians to coordinate remote hearings and pre-hearing meetings with patients

Nurses at Parnassus are unable to coordinate with legal team at Mt. Zion to allow conversation with patients prior to hearings

Residents and attendings are asked to provide logistical assistance, such as setting up a zoom call on a smartphone or iPad to mediate the conversation between the legal team and the CL psychiatry team

Occasionally, a member of the Parnassus CL team has had to physically travel to Mt. Zion to pick up a physical hold paperwork because the hold was signed by the legal team at Mt. Zion

The volume of LPS holds and conservatorships is expected to increase

Senate Bill 43 (SB43)has broadened the criteria for LPS holds:

Conservatorship of patients with substance use disorders

Expansion of grave disability criteria to includethe inability to provide personal safety and/or necessary medical care

Eating disorder patients will likely require LPS holds in the UCSF system

The acquisition of St. Mary’s and St. Francis hospital systems will require a coordination between sites to optimize resource allocation, and to standardize work flows across institutions

This patient population requiresspecialized follow-up care, as they frequently experience housing scarcity, limited financial and social resources, and scarcity of dispositional options

Transfer to inpatient psychiatry facilities, which have limited availability and may accept or reject patients based on institution-specific requirements

Transfers to special treatment programs, such as partial hospitalization programs, intensive outpatient programs, or residential treatment programs

Mental health outpatient referrals, both internal to UCSF and external

Filing for conservatorship, which requires intensive coordination and expertise with regional legal statutes. Many of these time-intensive tasks are left to house staff, who have limited training in facilitating these outcomes and are drawn away from providing consultation to primary teams

ECT is an extremely effective treatment for treatment-refractory conditions and can be lifesaving, but the process of approving treatment in California includes significant bureaucratic and legal hurdles

Results lead to delayed treatments or sometimes inability to offer patients ECT, thereby worsening patient outcomes or delaying discharge

Prolonged stays with confined movement further increase iatrogenic harm and social isolation

TARGET

1. Reduced length of stay for psychiatric patients with complex legal and dispositional needs over the course of one year with the patient navigator, compared to the previous year.

UCSF Adult Financial Services estimates the direct cost of providing care for patients who no longer require inpatient interventions to be $1688 per day in 2024 on the med/surg and transitional care beds.

In 2024, there were:

674 psychiatry consultations on med/surg beds

379 holds and conservatorship orders on med/surg beds

195 5250s/5260s/5270s (requires hearings)

27 Temporary and Permanent Conservatorships filed

156 of 379 of patients on holds and conservatorships went to a disposition that was not home care

A range of 4-7 patients per year who receive ECT on the medical floors annually

An estimated range 3-8 patients (varies based on diagnosis of anorexia nervosa vs failure to thrive / ARFID) per year which may require LPS holds in the future

This does not include patients who are not on holds, who also require close coordination with social work and case management

In the most conservative estimate, a reduction of just 1 day in length of stay in only conserved patients in the hospital system over a 12-month period would yield:

Patient population	Encounters in 2024 that required conservatorship	LOS stay reduction per encounter	Cost/day of one hospital bed	Cost reduction
Only conserved patients	27	1 day	$1688	$45,576

Realistically, if 25% patients of patients on 5250s or longer have a 2 day decrease in length of stay:

Patient population	Encounters in 2024	LOS stay reduction per encounter	Cost/day of one hospital bed	Cost reduction
25% of LPS patients	(195 + 27) * 0.25	2	$1688	$187,368

This would not include patients NOT on holds for which CL psychiatrist is consulted, who also are complex and would benefit from a navigator.

These calculations also does not include the opportunity days saved.

2. Reduction in non-clinical clerical work from medical staff

A survey of residents and attendings suggest about 1 hour per work daythat goes into non-clinical clerical work. We hope to reduce this by 50%, which would open more time for increased volume and quality of consultations by the CL team.

GAPS

There are multiple systems barriers to care forthis patient population

Patients in our target population are vulnerable due to their cognitive impairment, age and psychosocial barriers. Many have substance use or mental health disorders and are often homeless without support for medication management and activities of daily living support.

Acute medical units are not conducive to the care of the elderly, cognitively impaired or patients with mental health disorders. Being restricted to their rooms due to the concern of elopement or harm to staff or themselves can contribute to their agitation.

The legal process of conservatorship or Medi-Cal insurance acquisition is long drawn and a systems issue outside the scope of UCSF Health

There is reduced availability of inpatient psychiatric beds and community resources especially for uninsured or Medi-Cal patients

INTERVENTION – A dedicated care coordinator for 12 months to support the CL and SW team to perform:

Helping MD/SW team with conservatorship paperwork and logistics

Scheduling and coordinating probable cause LPS hearings with legal team

Legal documentation management, such as storing hold/RIESE/conservatorship paperwork

Accelerating voluntary/involuntary ECT paperwork and coordination

Assisting SW with inpatient psychiatry referrals

Helping with finding outpatient disposition within and outside of the UCSF health system

Obtaining collateral from patients and records from outside hospitals, which can accelerate treatment planning and initiation

Liaising between patients, families and for improved quality and speed of communication, improving patient experience

Allowing house staff and SW to practice at maximum scope

For example, SW can eventually participate in probable cause hearings as in other institutions in California

RETURN ON INVESTMENT (ROI)

Financially, a conservative estimate of direct savings would be ~$187,000 over a 12 month period.There will also be increased revenue via opportunity days for the hospital system.

Enhanced patient and family experience from increased frequency and quality of communication.

Enhanced work and training for MDs and social workers, who have more time to practice at the highest level allowed by their license.

SUSTAINABILITY – If successful, a proposal outlining the ROI and qualitative outcomes of this project will be prepared for executive leadership within the Division of Hospital Medicine and Adult Services to request that navigator be budgeted in the upcoming fiscal year.This would also serve as a model for mental health coordination as multiple hospitals are integrated.

BUDGET ($50,000) - Patient navigator salary support of $50,000.

IV Diphenhydramine: A Hidden Risk that Impacts Patient Safey and Hospital Stay

Submitted by Ethel Wu on February 28, 2025 - 4:55pm Last revised by Rasmyah Hammoudeh on March 11, 2025 - 2:02pm.

Proposal Status:

Review Complete

PROJECT LEAD(S):Omid Shah, MD, Ethel Wu, MD

EXECUTIVE SPONSOR(S): Bradley Monash, MD

ABSTRACT: Diphenhydramine is a first-generation antihistamine that is frequently used for a broad range of indications such as pruritis, allergy, nausea, vomiting and insomnia. Its useis linked with various side effects including sedation, delirium, and cognitive dysfunction. It is also one of the most abused medications in the United States;with its presence detected in approximately 15% of deaths from overdose.

Most use of parental diphenhydramine in the hospitalized patient is unnecessary and prolonged. For most indications, there are other safer, more effective medications. Preliminary data from UCSF Health shows a longer length of stay (~21 days) for those receiving ongoing IV diphenhydramine than the average hospitalized adult patient. In focus groups asking providersat UCSF about management of complex patients, a source of distress for providers has been the often-contentious negotiations around weaning off IV diphenhydramine on the path to safe discharge.

Reduction of the use of IV diphenhydramine at UCSF Health can be achieved through agreement across stakeholders to develop a system wide standard. Work on this topic has stalled in the past because of the breadth of applications for the medicine. Now with increased on the ground acknowledgement of IV diphenhydramine as an issue (despite very little published data) there is widespread interest in addressing the problem in the health system. Our first step is to standardize IV diphenhydramine ordering and recommendations around alternatives. Next, we will work to enhance EHR ordering guidelines and potentially develop “hard stops” especially for ongoing IV diphenhydramine use. Finally, we plan to create education and support around the shift in practice, especially in supporting patients for whom this change in practice may affect most.

TEAM:

Omid Shah, MD (Hospital Medicine Faculty)
Ethel Wu, MD (Hospital Medicine Faculty)
CandyTsourounis, PharmD (Professor, Department of Clinical Pharmacy)
Elise Wozniak, PharmD (Department of Pharmaceutical Services)
Nader Najafi, MD (Hospital Medicine, Data Core Director)
Keerthana Radhakrishnan (Data Core Analyst)
Sarah Apgar, MD (Hospital Medicine Faculty, Code CARE Medical Director)

PROBLEM:

Diphenhydramine was approved by FDA in the 1940s and has long been used by patients and providers alike as a go-to medication for a broad range of indications. It is a first generation H1-antihistamine that has effects throughout the body including the respiratory, gastrointestinal and central nervous systems. It is used to treat mild to severe allergic reactions, migraines, nausea and vomiting, pruritis and insomnia amongst other complaints. Second generation antihistamines do not cross the blood brain barrier and so do not have sedating and other CNS effects that are commonly seen with diphenhydramine.Its anticholinergic properties add to the list of side effects that second generation antihistamines do not have.

In CDC data from 2019-2020, antihistamines were found in 15% of deaths due to overdose, almost all diphenhydramine, 3.6% of those deaths were due to antihistamines alone. Most were found to co-involve opioids. Abuse of antihistamines has been reported in medical literature since the 1970s and 1990s, little has been further published on the subject since. It is theorized that diphenhydramine hasadditional direct and indirect effects on neurotransmitters which can then have euphoric and anxiolytic effects.

For most indications, there are other safer, more effective medications than diphenhydramine. Most use of parental diphenhydramine in the hospitalized patient is unnecessary and prolonged. Preliminary data from UCSF Health shows a longer length of stay (~21 days) for those receiving ongoing IV diphenhydramine than the average hospitalized adult patient. Ongoing use is defined in this data set as more than 8 administrations of IV diphenhydramine per encounter via standing orders or ongoing PRN orders (all one-time IV diphenhydramine orders were excluded). Over fiscal year 2023-2024, this subset of patients represented nearly 3000 patient days at UCSF Health. Discussions around its administration and preparation for discharge has become a point of distress for patients and providers. In focus groups asking providers at UCSF about management of complex patients, a repeated topic to address has been around use of IV diphenhydramine.

TARGET:

Our goal is to decrease overall use of parental diphenhydramine for adult patients hospitalized at UCSF medical center. Specifically, we would like to see an overall decrease in its administration in at least 20% of patients who receive ongoing IV diphenhydramine over the course of one year. While there are subcategories of patients who frequently get this medication, from an equity lens we are choosing not to focus on a specific diagnosis. We will partner with multiple stakeholders to develop a comprehensive policy and plan to roll out this change that will provide support to both patients and providers.

GAPS:

Systems gaps: it is easy to order IV diphenhydramine, there is no stewardship around use of this medication,there is no guidance, no alternative given
Education: Because diphenhydramine has been an available over the counter medication since the 1940s there is familiarity and comfort in using this medicine amongst providers and patients. Outside of education around its avoidance in older patients, there is lack of knowledge around its additional harms.
Patient preferences: There is likely a degree of ongoing use driven by patient experience, prior use and preference.

Current State:

In 2023-24, UCSF Health had 137 encounters of patients who were ordered and administered ongoing IV diphenhydramine during their hospital stay. Eighty-six patients made up these 137 encounters.

The average length of stay for these encounters was 21.3 days, and equaled 2917 total patient days.

INTERVENTION:

Stakeholder engagement: We aim to put together a multidisciplinary working group to develop standardization around the use of IV diphenhydramine and recommendations for alternative options. Alignment on how to limit IV diphenhydramine and policy around its use will need to be determined amongst many stakeholders across our institution. We have already engaged representatives from the emergency department, pharmacy, code CARE and chronic pain. We plan to reach out to many more stakeholders.

EHR modification: Based on the policy agreed upon, we will design a new APeX orderset that likely put some limit to access of IV diphenhydramine as well as develop guidelines for use and provide alternative medications for different indications.

Education: We plan to develop educational materials, talking points, and patient facing materials around use of diphenhydramine. Among side the stakeholder engagement, we will also explore ways to provide educational sessions for specific and targeted provider groups. With engagement of the Code CARE team, we will develop strategies to inform and prepare patients of upcoming changes.

PROPOSED EHR MODIFICATIONS: Please see above the above section.

RETURN ON INVESTMENT (ROI):

In work done at our institution, when a concerted effort was made to reduce IV opioids in specific patients with targeted care plans by the Chronic Pain team, the Code CARE team, and Hospital Medicine, LOS and readmissions were drastically reduced.

In a retrospective study, looking specifically at the sickle cell patient population, patients on oral diphenhydramine had an average length of stay of ~10 days compared to the patients receiving IV diphenhydramine ~29 and 30 days.

Taking UCSF Health, 2023-2024, patient data, if we candecrease LOS by 25-50% in 20% ofpatient encounters, we anticipate a direct cost savings of $242,600 - $485,200.

137 patient encounters (86 unique patients)		20% patient encounters	27 patient encounters
Average LOS	21.3 days	25-50% reduction in LOS	5.3 to 10.6 days
Estimated room & board per day			$1688
Estimated cost savings			$242,600-485,200

SUSTAINABILITY: These interventions will be sustained by Hospital Medicine leadership, specifically service directors, who will continue to support faculty and faculty education. They will continue engagement with specific key stakeholder groups such as Code CARE to determine ongoing patient and nursing needs.

BUDGET:

Omid Shah – project lead – 25K
Ethel Wu – project team – 10k
Data analytics, campaign and educational material, IT support– 15k

Supporting Documents:

references.pdf

Expanding the Accelerated Discharge Program: An Interprofessional Effort to Use Early Identification and Coordination of Next Day Discharges to Improve Rate of On-Time Discharges and Reduce Length of Stay

Submitted by David Arboleda on February 28, 2025 - 4:59pm Last revised by Rasmyah Hammoudeh on March 30, 2025 - 6:36am.

Proposal Status:

Selected for 2nd Round

PROJECT LEAD(S):

Monisha Bhatia, MD – Assistant Professor, Division of Hospital Medicine
David Arboleda, MD – Assistant Professor, Division of Hospital Medicine
Guinn Dunn, 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
Michelle Mourad, MD - Vice Chair of the Department of 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. Discharge delay can result from (1) variability in discharge planning practice patterns among hospitalists, (2) inadequate alignment among interprofessional 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,” (“ADP”), designed to enhance communication of anticipated discharge and streamline coordination on discharge tasks for patients most likely to discharge the following day. The ADP team systemically collected data on common discharge barriers, developed expertise in addressing common discharge barriers and inefficiencies, improved identification of patients likely to discharge and assisted with completing discharge tasks. Length of stay improved from 8.1 to 7.4 days in the intervention group.

Through the Caring Wisely program, our interprofessional team seeks to develop a platform to communicate discharge barriers with other disciplines at the unit and the health system level through Informatics and APeX build support. We ultimately aim to increase the number of on-time discharges, reduce length of stay, 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
Ongoing discussions with Medicine Case Management Leadership, Nursing Leadership and Patient Capacity Management Center Leadership on partnership and integration
Bradley Monash, MD – Vice Chief of Clinical Affairs, DHM, Executive Sponsor

PROBLEM:

The UCSF 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 include but are not limited to:

Suboptimal patient satisfaction due to prolonged ED and post-anesthesia care unit (PACU) boarding
Suboptimal care quality and risk of patient safety events, as the number of admitted patients “boarding” in the ED 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 who require UCSF quaternary care
Prolonged length of stay for admitted patients (e.g. discharge barriers not addressed earlier in the admission, adding subsequent day(s) to the patient’s hospitalization for ongoing care coordination)

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

HMS multidisciplinary discharge rounds (MDR) are intended to raise awareness of anticipated discharge and discharge coordination tasks but lack a structured communication method to alert other members of the interdisciplinary team and health system leaders of these tasks.
The current workflow relies on accurate EDD to alert and prioritize core services (Case Management (“CM”), Medical Social Work, Nursing, Pharmacy, Radiology, Rehabilitation Services) when there are pending tasks for a patient expected to discharge. Inaccurate EDD misdirects resources and risks further delays to other patients more likely to discharge.
Similarly, as the patient’s clinical condition and discharge needs evolve, we rely on CM to update EDD but there is variability in practice pattern on the frequency and detail of communication between clinicians and CM, without structured communication or feedback pertaining to changes that extended the EDD.

TARGET:

We seek to increase the number of on-time discharges of HMS patients by improving communication of identified discharge barriers. Specific targets include:
- Develop a method for centralized, structured communication of identified discharge barriers which is visible to multidisciplinary team members at the unit and health system level and integrates with frontline multidisciplinary team workflows
- Leverage current Patient Capacity Management Center (“PCMC”) workflows and integrate with upcoming changes in throughput optimization efforts (via Deloitte redesign for Proactive, Timely Discharge Planning) to more proactively address discharge barriers on up to 2 days prior to EDD.
- Through these interventions we hope to achieve further 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 0.3 days.

GAPS

System issues and technological gaps include:

Lack of centralized, structured communication of discharge barriers that can be easily updated directly by the physician caring for and ultimately discharging the patient. Care team members use different EHR-based tools to track discharge barriers (such as Discharge Milestones, Discharge Comments, the MDR Discharge Planning Tool, and structured and unstructured text in clinical notes and patient list columns), leading to compartmentalization and redundancy of information in discordant areas in the electronic health record (EHR), inaccurate EDD, and misdirection of resources.
Inconsistent documentation of the discharge plan in primary team clinician notes or in other locations like sticky notes, discharge navigators. There is variability in documentation of the discharge plan, which we are attempting to address with standardized note templates. However, even when these fields are completed, the information is not readily available to other members of the interprofessional team and health system leadership who are attempting to expedite discharges.
No shared understanding of the global discharge plan between disciplines despite implementation of the discharge milestones tools. Each member of the interprofessional team has access to important information that may alter the discharge plan but this information is not quickly accessible to the care team and currently requires duplication of work and additional person-to-person communication, increasing the burden of communication.

Educational gaps include:

Suboptimal interprofessional 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 HMS’s direct care teams, which involved streamlining outreach to identify likely next day discharges, discharge barriers, and delegate specific tasks to our Clinical Assistant. ADP has developed standard work for interprofessional team members to take on discharge tasks and, through a Division of Hospital Medicine internal grant, plans to develop a novel discharge prediction model, structured tools for asynchronous communication and handoff between clinicians and interprofessional team members, and will pilot a delegated discharge model to offload the discharge of clinically stable patients from the primary clinician.

Moving forward, we seek increased support through Caring Wisely to develop a platform to communicate discharge barriers with interprofessional team members and the health system with the goal of reducing length of stay by a further 0.3 days. Our proposal expands the ADP which has already demonstrated LOS reduction and cost savings, with the hope to yield sustained improvement. Specifically:

Feasible EHR enhancements to existing discharge-focused EHR tools. We have laid the groundwork for interprofessional communication using an order set and discharge checklist to identify discharge tasks and seek to work with Informatics and APeX build support to communicate this at the unit and health system level in a structured and centralized manner. We recognize this will need to synergize with the existing Case Management MDR tool launched 3/12/2025, but hope to use human-centered design principles to optimize how primary hospitalists making the decision to discharge can best interface with the tool in real time, as discharge plans vary throughout the day.
Improve case management, clinician, and nursing education about discharge-focused tools which can be leveraged in real-time to confirm, document, and overcome discharge barriers.
Continue to develop, expand and integrate current ADP deliverables (discharge prediction model, ADP order set, discharge checklist) into a centralized, structured area in the EHR which can be accessed at the unit and health system level and be used by PCMC or individual nursing units to direct resources to ensure timely mobilization after the patient is determined to be medically ready for discharge and discharge orders are placed.

PROPOSED EHR MODIFICATIONS:

We will explore the following modifications which may reduce LOS.

Expansion and development of current “Discharge Delay” function to identify/flag discharge barriers which already integrates with PCMC workflow
Continued modification and integration of the standardized inpatient hospital medicine progress note (which now includes listed discharge barriers) and connect this information to the developed centralized EHR enhancements for visibility at the unit and health system level, to escalate and execute discharge tasks.
Explore similar modification and integration of current Care Management notes as above.
Reduce redundant areas of interprofessional discharge communication (e.g. Discharge Comments, Case Management Discharge Sticky Note, Patient List columns), instead focusing on the centralized and visible EHR enhancements.

RETURN ON INVESTMENT:

We anticipate the ADP to produce cost savings through reduction of length of stay in HMS patients. In the latest analyzed data from our current pilot, we found that from October 2023-June 2024, the average length of stay was 7.4 days. This was a 0.7 reduction from the average length of stay of all patients treated by the HMS direct care hospitalists prior to the intervention July 2022-September2023 (8.1 days). We identify a 0.3 day reduction in LOS as a conservative estimate of length of stay reduction by improving interprofessional communication with future support from Caring Wisely. This target is scalable and realistic, even for services with shorter baseline LOS. We identify a 0.7 day reduction in LOS as an optimistic estimate given the data collected.

Collectively, we anticipate direct cost savings to the health system attributed to reduction in HMS length of stay. This will lead to decreased direct variable costs from bed days saved over one year’s time to range from $1,315,242 (0.3 reduction in length of stay for GMS service) to $3,068,898 (0.7 reduction in length of stay for GMS service) as outlined in the attached document. The true financial impact is expected to exceed these figures, as we expect additional savings from cost of care delivery beyond direct variable bed-day cost and increase in revenue /contribution margin from backfill of the UCSF Health Parnassus. We have aimed for a smaller impact in part because of anticipated increases in complex patients admitted to Parnassus campus as a result of health system efforts to transfer lower acuity patients to other sites (St. Mary’s Hospital, Mt. Zion Hospital), changes in scheduling practices within HMS, and other system-wide changes which may make it challenging to analyze the individual impact of our project. We believe our project is even more vital in this environment, as the forward flow of patients from all sites will remain a system priority that will be even more challenging for individual clinicians to navigate without care coordination support. To address the challenge of controlling for other concurrent health system efforts, we will continuously adapt our approach and iterate our processes with the guidance of our interprofessional stakeholders, advisors and executive sponsors.

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 (afternoon discharge planning), Flow Control Team, HMS direct care 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 a successful centralized and structured communication enhancement within APeX that can be feasibly adopted by current process owners for hospital discharges and throughput. Once adopted, our intervention will not require ongoing support for maintenance. We anticipate success in this project to lead to adoption of ADP core features and structured communication to scale to other service lines, including our partner sites (St. Mary’s Hospital, Mt. Zion Hospital) which will allow information sharing to enhance discharge workflows across the entire health system.
We believe our interventions will 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 improving communication practices, establishing norms, and enhancing APeX as described above.

BUDGET:

$35,000 – effort for project lead(s)
$15,000 – reserved for as-needed clinical informatics support (e.g. data analysis, EHR modifications)

Supporting Documents:

LOS reduction

Cost Savings estimates

Reducing Inpatient Admissions for Vasa Previa

Submitted by Chiara Corbetta-Rastelli on February 28, 2025 - 5:01pm Last revised by Rasmyah Hammoudeh on March 11, 2025 - 2:02pm.

Proposal Status:

Review Complete

PROJECT LEAD(S):

-Chiara Corbetta-Rastelli, MD

-Kate Swanson, MD

EXECUTIVE SPONSOR(S):

-Juan Gonzalez, MD, MS, PhD, Division Chief, UCSF Maternal Fetal Medicine

-Melissa Rosenstein, MD, Medical Director for Quality and Patient Safety for UCSF OB

ABSTRACT:

Vasa previa is a condition where fetal vessels unprotected by umbilical cord or placental tissue course through the membranes in close proximity to the internal cervical os. Before prenatal detection of vasa previa by ultrasound, this condition was associated with very high perinatal mortality rates. There is no difference in neonatal outcomes when comparing inpatient versus outpatient management of this condition. However, historically our practice at UCSF has been to admit all patients diagnosed with vasa previa between 28 – 32 weeks’ gestation, until delivery at 34 – 37 weeks’ gestation. This leads to prolonged hospital stays, resulting in patient-associated burden, but also significant resource utilization and healthcare systems costs. The aim of this proposed initiative is to reduce the proportion of vasa previa patients who are routinely admitted to the UCSF Birth Center by 50% in FY2026. Through a series of interventions including clinician and patient education, qualitative assessments, and system changes, this project will have an estimated direct cost savings of $286,870 during FY2026.

TEAM:

-Chiara Corbetta-Rastelli, MD, PGY-6 in Maternal Fetal Medicine, UCSF

-Kate Swanson, MD, Assistant Professor of Maternal Fetal Medicine, UCSF

-Juan Gonzalez, MD, MS, PhD, Division Chief, UCSF Maternal Fetal Medicine

-Melissa Rosenstein, MD, Medical Director for Quality and Patient Safety for UCSF OB

-Marley Rashad, MD, PGY-6 in Maternal Fetal Medicine, UCSF

PROBLEM:

Vasa previa is a rare condition in pregnancy that refers to unprotected fetal vessels running through the membranes in close proximity to the internal cervical os^1,2. Before wide stream use of prenatal ultrasound and antenatal diagnosis, this condition was associated with a high perinatal mortality rate (~60%) due to fetal exsanguination when the membranes rupture or when the cervix dilates in labor³. Currently, neonatal survival is ~99% with excellent neonatal outcomes when vasa previa is diagnosed antenatally and delivery is performed by cesarean section (before rupture of membranes or labor)⁴.

Once a vasa previa is diagnosed in pregnancy, patients can be managed in the outpatient or inpatient setting. Outpatient monitoring involves serial growth and cervical length ultrasounds, along with twice weekly fetal heart rate monitoring. Inpatient monitoring involves admission to the hospital, as early as 28 weeks’ gestation, with daily (or twice daily) fetal heart rate monitoring, serial ultrasounds and monitoring for any symptoms or signs of vaginal bleeding, contractions, rupture of membranes which could prompt an urgent or emergent cesarean delivery. There are limited retrospective studies assessing whether inpatient versus outpatient management is preferrable – in general, available evidence has shown no difference in neonatal outcomes^5–8. Outpatient monitoring is more highly associated with urgent cesarean delivery whereas inpatient monitoring is associated with iatrogenic preterm delivery. Both management options should be routinely offered, taking both patient and logistic risk factors into account. However, our current practice at UCSF is to admit most patients with vasa previa to our antepartum service, with very few providers even discussing outpatient monitoring as an option.

In the last two years (FY2023 and FY2024), approximately 18 patients were admitted to the UCSF Birth Center for “prophylactic” admission for vasa previa, resulting in a total of $1,286,823 direct costs to the hospital system. The average length of stay was 25 days. Given unclear benefit of prophylactic admission regarding clinical outcomes for vasa previa, there is an opportunity for education and system change to reduce inpatient admissions for those patients interested and eligible for outpatient management. Additionally, our Birth Center has struggled with increasing need for divert status, in part due to the limited number of antepartum monitored beds. In the last two years (2023-2024), our unit was on divert for 924 hours (38 days) resulting in 77 transports declined/diverted. By freeing up monitored antepartum beds by reducing these prolonged vasa previa admissions, we may also decrease the need for divert and provide greater access to patients who require transport to UCSF.

TARGET:

Our goal is to reduce the proportion of prophylactic inpatient admissions for vasa previa at the UCSF Birth Center by 50% by the end of FY2026 (ie. 4-5 patients admitted per year for this indication, rather than 9-10 patients). The goal of 50% was primarily chosen to meet the Caring Wisely goal of estimated ROI > $250,000. We also felt that this goal would be achievable; not all patients diagnosed with vasa previa are eligible for outpatient management, for instance, patients with a history of preterm birth or a short cervix would be recommended for inpatient monitoring since their a priori risk of preterm delivery is higher than the general population. Thus, only a subset of patients diagnosed with vasa previa will be offered outpatient management.

The quantitative benefit of this project is to reduce the direct costs associated with prophylactic inpatient admission of vasa previa patients. The total direct cost on average per patient admitted for vasa previa is $71,490. By reducing the number of patients admitted per year to approximately five, the total direct cost savings would be $357,450 (not accounting for outpatient monitoring costs, see below for additional details). Through this project, we would also plan to collect maternal and neonatal outcomes comparing the inpatient versus outpatient groups.

The qualitative benefits include patient satisfaction with an alternative to a prolonged inpatient admission; provider satisfaction with being able to provide alternative options to patients and engaging in a shared decision-making model; assessment of patient experience between inpatient and outpatient management through survey questions and focus groups; possibility of decreasing divert time for Birth Center which leads to improved access for transported patients and higher satisfaction for providers on the unit.

GAPS:

Educational Gaps

-MFM physicians’ lack of knowledge of and/or discomfort with offering outpatient management.

-Nursing lack of knowledge regarding outpatient management for vasa previa (as this is not common practice at UCSF).

-Patient misinformation or lack of understanding regarding vasa previa diagnosis and management.

-No available evidence regarding patient experience after vasa previa diagnosis and decision-making around inpatient versus outpatient monitoring.

Technological Gaps

-None identified.

System Gaps

-Lack of departmental standardized counseling regarding vasa previa management which leads to patient confusion and distrust in medical care team when they receive differing opinions/counseling.

-Lack of departmental standardized algorithm/approach for outpatient management of vasa previa.

INTERVENTION:

-Practice Setting: UCSF Birth Center (Inpatient), Prenatal Diagnostic Center (PDC) & Antenatal Testing Unit (Outpatient)

-Target Population: Pregnant patients diagnosed with vasa previa and planning delivery at UCSF

-Proposed Interventions, description and rationale: See table below

Intervention	Description	Rationale
Educational sessions for physicians at MFM division meetings	At the start of the study and every 3 months, the project team will provide education regarding outpatient monitoring of vasa previa, reviewing the previously published evidence on this topic, counseling strategies, and eliciting feedback from clinicians throughout the study.	MFM clinicians may be unfamiliar with outpatient management option for vasa previa.
Educational sessions for outpatient nurses at Operations meetings	At the start of the study and every 3 months, the project team will provide education regarding outpatient monitoring of vasa previa, reviewing what nurses should look out for when patients are presenting for fetal heart rate monitoring and serial ultrasound monitoring (and when to escalate to physician).	Outpatient nurses will be unfamiliar with outpatient monitoring of vasa previa, as this is not currently common practice at UCSF.
Handout for patients who are diagnosed with vasa previa	Handout will contain general information about vasa previa, along with differences in outpatient versus inpatient management. It will be available to patients in their AVS after they are diagnosed with a vasa previa in the PDC.	Patients may be exposed to misinformation from unreliable sources.
Patient survey and focus groups regarding experience with vasa previa diagnosis and management	Would request voluntary participation from patients to complete a brief qualitative survey regarding patient experience after vasa previa diagnosis, management, counseling, etc. Patients would be invited to participate in small focus groups / in-depth interviews to further elaborate on their experience.	No information regarding patient experience with this rare, highly stressful condition. No data on how patients decide on inpatient versus outpatient management. Will better aid clinicians in how to approach counseling.
Handout for MFM clinicians regarding vasa previa management	Comprehensive information sheet would be created for clinicians to reference and utilize as a decision aid when counseling patients regarding management options for vasa previa.	No standardized approach or information regarding counseling on vasa previa management which leads to confusion for patients.
Outpatient monitoring algorithm proposal	Flowchart that describes contraindications to outpatient management, along with monitoring plan and delivery timing recommendation for patients managed as outpatients.	Our department does not have an approach for managing these patients as outpatients, thus this algorithm can provide an initial framework for clinicians.

-Barriers to Implementation: Clinicians and patients may have a strong preference for inpatient management of vasa previa. This proposal for outpatient management is not meant to force patients into outpatient monitoring, but to provide an alternative for both patients and clinicians, that is evidence-based and safe. We want to continue supporting shared decision-making and an individualized approach to counseling, but want to create a framework for how outpatient management may be conducted and offered.

-Adverse Outcomes: Although the evidence, albeit limited, does not support this, it is possible that we may see adverse neonatal outcomes with outpatient management. We will collect neonatal outcomes during this project to further assess the safety of outpatient management of vasa previa.

-Plan to measure and close equity gaps: We will collect race/ethnicity, socioeconomic information, highest education level achieved, and preferred language during this project and assess whether certain populations are being offered one management option over the other. If any inequities are identified, we will raise these at our educational meetings with MFM clinicians, and look into specific ways of addressing or closing these gaps. One inequity for recommending inpatient admission (rather than outpatient) is for patients who live far from UCSF. For this project we will identify other tertiary/quaternary hospitals with OB/MFM available 24/7 in Northern California. By identifying nearby hospitals capable of caring for both mother and preterm infant, patients living in more rural areas may still be eligible for outpatient management.

PROPOSED EHR MODIFICATIONS: None

RETURN ON INVESTMENT (ROI):

Inpatient costs

FY2023 – FY2024: 18 patients with vasa previa were admitted to the UCSF Birth Center for a “prophylactic” admission. The average length of stay per patient was 25 days. The average total direct cost per patient was $71,490, ranging between $25,943 to $117,765.

Outpatient costs

Outpatient monitoring would include serial cervical length monitoring (every 2 weeks starting at 28 weeks) and antenatal testing (ie fetal heart rate monitoring) twice weekly starting at 32 weeks until delivery. Cervical length ultrasounds cost $1,378 x 2 additional ultrasounds (compared to inpatient) = $2,756. Antenatal testing cost $1,420 x 8 sessions (2x/wk x 4wks on average) = $11,360. The average total charges per patient for outpatient monitoring would be $14,116.

If our goal is to reduce inpatient admissions by 50% for FY2026, we would aim to only admit 5 patients per year (rather than 10).

-$71,490 x 5 patients (inpatient) = $357,450

-$14,116 x 5 patients (outpatient) = $70,580

-Inpatient – outpatient cost = $357,450 – $70,580 = $286,870 direct cost savings to health system

SUSTAINABILITY:

If successful, these interventions will be sustained by the MFM division at UCSF led by Dr. Gonzalez. However, these interventions are primarily self-sustaining in that once the handout/information has been circulated and/or created it can be maintained within the department’s clinic and prenatal diagnosis center spaces. This outpatient management protocol can be emphasized during the onboarding process of new hires (specifically MFM physicians). The patient experience data can be summarized and circulated to the department to further guide patient-centered counseling strategies in the future.

BUDGET:

-Salary support for project co-leads for project implementation: $20,000 - $30,000

-Salary support for research assistant: $10,000

-Development of educational materials, data analytics: $5,000 - $10,000

-Patient compensation for survey/interview responses: 10 patients x $100 gift card = $1,000

REFERENCES:

1. Sinkey RG, Odibo AO, Dashe JS. #37: Diagnosis and management of vasa previa. American Journal of Obstetrics and Gynecology. 2015;213(5):615-619. doi:10.1016/j.ajog.2015.08.031

2. Oyelese Y, Javinani A, Shamshirsaz AA. Vasa Previa. Obstet Gynecol. 2023;142(3):503-518. doi:10.1097/AOG.0000000000005287

3. Oyelese Y, Catanzarite V, Prefumo F, et al. Vasa Previa: The Impact of Prenatal Diagnosis on Outcomes. Obstetrics & Gynecology. 2004;103(5 Part 1):937. doi:10.1097/01.AOG.0000123245.48645.98

4. Zhang W, Geris S, Al-Emara N, Ramadan G, Sotiriadis A, Akolekar R. Perinatal outcome of pregnancies with prenatal diagnosis of vasa previa: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2021;57(5):710-719. doi:10.1002/uog.22166

5. Fishel Bartal M, Sibai BM, Ilan H, et al. Prenatal Diagnosis of Vasa Previa: Outpatient versus Inpatient Management. Am J Perinatol. 2019;36(4):422-427. doi:10.1055/s-0038-1669396

6. Villani LA, Al‐Torshi R, Shah PS, Kingdom JC, D’Souza R, Keunen J. Inpatient vs outpatient management of pregnancies with vasa previa: A historical cohort study. Acta Obstet Gynecol Scand. 2023;102(11):1558-1565. doi:10.1111/aogs.14595

7. Laiu S, McMahon C, Rolnik DL. Inpatient versus outpatient management of prenatally diagnosed vasa praevia: A systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2024;293:156-166. doi:10.1016/j.ejogrb.2023.11.033

8. Vasa Previa: Outpatient management in low-risk asymptomatic patients is reasonable. European Journal of Obstetrics & Gynecology and Reproductive Biology. Published online December 14, 2023. doi:10.1016/j.ejogrb.2023.12.017

Headache Evaluation and Diagnosis - with Generative Artificial INtelligence (HEAD-GAIN): Improving Access, Reducing Overutilization

Submitted by Pierre Martin on March 1, 2025 - 12:00pm Last revised by Rasmyah Hammoudeh on March 11, 2025 - 2:01pm.

Proposal Status:

Review Complete

PROJECT LEAD(S):

- Pierre Martin, MD, MEd

- Andrew Breithaupt, MD

EXECUTIVE SPONSOR(S):

- Maggie Waung, MD, PhD

ABSTRACT

Clinicians must distinguish between primary headaches and secondary headaches that require neuroimaging. Limited access to subspecialty headache care leads to misdiagnoses, delays in management, overutilization of neuroimaging, and increased costs, despite clinical practice guidelines and Choose Wisely campaigns.^1–3 Large language models (LLMs), are increasingly used for clinical decision support.⁴ We hypothesize that a chatbot-delivered pre-visit assessment (PVA) combined with an LLM can efficiently collect a comprehensive patient history, accurately diagnose headaches, and provide neuroimaging recommendations similar to an in-person neurologist. The goal of the intervention is to improve access to headache care and reduce overutilization of neuroimaging, along with associated costs. For the development and validation phase, participants will be randomized to a person-delivered pre-visit assessment (PVA) or an automated chatbot-delivered PVA. UCSF Versa, a HIPAA-complaint AI platform, will analyze transcripts to generate a history of present illness, diagnosis and positive or negative recommendation for neuroimaging, for comparison with an in-person neurologist. The chatbot-delivered PVA will later be implemented into clinical workflows by the UCSF General Neurology Clinic and various metrics, including time to diagnosis, neuroimaging utilized and cost of neuroimaging will be calculated for the 6 months before and after implementation.

TEAM

- Project Lead: Pierre Martin, MD, MEd

- Project Lead: Andrew Breithaupt, MD

- Lead Researcher: Psalm Pineo-Cavanaugh, BS

- Lead Developer: Forest Pineo-Cavanaugh, BE

PROBLEM:

Headache disorders affect a wide swath of the population as the third highest cause of disability-adjusted life years worldwide⁵ and often impact people during their peak productive years, extracting a significant financial toll at upwards of $20B annually.^6,7 Accurate and rapid diagnosis of headaches is imperative to treat potentially life-threatening conditions such as subarachnoid hemorrhage, meningitis, or brain tumors. Moreover, early identification and treatment of primary headache disorders (98% of all headaches)⁸ improve outcomes, preventing headaches such as migraine from progressing into debilitating, chronic conditions.⁹ A critical decision point in the accurate diagnosis of headaches is whether brain imaging is needed. If every person with headaches received a MRI Brain, this would place unnecessary strain on the health system¹. However, not obtaining an MRI in a patient with secondary headaches can be devastating.¹⁰

Two-thirds of the 27 million ED visits are “avoidable”¹¹ and there are 3.5 million “potentially preventable” adult inpatient admissions yearly, accounting for $33.7B in the aggregate¹². Disease management in neurology is particularly expensive because of the complex diagnostic procedures, chronic disease management as well as indirect costs (e.g., lost productivity, disability accommodations). While neurologist involvement in the ambulatory care setting leads to greater unadjusted allowed third-party payments, it is also associated with increased utilization of both symptom-ameliorating and disease-modifying medications, decreased adverse events, and decreased utilization of both acute and post-acute healthcare resources.¹³ There can be significant interprovider differences in ordering practices and the reasons for this overutilization are multifold, including desire to address the concerns of referring clinicians, appeasement of patients, shortcuts in a busy practice, cognitive bias and defensive medicine.^14,15 Overutilization burdens the healthcare system, can impact insurance coverage and in turn reduces access to care for patients with more critical neurological conditions. Reduced access to care invariably leads to a worsened prognosis and increased acute care utilization (e.g., ED visits and inpatient admissions).

Standardization and clinical practice guidelines help to narrow practice variation and can reduce cost without a reduction in clinical outcomes.¹⁶ The American Headache Society and American College of Radiology emphasize that neuroimaging is not necessary for uncomplicated headaches that meet ICHD-3 criteria for migraine, do not have “red flag” symptoms/signs and maintain a normal neurological examination.¹⁴ For example, most brain tumor patients present with multiple symptoms/signs, while only 12% present with isolated headache and 3% are incidental.¹⁷ Despite clinical practice guidelines and Choose Wisely healthcare campaigns, 12 – 16% of patient with primary headaches undergo MRI neuroimaging^1–3 as overutilization in this setting contributes to $1 – 3B per year in avoidable imaging costs.¹⁴ Moreover, overutilization of neuroimaging can lead to false positives, resultant patient anxiety and unnecessary follow-up diagnostics, interventions and consultations with their own associated risks.

Headaches are one of the more common neurological conditions managed in the UCSF General Neurology Clinic. During 2024, the UCSF General Neurology Clinic received between 1000 - 1400 new patient referrals per month and a significant proportion of those referrals were related to headache management, between 100 - 280 referrals per month. And the catchment area for UCSF General Neurology Clinic is increasing in size, year by year. Hundreds of new headache patients are seen per month between UCSF General Neurology and UCSF Headache clinics, some presenting with or without recent neuroimaging. Moreover, there are growing concerns that changes in both federal and state level healthcare policies will lead to significant reductions in insurance coverage, funding cuts to Medicaid, and changes in reimbursement rates, which will all further exacerbate the problem of reduced access to neurological care. This will be particularly true for underserved regions and vulnerable patient populations. Innovative solutions to improve access to neurological care and reduce healthcare costs are imperative.

TARGET:

Goal: We aim to develop, validate and safely implement a chatbot-delivered PVA combined with a LLM to 1) improve patient access to headache care and 2) reduce overutilization of neuroimaging for headache management.

Expected quantitative benefits:

- Decrease in time to diagnosis

- Decrease in time to diagnostic testing

- Decrease in unnecessary diagnostic tests (i.e., neuroimaging)

- Reduction in healthcare expenses associated with the decrease in unnecessary diagnostic tests (i.e., neuroimaging)

- Reduction in acute care utilization

Expected qualitative benefits:

- Improved and more efficient clinical workflow for patients

GAPS:

While neurologists are well equipped to evaluate and diagnose headache disorders, primary and acute care providers are usually the first line of care for patients with headache^9,18. Quality and depth of training for these providers on the management of headache disorders is highly variable.^19,20 And providers maintain variable awareness of clinical practice guidelines and Choosing Wisely Campaigns. Furthermore, the global shortage of neurologists results in limited access to subspecialty headache care, often leading to misdiagnosis and delays in management, which are further compounded in low-resource and rural settings.²¹ There has been increasing research into the potential of large language models, a subset of generative AI, to help providers (neurologists and non-neurologists) more accurately and efficiently triage, diagnose and manage headache patients.²²

INTERVENTION:
Generative AI with LLMs like OpenAI’s generative pre-trained transformers (ChatGPT-3, ChatGPT-4) is being increasingly studied and implemented throughout medicine, from virtual assistants to clinical decision support.^23–26 Despite the promise of utilizing LLMs for medical purposes, the data on the diagnostic accuracy of generative AI compared to physicians is mixed.^27–31 With respect to LLMs in particular, ChatGPT-3 has been used to develop lists of five differential diagnoses based on ten mock clinical vignettes and contained the correct diagnosis upwards of 80% of the time.³² LLMs may outperform physicians in terms of diagnosis and clinical reasoning in certain circumstances, but may actually hamper physician accuracy when used without appropriate training.³³ That being said, these systems will need to be investigated further given continued concerns about accuracy, reliability and bias in clinical settings.³⁴ LLMs can incorporate clinical practice guidelines³⁵ and can be integrated into clinical workflows for clinical decision support such as structured symptom assessments for patient triage, risk stratification and initial recommendations. As a result, there is ongoing research into how to appropriately implement these systems,^36,37 including for headache diagnosis and management. Headache classification is a common application of generative AI with PVAs serving as a source of rich phenotypic data.³⁸ Technological advances such as enhanced LLMs that incorporate clinical practice guidelines have the opportunity to increase clinical efficiency, improve access to neurological care and promote diagnostic stewardship, all the while decreasing overutilization of resources and driving down costs.

Approach:

Hypothesis: We hypothesize that a chatbot-delivered PVA combined with an LLM can efficiently collect a comprehensive patient history, accurately diagnose headache syndromes, and provide imaging recommendations similar to an in-person neurologist.

Aim 1: Evaluate the diagnostic accuracy and imaging recommendations of an LLM for primary and secondary headaches. We hypothesize that a fine-tuned LLM using the results of a chatbot-delivered PVA will diagnose headache disorders and make imaging recommendations with a concordance of at least 0.8 with a blinded in-person neurologist.

Aim 2: Evaluate clinical efficiency, resource utilization and cost reductions associated with implementation of a chatbot-delivered PVA combined with an LLM for headache management. After implementation for new headache patient referrals, we will calculate the time to diagnosis (by fine-tuned LLM and then in-person neurologist) as well as record if the LLM recommended neuroimaging, if patients underwent neuroimaging and the costs associated with neuroimaging (based on EHR logs and administrative billing records). We will compare the aforementioned metrics during the 6 months before and after implementation of the chatbot-delivered PVA and LLM into clinical workflows.

Methods: Development and Validation

160 participants will be recruited to achieve a 95% CI with a sensitivity of 0.80 and a margin of error of ±0.062. and include adult English-speaking patients scheduled to be seen in the UCSF General Neurology Clinic for headache management within 6 months of enrollment. This study will be conducted in collaboration with the neurology and computer science departments at Emory University, who will provide chatbot and secure server support.

Participants will be randomized to either a 1) person-delivered PVA administered by study staff via Zoom or 2) an automated chatbot-delivered PVA. A chatbot for the PVA was developed and will be deployed via Emory’s Amazon Web Services (AWS; cloud computing platform for storage, computing, and databases). Participants will undergo 1:1 block randomization between the 2 arms.

Audio recordings of the PVAs will be transcribed to text via OpenAI’s Whisper (automated speech recognition system). Recordings and transcripts will be stored on the UCSF Research Analysis Environment (data hosting and collaboration tool). Whisper- and chatbot-generated transcripts of the PVA will be entered into UCSF Versa, a HIPAA-complaint AI platform that allows users to interact with ChatGPT-3.5 and ChatGPT-4.0. UCSF Versa will be prompted to analyze the transcripts, generating both a diagnosis based on International Classification of Headache Disorders 3 criteria⁴¹ and a positive or negative recommendation for neuroimaging.

All patients will receive a detailed clinical history and neurological physical examination, which will be documented by the blinded in-person neurologist. Blinded study staff will review the neurologist’s clinic note for each patient and enter the diagnosis and imaging recommendations into REDCap.

This proposal has already been approved by the UCSF IRB (23-40675). Development of a REDCap Database and person-delivered PVA questionnaire has been completed. Participant recruitment has started; 10 have completed PVAs.

Methods: Implementation and Evaluation

Subsequently, the chatbot-delivered PVA will be implemented into the clinical workflow for new headache patient management in the UCSF General Neurology Clinic. New headache patient referrals will be randomized to either chatbot-delivered PVA and LLM evaluation vs standard of care. Results of the chatbot-delivered PVA and LLM will be sent to primary care physicians for headache management. The time to diagnosis (via LLM or neurologist), neuroimaging recommended/obtained and cost of the associated neuroimaging obtained will be calculated for the 6 months before and after clinical implementation. And the results will be compared between the two cohorts.

UCSF General Neurology Clinic:

Provider Characteristics: There are 9 board certified neurologists and 1 physician assistant employed.

Staff Characteristics: There are multiple patient coordinators, nurses and other staff.

Patient Characteristics: Adult patients 18+ years old

Potential Barriers to Implementation:

LLMs are being increasing used in medicine for various purpose from administrative tasks to clinical decision support.⁴ That being said there remain concerns related to the accuracy, reliability, and bias associated with LLMs as up as until recently they maintained limited clinical reasoning and produced hallucinations.³⁴ This LLM will be enhanced with the ICHD3 criteria for headache diagnosis in order to improve diagnostic accuracy. And the initial phase of the project involves validation of the LLM’s diagnostic performance. Moreover, effective engagement with these systems by patients necessitates a level of digital health literacy, which could be a potential source of equity bias. Patients may benefit from educational resources to facilitate engagement with the chatbot-delivered PVA. There is a need for standardized validation procedures and actionable guidelines for healthcare organizations as well as providers to ensure responsible implementation of LLM in the clinical setting.³⁴

We anticipate that the risks to the patient are minimal. Some patients have reservations about the accuracy, lack of empathy, and potential for privacy breeches associated with AI-integrated technologies.⁴² Patient data is de-identified and we rigorously adhere to IRB protocols and privacy standards to ensure that patient confidentiality is fully maintained. Moreover, while the goal is to reduce the overutilization of neuroimaging for uncomplicated headaches, a proportion of patients may receive a recommendation to obtain neuroimaging, which uncovers an incidental finding and leads to subsequent unnecessary testing and avoidable patient anxiety.

PROPOSED EHR MODIFICATIONS:

After the initial validation and implementation of the chatbot-delivered PVA and LLM, it could be incorporated into the electronic health record and require the following features 1) inclusion of MyChart Link for patients to access chatbot-delivered PVA and 2) an automated process to capture the results of the chatbot-delivered PVA with LLM and send results to referring providers and future neurologist.

RETURN ON INVESTMENT (ROI)

MRIs alone account for 51% of total healthcare expenditures in outpatient neurology.⁴¹ And the average cost of an MRI ranges from $1,600 – 8,400⁴² depending on extent of structures evaluated, insurance coverage, healthcare facility location, healthcare facility type, and need for contrast media. One Choosing Wisely campaign assessing the impact of the campaign on the use of brain MRI in preterm infants was associated with a significant decrease in non-indicated MRIs with expenditures decreasing from $1.3M in 2006 to $260,000 in 2016.⁴³ While another study revealed that a Choosing Wisely campaign for headaches was associated with a significant reduction in imaging for uncomplicated headaches from 10.8% to 6.9% in a 3-year period, which led to significant savings.⁴⁴ Over the long-term period, indirect cost savings will include reductions associated with a decrease in acute care utilization (e.g., ED visits, inpatient admissions), decrease in unnecessary diagnostics following up incidental findings as well as improvements in lost productivity of patients.

SUSTAINABILITY

The Technology Chief for UCSF’s General Neurology Division will be responsible for ongoing enhancements to the system. The Division Chief for UCSF’s General Neurology Division will be the executive sponsor for oversight and budgeting operational resources.

BUDGET

Faculty Protected Salary Time for Project Implementation: $38,000.00

Research Coordinator Stipend(s): $12,000.00

Supporting Documents:

HEAD GAIN REFERENCES

Laser hair removal as a treatment modality in pilonidal disease: Providing access to care in the East Bay and beyond

Submitted by Alicen Kershaw on March 2, 2025 - 11:37am Last revised by Rasmyah Hammoudeh on March 11, 2025 - 1:59pm.

Proposal Status:

Review Complete

PROPOSAL TITLE: Laser hair removal as a treatment modality in pilonidal disease: Providing access to care in the East Bay and beyond

PROJECT LEAD(S): Alicen Kershaw, NP, Layna Blurton, NP, Kreev Joundi, RN, Dr Sunghoon Kim

EXECUTIVE SPONSOR(S): Christopher Newton, MD

ABSTRACT: Pilonidal disease, characterized by the formation of cysts or abscesses in the sacrococcygeal area, primarily affects young adults and often leads to recurrent infections, discomfort, and significant quality-of-life issues. Conventional treatments, including antibiotics and surgery, have high recurrence rates, especially among adolescents, contributing to long-term health and social challenges. This proposal explores the use of laser hair removal as a preventive treatment to reduce recurrence and alleviate disease burden. Laser hair removal targets hair follicles in the affected area, thereby minimizing hair entry into the cystic space and preventing further cyst formation. While traditionally a cosmetic procedure, recent shifts in insurance coverage and clinical evidence suggest that laser hair removal can serve as an effective, low-risk adjunct to surgery in managing pilonidal disease. This initiative aims to provide laser hair removal treatments at the Oakland Pediatric Surgery Clinic, targeting adolescents with pilonidal disease, to reduce the need for surgical interventions by at least 50%. By addressing access disparities and offering this treatment as part of a comprehensive care approach, the project seeks to improve patient outcomes, reduce healthcare costs, and increase overall quality of life for patients. The intervention will be assessed through patient surveys and surgical recurrence rates, with a focus on equity in treatment access.

TEAM: Alicen Kershaw, NP, Pediatric Surgery and Trauma APP Layna Blurton, NP, Pediatric Surgery and Trauma APP Kreev Joundi, RN, Pediatric Surgery Clinic RN
Sunghoon Kim, MD, Pediatric Surgeon

PROBLEM: Laser hair removal is an effective treatment option for pilonidal disease, but there is little access to this treatment modality for patients in the Oakland Pediatric Surgery referral area

Pilonidal disease is a painful condition characterized by the formation of a cyst or abscess in the sacrococcygeal region, typically associated with hair, debris, and skin cells. It commonly occurs in young adults and can lead to recurrent infections, discomfort, and chronic pain. Pilonidal disease can be debilitating in the adolescent population, leading to long term dependence on caregivers, social withdrawal, and overall reduced quality of life. Treatment options for pilonidal disease vary based on the severity of the condition. For acute infections, antibiotics are prescribed, and surgical intervention may be necessary to drain abscesses or excise the cyst. However, recurrence rates are notable, prompting the exploration of alternative treatment modalities.
Laser hair removal is an effective preventative measure for pilonidal disease. The rationale behind this treatment is that reducing hair density in the affected area may decrease the risk of cyst formation or recurrence by minimizing the introduction of hair into the cystic space. Laser hair removal targets hair follicles, which can lead to significant and permanent hair reduction over time.
In the past, laser hair removal has been considered a cosmetic procedure, therefore only accessible to those who could afford to pay out of pocket, thus creating a wide socioeconomic disparity in this disease. However, insurance companies have started to reimburse for this necessary procedure in the face of data exemplifying the reduction in recurrences in the disease process with the use of laser hair removal.

TARGET: The goal is to reduce the burden of pilonidal disease by decreasing the need for surgical intervention in the adolescent population by at least 50% in the East Bay area and beyond by providing laser hair removal treatment. This would be measured by the rate of healing or improvement after patients undergo laser hair removal treatments and by rate of need for surgical intervention/recurrence with surgical intervention. Healing is defined as the absence of discharge or pain without any clinical documentation of pits, sinuses, or inflammation in the sacrococcygeal area. Improvement is defined as decrease in symptoms (pain, discharge, interference with work or school) but without complete resolution of pits, sinuses, inflammation. Symptoms would be measured pre and post intervention using a patient survey. The expected benefits would be decreased burden of disease, a decreased need for surgical excision and lower recurrence rates.

GAPS: Pilonidal disease has historically been a complex and difficult disease process to treat with a high recurrence rate even after multiple surgical interventions. Compliance rates with current hair removal treatments such as chemical dilapidation and shaving are low as both have side effects and require both long term and frequent intervention. Laser hair ablation has been shown to be the most effective long-term strategy for the treatment of pilonidal disease. Laser hair removal began as a cosmetic intervention in health care and therefore has been unavailable to lower socioeconomic populations thus creating a major gap in access to care despite this being the gold standard for treatment in pilonidal disease. Currently, there is limited access to this treatment for patients with pilonidal disease in the UCSF Benioff Children’s Hospitals catchment area as UCSF does not offer this treatment.

INTERVENTION:

Our proposed intervention is to implement laser hair removal at the onset of diagnosis of pilonidal disease as this has been well documented to decrease disease burden over time and reduce necessity of surgical interventions.
Patients will undergo hair dilapidation treatments monthly until hair removal is achieved. The exact number of treatments varies by patient but averages 5.
We will use a validated patient survey tool as well as number of surgical interventions for each patient as our measurable forms of improvement with our specified treatment modality and will specifically include race and socioeconomic status in the surveys to ensure equitable treatment for the whole of our patient population.
Our practice setting is the pediatric general surgery clinic where we will provide laser hair removal treatment at a minimum of 3 days a week with the goal to increase to 5 days a week as we have an increase in patient volume.
Our targeted population would be any adolescent under the age of 21 with the initial diagnosis of pilonidal disease or pilonidal abscess referred from the community or emergency department or self-referred.
The biggest barriers to implementation are the initial capital cost of obtaining a laser, as well the cost of training staff members to perform the treatment. Other barriers are the lack of an established 240v electrical outlet (required for laser hair machine).
Another potential barrier is obtaining reimbursement from insurance companies as laser hair removal therapy has been considered cosmetic in the past; however, the pediatric surgery community has been working towards increasing insurance coverage for laser hair removal in pilonidal disease and reimbursement rates have been improving overall.
Side effects of laser hair removal include blisters, burns, muscle spasms, fatigue, nausea, and headaches. Long term effects can include hypopigmentation, hyperpigmentation, scars, and other permanent skin blemishes. However, with appropriately trained staff and quality medical grade equipment, laser hair removal is considered safe and has minimal side effects.

PROPOSED EHR MODIFICATIONS

Create a template for documenting the treatment.
Create a template for the initial H&P that justifies the need for the laser hair
removal
Create an EHR Report to track the number of treatments, number of recurrences,
need for surgical intervention

RETURN ON INVESTMENT (ROI): Revenue will be obtained by performing treatment on patients and through insurance reimbursement. The average number of treatments is 5. Estimated insurance reimbursement per treatment is $100. Our surgical group currently sees approximately 20 patients with a diagnosis of pilonidal disease per month. With an average of 5 treatments per patient at an estimated reimbursement rate of $100, revenue would be $10,000 per month with a return on investment within 6-8 months of implementation of the new treatment plan. This does not include the overall health savings of reduced trips to the OR for surgical intervention and reduction in emergency department visits.

SUSTAINABILITY:The project will be sustainable via reimbursement from insurance companies, which will provide continued revenue to support the ongoing laser treatments. The capital costs could further be offset by expanding laser treatment to include other disease processes through collaboration with the dermatology department, who also uses laser therapy for treatment of dermatological diseases. Operational leaders: Christopher Newton, MD Division Chair, Department of Pediatric Surgery at UCSF Benioff Children’s Hospital of Oakland. Mo Sullivan, MS-HCA, Practice Administrator | Ambulatory Services, Audiology, ENT, GYN, Pediatric Surgery, & Urology

BUDGET:

Laser - 38,000

Staff training – 5,000

Upgrading electrical system - 5,000

Creating and administering pre and post intervention surveys - 1,000

Total cost: 49, 000

Supporting Documents:

caringwiselyreferences.pdf

Pre-Surgery Clinic Patient Resource Navigator Program for the Benioff Children's Hospital

Submitted by Lan Vu on March 2, 2025 - 11:05pm Last revised by Rasmyah Hammoudeh on March 11, 2025 - 1:58pm.

Proposal Status:

Review Complete

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 drivers 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 in the Pre-Surgery clinic at Children’s Hospital in San Francisco and Oakland.

TEAM -
Phillip Herrera (ZSFG Health Advocate Program coordinator): Mentor/Consultant
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)
Lauren Puplampu and Alondra Aguilar (currently students in the UCSF-UC Berkeley Joint Medical Program, in the progress of training to become patient navigators in the ZSFG Health Advocate Program)

PROBLEM – Surgical quality outcomes is strongly tied to social drivers 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 limited social worker resource (0.25 FTE) in the Pediatric Pre-surgery clinic to address these needs when identified.
TARGET - Children scheduled for surgery at the Benioff Children’s Hospitals in San Francisco and Oakland.

Outcome metrics:

Distribution of individual-level and neighborhood-level SDoH in our current surgical patient population
Successful contact with families by the patient navigator
Quality metrics: Surgery same day cancellations rates and ED visits within 30 days of procedure before and after implementation of patient navigator program
Comparing individual-level SDoH with neighborhood level-level SDoH (SVI and COI) and their impact in on the surgical outcomes in the NSQIP-P database.
Results of patient/family satisfaction survey after enrollment in the program

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 limited 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 (already started on January 2025)

6 to 12- month commitment to the Health Advocate program at ZSFG
Needs assessment: Mapping the geographic distribution of the surgical patients, identifying the high yield counties, and creating county-based community resource algorithms addressing the key SDoH.

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
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 (plus administration of 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) in one year

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 and COI 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 a cross-bay program coordinator who will work in synergy with the social workers in the Pre-Surgery Clinic at Mission Bay and Oakland. Dr. Lan Vu, as the current Medical Director of Surgical Quality and Safety at Mission Bay will take on the additional responsibility of supervising this program. The role and responsibilities of that program coordinator are listed below. 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

Stipend for Health Advocate Program Coordinator as consultant $30,000
0.1FTE Medical Director $10-20,000

See below for shared responsibilities of Program coordinator and Medical Director

Patient Navigator Program Development: Leverage experience from the Health Advocates program to assist with the implementation of a patient resource navigator program tailored to the Pre-Surgery Clinic's needs.

Workflow and Algorithm Creation: Develop and optimize workflows and algorithms to ensure efficient SDoH screening, resource referrals, and follow-up, drawing on proven methodologies from Health Advocates program.

Community Resource Collaboration: Provide strategic input into the identification and integration of county-specific resources, ensuring navigators are equipped with actionable tools to address diverse patient needs across California.

Data-Driven Quality Improvement: Collaborate with identifying appropriate methods for collecting and analyzing program data, such as SDoH impact metrics and patient satisfaction, to demonstrate program effectiveness.

Strategic Stakeholder Engagement: Collaborate with clinical teams, community organizations, and the study leadership to align program objectives and foster partnerships that enhance resource accessibility and patient outcomes

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.

Reducing Hospital-Acquired Infections Through Creation of HAI Diagnostic Excellence at UCSF

Submitted by Amy Larsen on March 3, 2025 - 8:46am Last revised by Rasmyah Hammoudeh on March 11, 2025 - 1:57pm.

Proposal Status:

Review Complete

PROJECT LEAD(S): Cass Sandoval, Adult Critical Care CNS; Amy Larsen, Adult Critical Care CNS; Lindsay Bolt, Adult Medical CNS

EXECUTIVE SPONSOR(S):

True North Outcomes Committee:
- Art Dominguez, Chief Nursing Officer for Adult Services
- Nerys Benfield, Chief Medical Officer for Adult Services
- Debbie Yokoe, Medical Director, Hospital Epidemiology and Infection Prevention

ABSTRACT

In alignment with UCSF True North goals and national practice guidelines, this initiative aims to develop and implement a program of HAI Diagnostic Excellence for hospital-acquired infections (specifically CLABSI, CAUTI, and CDIFF) in the form of standard work for diagnostic evaluations of urine, blood and C. difficile laboratory testing. This program will include a range of components from practice guidelines, HAI-related testing and collection workflows, related APeX workflows, and analysis/reporting capabilities. The HAI Diagnostic Excellence Program will not only reduce the occurrence of clinically insignificant infections but also can potentially save the organization an approximated $560,000 a year, or more. Indirectly, the output from this initiative will lead to savings through reduced equipment and supply needs and reduced clinician time spent performing these tests. Finally, this initiative maximizes patient safety and outcomes by avoiding unnecessary antibiotic use resulting from the treatment of clinically insignificant test results, aligning with principles of antibiotic stewardship, and overall lowering hospital length of stay.

TEAM

Nursing Clinical Leads: Cass Sandoval, Adult Critical Care CNS; Amy Larsen, Adult Critical Care CNS; Lindsay Bolt, Adult Medical CNS
Nursing Operational Leads: Tristin Penland, Interim ACNO for St Mary’s and St Francis hospitals; Elizabeth Sin, PCD Adult Transitional Care; Janice Elzinga, UD Adult Surgical ICU; Mark Apavatjrut, UD Adult Medical ICU
Provider Leads: Lindsay Huddleston, MD; Catherine Lau, MD; Daniel Escobar, MD
HEIP Leads: Renee Graham-Ojo, Infection Preventionist; Steffanie Lee, Infection Preventionist; Michelle Downing, Infection Preventionist

PROBLEM

Hospital acquired infections (HAI) such as CAUTI (catheter-associated urinary tract infections), CLABSI (central line-associated bloodstream infections), and CDI (clostridioides difficile infections) are preventable harms known to increase morbidity, mortality, hospital length of stay and overall hospital costs. While preventing patient harm and returning a patient to at least their baseline level of health is always top priority, it is also acknowledged in the literature that the strict surveillance criteria for these infections is estimated to over-diagnose CAUTI by ~37%, CLABSI by ~30%, and CDI by ~15%–53% (Madden et al., 2018). Clinically, inappropriate testing can lead to overtreatment, often with antibiotics, which itself can lead to adverse drug events such as rash, candidiasis, and diarrhea, as well as increased rates of bacterial resistance and true CDI.

At UCSF, we know we are over-diagnosing and over-treating these HAIs based on CAUTI, CLABSI, and CDI case reviews where individual cases are discussed. However, the full scope of the problem is unknown since there are patients who develop UTI or bloodstream infections that do not meet the specific surveillance criteria for CLABSI or CAUTI (so do not get review by the HAI committees) but would otherwise be considered clinically insignificant yet still receive antibiotic treatment. It is well established that antibiotic therapy increases a patient’s risk of developing CDiff, potentially hindering our improvement efforts surrounding CDiff.

In alignment with our True North pillars, reduction work for preventable harms has been in place for several years. One of the few remaining major opportunities shared among the three HAIs is that of diagnostic excellence. As the CDC describes, diagnostic excellence is a broad term that encompasses practices aimed at ensuring the right patient gets the right test at the right time and is given the right treatment (diagnostic stewardship). It also includes systems to support these practices from an EHR/documentation and reporting/quality analytics perspective. In 2023, the Society for Healthcare Epidemiology of America (SHEA), the Infectious Disease Society of America (IDSA), and the Association for Professionals in Infection Control and Epidemiology (APIC) published a compendium of practice recommendations for HAI prevention in acute-care hospitals, listing diagnostic stewardship as an essential practice (Yokoe et al.). Finally, multiple studies have concluded that implementing diagnostic excellence strategies can aid in diagnosis and improve patient outcomes while also maximizing care efficiency and, ultimately, cost savings to the organization.

TARGET

Fewer deviations from existing practices for ordering and collecting specimens
Fewer HAI deemed to be clinically insignificant
Achieve True North SIR goals for CAUTI, CLABSI and CDiff

GAPS

We have a large diverse provider population involved in patient care who independently order HAI diagnostic tests. It is difficult to keep providers up to date on current diagnostic guidelines and mindful of diagnostic stewardship. Other provider related reasons include disbelief in diagnostic stewardship or malpractice concerns. At times, there may be a lack of documentation to support the diagnostic indication (e.g., 3 loose stools for CDI) and sometimes patients or families themselves play a role when insisting on a given diagnostic work up.

INTERVENTION

Developing a program of diagnostic excellence will include the following:

Establishing best practices for testing and treating CLABSI, CAUTI, and CDIFF based on currently available literature, guidelines, and community standards.
Adapting those best practices to create UCSF standard work for testing and treating.
Develop EHR workflows to support that standard work for direct care clinicians.
Develop standard work for assessing process measures and compliance with new workflows through newly developed reports and a feedback loop to clinicians.
Develop reporting workflow on compliance to promote transparency and sustainability. This would likely occur at True North Outcomes meetings.
Develop education and dissemination plan to socialize new standard workflows to nursing, ordering clinicians, clinical care partners, and laboratory and phlebotomy staff.
Education campaign highlighting proper specimen collection for testing.

Initial scope would include adult inpatient areas at Parnassus, Mission Bay, and Mount Zion campuses.

Anticipated barriers include the following:

There may be specific questions that arise during standard work development that do not have definitive answers in the current body of literature. This would require consensus decision with a group of subject matter experts.
Creating a build in the EHR may require waiting for analyst workflow availability. There may also be limitations of our EHR system that are unavoidable.
It is expected that changing the current culture and workflow for testing will be challenging. Many of the existing practices are deeply rooted and will require patience as those practices are de-implemented and new workflows introduced and established.

Potential adverse events include the following:

There is a potential of delayed treatment of a true infection if a specific patient condition falls outside the guidelines of standard work. Based on experiences at other organizations, this is a fear rarely actualized, though is always possible.

Equity considerations:

In our current state, we are unable to assess any gaps in equity due to gaps in our analytic capabilities. Assessing for and addressing any equity gaps in our performance with CLABSI, CAUTI, and CDiff would be a high priority consideration for this work.

PROPOSED EHR MODIFICATIONS

In the current state, there is considerable variability in practice between clinicians in both ordering and collecting lab specimens. There is also minimal clinical decision support built into APeX to reduce the cognitive burden of adhering to existing workflows, further contributing to variability in practice.

We currently rely on manual chart reviews and live huddles to investigate each infection. Recently, a Qualtrics survey was developed to collect data from these huddles but is not fully integrated with APeX. There are reports also available to identify certain data relevant to HAI review. However, they provide a small portion of the data required for case review.

Our goal requires the following in the EHR/APeX:

Decision support and “smart” order panels for testing indications and specimen collection. For example, populating a specific set of orders based on whether a patient has an indwelling urinary catheter or not.
Report build for assessing compliance with approved workflows, also allowing the organization to promote clinician accountability.

RETURN ON INVESTMENT (ROI)

Based on AHRQ data of cost to the organization per infection from 2017 that is adjusted for inflation to 2021, and our average performance over the past 5 years (Jan 2020 – Jan 2025), we could expect the following ROI:

Infection	Total Count (1/2020-1/2025)	Avg count/ year	Est Cost per case (Low)	Est Cost per case (Median)	Est Cost per case (High)	Est UCSF Cost/year (low end)	Est UCSF Cost/year (Median)	Est UCSF Cost/year (High End)
CLABSI	288	57.6	31,221	55,154	79,087	1,798,307	3,176,885	4,555,398
CAUTI	306	61.2	5,754	15,813	25,873	352,152	967,770	1,583,457
CDIFF	363	72.6	10,709	19,788	28,868	777,484	1,436,611	2,095,820
TOTAL						2,927,944	5,581,266	8,234,675

If we consider a 10% reduction in infections resulting from diagnostic excellence work through Caring Wisely (studies show this a reasonable estimate which also aligns with our True North goals), and the estimated costs from above, we could expect the following savings to the organization in the first year:

Infection	Median Cost Savings (low end – high end)	Est Cost Savings/ year (low end)	Est Cost Savings/ year (median)	Est Cost Savings/ year (high end)
CLABSI	317,689 (179,831-455,540)	179,831	317,689	455,540
CAUTI	96,777 (35,215-158,346)	35,215	96,777	158,346
CDIFF	143,662 (77,748-209,582)	77,748	143,661	209,582
TOTAL	558,127 (292,794-823,468)	292,794	558,127	823,468

In summary, while this data is not specific to UCSF, we can safely assume that the cost to UCSF is at least comparable to the median costs estimated by AHRQ. Using those estimates, the combined annual cost to UCSF for CLABSI, CAUTI, and CDIFF is about $5.5 million. Using a conservative reduction estimate of 10% resulting from Diagnostic Excellence work, we can estimate an annual savings of about $550,000. Note: these estimate ONLY considers infections classified as CLABSI, CAUTI, or CDIFF. It does NOT count infections in patients who do not meet criteria for CLABSI or CAUTI, meaning the actual cost and savings to the organization are likely higher than these conservative estimates.

SUSTAINABILITY

After the initial infrastructure is built during the funding year, the existing structure of True North Outcomes, which encompasses CLABSI, CAUTI, and CDIFF committees, will support ongoing maintenance, reporting, and other enhancements identified. Part of the intervention will be identifying a standard workflow that encourages sustainability of the program.

BUDGET

Materials/Supplies (printing, socialization/dissemination materials): $ 2,000
Support for non-clinical time for team members/Project manager: $30,000
Report writer: $ 9,000
Data analysts: $9,000
Total: $50,000

Establishing a Pharmacist-led Cytomegalovirus Stewardship Program to Reduce Hospital Admissions, Length of Stay, and CMV Resistance

Submitted by Jessica Reeves on March 3, 2025 - 11:04am Last revised by Jessica Reeves on March 27, 2025 - 12:39pm.

Proposal Status:

Selected for 2nd Round

PROJECT LEAD(S): Jessica Reeves, PharmD and Aida Venado, MD

EXECUTIVE SPONSOR(S): Steven Hays, MD; Lori Coleman, RN; Ashley Thompson, PharmD; David Quan, PharmD

ABSTRACT  Cytomegalovirus (CMV) infection is a prevalent and serious opportunistic infection in immunocompromised solid organ transplant (SOT) recipients, with significant impacton graft survival, morbidity, and mortality. Valganciclovir, the first-line agent for prevention and treatment of CMV, requires precise dosing to avoid breakthrough infection and development of resistance due to underdosing and myelosuppression from overdosing. With the growth of our transplant program, admissions for CMV have increased from 13 in 2020 to 30 in 2024. Correspondingly, the average length of stay has risen from 69 days to 438 days, resulting in a significant increase in cost from $358,549 in 2020 to $2,470,406 in 2024.To address these challenges, we propose the implementation of a pharmacist-led CMV stewardship program utilizing existing tools within the Apex system to optimize medication dosing and monitoring. Literature supports that pharmacist-led stewardship programs can reduce the incidence of CMV viremia, prevent breakthrough infections, accelerate time to viral eradication, lower resistance rates, and decrease CMV-related hospital admissions by shifting from reactive to proactive care.1-3 Utilizing published strategies, the proposed pharmacist-led CMV stewardship program aims to reduce inpatient days due to CMV infection by 25%, achieve cost savings exceeding $500,000 annually, and minimize CMV resistance, thereby improving patient outcomes, morbidity, and mortality in SOT recipients.

TEAM  We plan to initially implement the stewardship program within the lung transplant group, with the intention of expanding it to other SOT teams, all eager to improve CMV outcomes.Given that all SOT groups have similar outpatient lab review workflows and a dedicated pharmacist in clinic, this model will be easily applicable across other transplant populations. The initiative has the full support of both pharmacy and lung transplant leadership.

Transplant pulmonologist: Aida Venado, MD, MAS

Lung Transplant Pharmacists: Jessica Reeves, PharmD, Rebecca Florez, PharmD, Rachael Gordon, PharmD, Bo Yen, PharmD

Heart Transplant Pharmacist: Jose Lazo, PharmD, Victoria Nguyen, PharmD, Brandon Martinez, PharmD

Abdominal Transplant Pharmacists: Althea Han, PharmD, Melanie Mascetti, PharmD, KevenGomez, PharmD, David Quan, PharmD, Jennifer La, PharmD

PROBLEM  CMV infections are common in the general population, typically causing mild illness in healthy individuals. However, CMV is a major complication in SOT recipients and is associated with significant healthcare costs, morbidity,and mortality. Once exposed, CMV remains latentand can reactivate during immunocompromised states. Risk stratification in SOT recipients is based on CMV serostatus: CMV IgG positive indicates prior exposure, and CMV IgG negative indicates no exposure. SOT recipients who are CMV mismatch (donor IgG positive, recipient IgG negative) are at the highest risk for infection. Additionally, the profound immunosuppressionrequired to prevent allograft rejection increases the risk for CMV reactivation which can lead tointense viral replication and life-threatening infection.

Valganciclovir is an oral antiviral that is the first-line standard of care for both the prevention and treatment of CMV infection. Dosing requires careful adjustment based on renal function, as underdosing increases the risk of breakthrough infection and the development of refractory or resistant disease, while overdosing can lead to myelosuppression, potentially exacerbating complications in immunocompromised patients. When refractory or resistant CMV infection is suspected, a genotyping test is performed to detect mutations and confirm antiviral resistance. This test is typically not available at labs outside of UCSF and can only be performed when CMV viral loads exceed 1,000 copies.

While close attention must be paid to renal dose adjustments, clinical expertise and individualized, comprehensive patient evaluation should be considered before implementing a dosing change considering factors such as recent VL, serostatus, presence of neutropenia or thrombocytopenia, and level of immunosuppression.

Within the lung transplant program, lab results are reviewed collaboratively by nurse coordinators with an advanced practice provider (APP), fellow, or attending pulmonologist. Similar workflows are followed in the outpatient management of other SOT patients. During lab review, renal function and CMV VL are briefly assessed, and dosing changes to valganciclovir are made accordingly. Due to the high volume of patients, there is often insufficient time to conduct a comprehensive assessment of each case leading to instances of inappropriate dose reductions, contributing to breakthrough viremia or development of CMV resistance, which requires hospitalization for IV therapies.Furthermore, a lack of standardization in the formulas used to assess renal function among providers has led to dosing discrepancies, confusion about when to initiate treatment versus continue prophylactic dosing for low-level CMV viremia, and inconsistent use of CMV genotyping.This has resulted in increased burden to patients, such as the need to travel to long distances to UCSF for CMV genotyping, as well as increased costs to both UCSF and patients.

Rural and underserved communities can face disparities in care. Patients in communities that do not have LabCorp or Quest and rely on alternative facilities for lab work can experience significant delays in time to reporting of their labs, leading to delays in adjustment of dosing, initiation of treatment, or assessment for resistant disease. If resistant disease is suspected, these patients must travel to UCSF for CMV genotyping, as it is generally unavailable at outside laboratories.

Over the past five years, UCSF has seen a notable increase in inpatient admissions for the management of CMV infections, rising from 13 in 2020 to 30 in 2024, with the rate of CMV admissions per 1000 admissions increasing from 3.2 in 2021 to 8.1 in 2024. This has also been accompanied by a substantial rise in total inpatient days from 69 to 438 (with a median lengh of stay ranging from 4 in 2020 to 7 in 2024), suggesting a trend toward more severe or refractory cases. The financial impact of these admissions has also escalated exponentially, with total costs increasing from $358,549 in 2020 to $2,470,406 in 2024 with a median cost of $16,619 in 2020 and $31,075 in 2024. Please see attached document 'hospitalizations, length of stay, and costs' attached for further details and breakdown by organ group. Furthermore, multiple incident reports (IRs) have been filed concerning missed or delayed CMV lab results, as well as the development of severe, resistant CMV disease linked to the underdosing of valganciclovir. With regard to lab tests, the number of CMV genotyping tests performed has increased, from 22 tests in 2020 to 33 in 2024. Specifically, within the lung transplant group, 26 genotyping tests have been sent from 2020 to 2024. Confirmed CMV resistance has increased from 50% (1 out of 2 tests) in 2020 to 75% (6 out of 8 tests) in 2024. Additionally, eight of the 26 genotyping tests were sent inappropriately with insufficient VL for the test to be run.

This concerning trend of escalating inpatient days, costs, and increased morbidity and mortality is expected to persist as our annual transplant volume continues to grow. As of December 2024, UCSF ranks as the second all-time highest volume transplant center in the United States, having performed a total of 18,449 organ transplants, according to the Organ Procurement and Transplantation Network (OPTN).

TARGET Published literature supports that pharmacist-led CMV stewardship initiatives can reduce CMV infection rates, CMV-related hospital admissions, and CMV resistance rates by over 40%.1-3 Furthermore, when patients develop (val)ganciclovir resistance, literature suggests that there is a ten-fold increase in associated total hospital costs ($200,000 vs $20,000).4 Based on published literature and success of these pharmacist-led initiatives, our goal is to implement a pharmacist-run CMV stewardship program aimed at reducing CMV-related hospital admissions, inpatient days, associated costs, and the development of CMV resistance by 25%. This would result in a reduction of annual CMV-related hospital admissions from 30 to 22 and a decrease in inpatient days from 438 to 328. With an estimated direct variable cost of $1,688 per bed for the 2023-2024 academic year, we anticipatecost savings of at least $183,992 (excluding ICU bed costs) from a 25% reduction in patient days.

In 2024, the total cost associated with CMV infection admissions was $2,470,406. We project a 25% reduction in costs, resulting in total savings of $617,601. Lastly, we anticipate a 25% reduction in the development of CMV resistance. In 2024, 33 CMV genotyping tests were ordered at a cost of $1,945 per test. With a 25% reduction in resistance and the subsequent need for fewer genotyping tests, we expect to save $16,000.

We utilized Slicer Dicer within Apex to determine the number of admissions, total length of stay, and total associated costs for CMV infection as the principal problem for admission.

GAPS Currently, the primary gap is significant variability in CMV management within the lung transplant program at UCSF, as well as across other organ transplant groups. In the existing workflow, CMV viral load results are reviewed alongside renal function during daily lab review (Monday through Friday) with nurse coordinators and an APP, fellow, or attending. Due to the high volume of labs reviewed, there is often insufficient time to individualize and comprehensively assess each CMV result and corresponding change in renal function. Additional challenges include the absence of updated, standardized protocols regarding when to initiate treatment dosing of valganciclovir versus when to continue monitoring, resulting in confusion and inconsistent practices.

Within Apex, there has been the use of different creatinine clearance calculators that may utilize an inappropriate patient weight leading to under or over estimating creatinine clearance, further complicating dosing decisions. Additionally, if a patient has not had a weight or serum creatine in the past twenty-one days, Apex will not calculate a creatinine clearance, leading providers to potentially calculate it incorrectly. Moreover, there has been an overuse of CMV genotyping in patients without clinical suspicion of resistant or refractory disease, or without sufficient viral load for the test to be run, leading to unnecessary costs and increased patient burden due to the need to travel long distances to UCSF for testing.

Lastly, some patients routinely have laboratory tests conducted at non-UCSF facilities or facilities that do not result within Apex (i.e. NOT UCSF, Labcorp or Quest), requiring manual entry of results into the Apex system.This process introduces equity gaps, resulting in delays in receiving test results, adjusting valganciclovir dosing, and initiating timely treatment for breakthrough CMV infections.These delays contribute to the emergence of resistant CMV strains, which may ultimately necessitate inpatient treatment with intravenous foscarnet or maribavir. Patients who are most adversely affected are those residing in remote communities with limited access to local laboratory services.

INTERVENTION  We propose the implementation of a pharmacist-led CMV stewardship initiative, modeled after successful programs at other institutions, which have demonstrated reductions in the incidence of CMV viremia and breakthrough infection, faster time to CMV eradication, lower rates of CMV resistance, and a decrease in CMV-related hospital admissions.1-3 Furthermore, these stewardship models have facilitated a shift in patient-centered care from reactive to proactive, leading to improved patient outcomes and a reduction in the duration of valganciclovir therapy needed to achieve viral clearance, which can help reduce risk of myelosuppression in an already vulnerable population.1

This pharmacist led initiative will be implemented in the outpatient setting and integrated into the workflow of the covering outpatient pharmacist for each respective organ group.First, an updated UCSF CMV protocol will be developed in collaboration with Infectious Disease Specialists, Lung Transplant Specialists, and Transplant Pharmacists to align with current practices and streamline CMV management. To ensure the sustainability and long-term success of the initiative, we will initially focus on the highest-risk populations, including CMV mismatch patients (donor CMV IgG positive, recipient CMV IgG negative), individuals with an active CMV viral load, and those receiving alternative therapies for CMV (such asletermovir,maribavir, foscarnet, or cidofovir).

Working with Phoenix and informatics teams, an Episode of Care Encounter will be created to facilitate the enrollment and monitoring of these high-risk patients. A daily report (Monday through Friday) will be generated within Apex, enabling the covering clinic pharmacist to review enrolled patients. The pharmacist will clinically assess the patients' new lab results and may take one of the following actions, as clinically appropriate: adjust the dose of valganciclovir, modify the frequency of CMV viral load monitoring, or order CMV resistance genotyping. Additionally, the pharmacist will communicate with the covering attending physician and make recommendations regarding changes to immunosuppression, admission for intravenous therapies in cases of suspected refractory or resistant CMV, or switching to alternative therapies due to adverse effects.

Through the Episode of Care, the pharmacist will be able to document a concise, standardized note utilizing DOT phrases, which will be routed to the nurse coordinator and sent to the patient via MyChart. The nurse coordinator will then follow up with the patient to ensure the necessary changes are implemented. Communication of medication changes with patients by the nurse coordinator is already a standard of practice within our workflows. The pharmacist will also assign a follow-up date to the encounter, and the daily report will allow sorting based on the next follow-up date, enabling timely review of labs and ensuring that the pharmacist can reach out if labs are not completed as expected.

All high-risk CMV patients will be enrolled in the CMV initiative during their index hospitalization for transplantation by the covering inpatient transplant pharmacist. In the outpatient setting, when an CMV VL is detected, an alert will be triggered in Apex and sent to the respective pharmacist’s pooled in-basket. The pharmacist will then enroll the patient for ongoing management. Additionally, patients currently receiving alternative therapies will be enrolled for monitoring of CMV VL to detect any breakthrough viremia, or at the time of transitioning to alternative therapies.

This initiative has been discussed with our informatics and Phoenix teams and we believe the intiative to be feasible within the Caring Wisely year. We don't anticipate that this will be affected by the Beaker lab build freeze. The data we will need to utilize for this initiative is already available and will only require creation of a dashboard to track and monitor patients within Apex.

Potential barriers to implementation include ongoing challenges in obtaining lab results promptly for patients in remote areas whose EHRs do not integrate with ours, as well as difficulties in obtaining CMV resistance genotyping at outside hospitals or labs. Additional challenges include medication non-compliance leading to breakthrough CMV infection and insurance authorization for alternative therapies such as maribavir or letermovir. While we anticipate staffing coverage of this initiative to assimilate into our current workflow, there is a potential barrier for staffing gaps if a pharmacist(s) is on vacation and may require the inpatient pharmacist to review the daily report.

With regard to implementing this initiative within our respective teams, we plan to develop provider-facing material in the form of an updated CMV prophylaxis and treatment protocol for each solid organ transplant organ group as well as a written protocol detailing the CMV initiative and outlining the changes in workflow. We can also hold a Zoom meeting with the respective parties involved in lab review to educate on the workflow changes.

PROPOSED EHR MODIFICATIONS We need to develop a new workflow for CMV monitoring for transplant recipients at UCSF within Apex utilizing Episodes of Care Encounters. This platform will facilitatetimely, reliable, and closed-loop communication among multiple stakeholders—patients, transplant pharmacists, and nurse transplant coordinators—from laboratory result review to patient instructions. Please see the attached document outlining specific EHR modifications.

RETURN ON INVESTMENT (ROI)  Based on our goal of a 25% reduction in CMV-related hospital admissions, inpatient days, associated costs, and the development of CMV resistance, the following cost savings and revenue enhancement would be achieved:

Reduction of annual CMV-related hospital admissions from 30 to 22

Decrease in inpatient days from 438 to 328

Cost savings of $16,00 for reduced CMV genotyping tests, based on CMV genotyping test of $1,945

Cost savings of at least $183,992 in bed costs (excluding ICU bed costs) based on estimated variable cost of $1,688 per bed for the 2023-2024 academic year

Total hospital-admission cost savings of $617,601 based on total annual cost of $2,470,406 in 2024

SUSTAINABILITY Within the transplant programs, pharmacists and nurse coordinators are already established members of the team. With lung transplant pharmacists in clinic five days per week, we believe that this model will be sustainable, requiring approximately 1 to 1.5 hours of review time per day, Monday through Friday, based on the time commitment described by other institutions and estimated volume of labs to be reviewed. We believe that funding for this initiative would allow this project to be created, which would then be assimilated into pre-existing workflows allowing for sustainability and longevity beyond the funding year while improving patient care and resulting in cost savings.

Supervisors, managers, and transplant pharmacists are all in support of integrating this into their existing outpatient roles. The initial idea for implementation of this project arose from within our pharmacy group in response to incident reports. Additionally, this CMV stewardship initiative has support from our infectious disease colleagues and respective solid organ transplant teams. We expect that the success of this initiative will have a profound positive impact on patient care and reduce morbidity and mortality post-solid organ transplant. The additional workload is anticipated to be feasible and can be incorporated into existing clinic workflows. Typically, clinic days are only half day in regard to actively seeing patients. The pharmacist spends the other half of the day answering inbasket messages, reviewing patients for the following days clinic, providing medication access, etc. During this second half of the day, the pharmacist will be able to incorporate this new CMV workflow into their day.

Reviewing high-risk CMV patients through this protocolized initiative will also allow for improved workflow efficiency. In the current state, the pharmacist receives in basket messages when providers have questions about CMV medication dosing. This initiative will reduce these in basket requests and create a platform for a more streamlined, efficient approach for monitoring patients. With the buildout of a more systematic report within Apex, this would make our time, review and follow up of these patients more efficient and consistent providing equitable care to all solid organ transplant recipients.

Lastly, with this initiative we plan to build a dashboard within Apex that will be managed by the team and allow us to monitor and sustain the process measures, which will be integral to the success and longevity of this initiative. We anticipate that the build of this initiative would only take a couple of months (2-3) and first tests of change could be performed within the following six months.

BUDGET 

Salary support for project lead: $50,000

Supporting Documents:

ehr_modifications.pdf

resources.pdf

hospitalizations_length_of_stay_and_costs.pdf