2017-10-02 21:00:41 UTC

Spotlight on Fellow-Led Quality Improvement Projects

Oct. 3, 2017

These 19 projects presented at DDW® 2017 showcase the extensive work being done by fellows to improve the quality of care provided to GI patients.

Each year during Digestive Disease Week®, AGA hosts a session titled “Advancing Clinical Practice: GI Fellow-Directed Quality-Improvement Projects.” During the 2017 session, 19 quality improvement (QI) initiatives were presented — you can review these abstracts in Gastroenterology. Keep reading for a summary of these noteworthy projects that will ultimately improve the quality of GI patient care. Kudos to the promising fellows pictured below, who all served as lead authors for their QI project.

Barriers to Post-Surgical Biologic Therapy in Crohn’s Disease

Dr. Shirley Cohen-Mekelburg’s group reports on rates of delay for post-surgical biologic therapy in high-risk Crohn's patients and risk factors associated with such delays. This research reflects Dr. Cohen-Mekelburg's interest in post-surgical Crohn's disease management, which started as a first-year GI fellow after noticing the high rate of health care utilization amongst patients who had undergone multiple bowel resections.

Trainee Colonoscopy Withdrawal Time Is Influenced by the Independent Performance Characteristics of Supervising Physicians

Dr. SriHari Mahadev explains that trainees deliberately model supervisor behaviors, but they are also influenced subtly by supervisor traits, both good and bad. In their study, Dr. Mahadev and his team found that supervisors' own withdrawal times at colonoscopy "rub off" on the trainees they supervise. Quality measures in colonoscopy have become increasingly important, which warrants further study on the impact of supervisor traits on trainee performance.

Impact of Trainee Experience on the Decision to Perform Endoscopy on Weekends

Also led by Dr. SriHari Mahadev, this study identified that fellows were less likely to perform endoscopy on weekends as they progressed through the academic year. Greater trainee experience may result in greater comfort with resuscitating and waiting for a weekday procedure. Based on this research, further study on the impact of trainee behavior on patient outcomes in endoscopy is warranted.

Tube Feed App: A Novel Smart Phone Application for Enteral Nutrition

Dr. Sultan Mahmood’s team conducted a survey of resident physicians and identified a general lack of knowledge about enteral nutrition. Using American Society of Enteral and Parenteral Nutrition (ASPEN) and European Society of Enteral and Parenteral Nutrition (ESPEN) guidelines, his group worked to developed a Tube Feed App that can improve early enteral nutrition in the critical care unit. This abstract details the impact of the app in practice.

Colonoscopy-Naive Raters Can Accurately Assess Colonoscopy Inspection Quality
Dr. Anna Duloy’s team identified that it may be more efficient and equally as effective to use novice raters instead of expert raters to assess colonoscopy inspection quality (CIQ). Their abstract proves that novice rater assessments of CIQ correlate with expert rater assessments. Evaluation of CIQ by novice raters may augment current colonoscopy quality improvement programs by providing objective and actionable feedback to endoscopists without a need to rely on expert reviewers.

The Boston Bowel Preparation Scale: Introduction of a Valid and Reliable Tool to the DVAMC Endoscopy Unit

As part of a quality improvement initiative, Dr. Scharles Konadu and colleagues developed a method to transition the Durham VA Medical Center (DVAMC) endoscopy unit from their previously used subjective bowel preparation scoring system (excellent/good/fair/poor) to the objective Boston Bowel Preparation Scale. Their abstract details compliance to the new scale. The group achieved their compliance goal of 80 percent, and the new process was well received not only by the faculty and fellows but the nursing staff and endoscopy techs as well. 

Improving the Quality of Inpatient Ulcerative Colitis Management: Promoting Evidence-Based Practice and Reducing Care Variation

As both a GI fellow and inflammatory bowel disease (IBD) patient himself, Dr. Ryan McConnell recognized an opportunity to enhance inpatient care for hospitalized patients with moderate-severe ulcerative colitis. As detailed in his abstract, Dr. McConnell and his group found that using standardized management algorithms reinforced evidence-based principles of care and reduced unnecessary care variation.

Celiac Disease Testing in Type I Diabetics

Dr. Jamie Tjaden’s study identified a low rate of testing for celiac disease (4.7 percent) in eligible Type I diabetes mellitus patients, even though they had an indication for testing according to current clinical practice guidelines. These findings underscore the need for awareness of current guidelines and a better education of this high-risk population. 

A Good Bowel Prep, Can We as Physicians Do Better?

Inadequate bowel preparation is a common problem with potential impact on colorectal cancer screening quality. Dr. Noemi Baffy sought to determine whether a teaching intervention for ordering primary care physicians improves the patient’s bowel preparation quality and changes prescribing habits. While her team found that provider education had no measurable impact on bowel prep quality, they did learn that bowel preparation quality may be related to patient-related risk factors. These findings support more patient-specific bowel prep recommendations.

Implementation of a Standardized Sedation Classification System to Improve Endoscopy Unit Efficiency

This abstract describes a quality improvement project led by GI fellow Dr. Ricardo Badillo to improve his institution's endoscopy unit efficiency through a sedation classification system. Dr. Badillo recognized that one way of improving endoscopy unit efficiency is by being proactive in identifying patients and procedures that can be safely performed with moderate sedation rather than solely relying on anesthesia for monitored anesthesia care, especially at busy academic centers.

Assessing the Success of a Multidisciplinary Quality Improvement Initiative to Improve Outpatient Screening Colonoscopy Bowel Preparation

Dr. Shelini Sooklal's abstract details a multifaceted approach to improve screening colonoscopy bowel preparation quality that can be executed in a short timeframe. Dr. Sooklal’s multidisciplinary team implemented standardized bowel preparations, dietary counseling and pictorial dietary reinforcement, which improved the quality of screening colonoscopy bowel preparations and reduced both the number of aborted procedures as well as duration of screening colonoscopy without polypectomy.

Assessing the Quality of End-of-Life Care for Patients With End-Stage Liver Disease in a Safety-Net Hospital

Dr. Zachary Fricker’s study identified the value of palliative care services, which are often under-utilized in the care of patients with advanced cirrhosis. According to his abstract, adding these services offers potential improvement in the care of patients with advanced cirrhosis. 

Voice of the Veteran Analysis: Implementation of a Revised Pathology Letter After Colonoscopy

Dr. Krista Edelman’s team used veteran feedback to revise and improve their colonoscopy pathology report letter. They found that a significant number of patients who received the initial letter did not understand the results and implications for suggested follow-up. Making very simple changes in their template afforded a significant increase in comprehension. 

Creating a Personalized Smoking Cessation Pharmacotherapy Program in Smokers With Crohn’s Disease Utilizing Nicotine Metabolite Ratio

Despite the importance of smoking cessation, Crohn’s disease patients often do not use available cessation aids. However, through this study Dr. Elizabeth Scoville and her team found that when cessation medications are offered in an IBD clinic, smokers had high rates of satisfaction and decreased smoking. 

Effect of Standardized Consent Versus Standardized Consent Plus Informational Booklet on Patient's Perceptions About Colonoscopy

Obtaining consent for colonoscopy is one of a gastroenterologist’s most frequent responsibilities. Dr. David Fudman’s team was concerned that their colonscopy consent process was making patients anxious about their procedure, but this study provided reassurance that was not the case. 

Content of Consent for Colonoscopy: Comparison of Patient-Reported Preferences, Physician-Reported Practices and Observed Practices

This abstract, also by Dr. David Fudman, expands on which topics should be covered in colonoscopy consent. It turns out, patients and GIs differ on what should be included. This study identified opportunities to improve and standardize the consent process.

Improving Counseling and Interventions to Reduce HCV Transmission and Liver Disease Progression in Patients With Non-cirrhotic Chronic HCV Infection

Dr. Peter Caruana’s team found that a simple electronic medical record (EMR) template improved measures aimed at reducing hepatitis C virus (HCV) transmission and liver disease progression in patients with non-cirrhotic chronic HCV infection. This project was completed over the course of two years during Dr. Caruana’s GI fellowship.

Increased Emergency Department Utilization Following Colonoscopy in the Elderly

Dr. Laurie Grossberg’s research — which started as an assignment for a Harvard School of Public Health epidemiology class — found that elderly patients are twice as likely to visit the emergency department and five-times as likely to be admitted to the hospital after screening or surveillance colonoscopy. This research provides factors that should be considered when discussing consent and determining the appropriateness of colonoscopy in the elderly.

Timeliness to Antibiotics in Pediatric Short Bowel Syndrome Patients With Central Line and Fever in the Emergency Department

Dr. Erealda Prendaj’s research found that forming a multidisciplinary QI team can lead to a significant reduction in time to antibiotics in the pediatric emergency department. While the team did not achieve the aim of decreasing the time to antibiotics by 50 percent, the project is ongoing, and Dr. Prendaj is confident her team will achieve this goal within the next one to two years. 

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