Engaging our trainees in research and systems improvement and educational innovation at CHA

The Center for Professional and Academic Development seeks to nurture a learning community at CHA and works to link opportunities for personal and professional growth with institutional aims. 

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Reducing Polypharmacy Among CHA House Calls Program Patients

Project leader: Serena Chao, Geriatrics Division, DOM

Project: The following project has been in progress since January 2018.

Polypharmacy, typically defined as 5 or more medications, is a growing problem in the US. Among people 65 years of age or older, the prevalence of polypharmacy has more than doubled since 2000, from 24 to 39 percent. Studies have shown that polypharmacy increases our elders’ risk for such things as adverse drug reactions, functional decline, and medication non-adherence in older adults, which in turn are associated with ED and hospital visits. Our House Calls patients are no different than other older people in the US. Thirty-two percent of our patients have what has been termed “extreme polypharmacy”, or 10+ medications.

Our major project objectives are to:
• Reduce extreme polypharmacy among our CHA House Calls patients by
• Understanding our patients’ views about their medications and through
• Collaboration with CHA Pharmacotherapy services to optimize medication management.

Our overall project aim is to reduce ED and hospital visits by House Calls Program patients that might be related to polypharmacy. We decided upon 2 major contributing factors to our high extreme polypharmacy rate: 1) no prior concerted effort by our House Calls team members to reduce polypharmacy; and
2) our patients’ and families’ lack of knowledge about the potential harms that are associated with polypharmacy.
We then developed interventions that would target these contributing factors.

Opportunities for collaboration with learners: In AY 2019-2020, we would gladly welcome a trainee to help us develop patient education materials describing the concept of polypharmacy and why patients might be harmed by it. We are also planning to submit an abstract to the 2020 American Geriatrics Society Annual Meeting (due Dec 2019) as well as a manuscript sometime before the end of 2020.

Anticipated time commitment:
-1 hour/month attending QI project meeting when available (3rd Tuesday of month, 8:30-9:15 am)
-4-8 hours/month related to education material design and implementation (includes background lit/resource search, potential patient interviews), abstract preparation, manuscript writing

Specific skills and competencies we are seeking: enthusiasm, reliability, genuine interest in this topic

How likely is it that the project will offer trainees opportunities for publication and/or presentation external to CHA? Likely


 

Debunking erroneous penicillin allergy documentation in the ambulatory setting

Project leader: Lou Ann Bruno-Murtha, Medicine, Division of ID

Project: New Project

Most patients who report allergy to penicillin are in fact, not allergic and can safely receive a beta-lactam antibiotic. A very small minority have an IgE-mediated hypersensitivity reaction leading to anaphylaxis, angioedema, bronchospasm, or urticaria. Even rarer are the non-IgE mediated reactions (e.g., Stevens-Johnsons, toxic epidermal necrolysis (TEN), interstitial nephritis, hemolytic anemia). Incorrectly labeling a patient as penicillin allergic often results in suboptimal alternative therapy. Nausea, vomiting, headache and other non-specific symptoms are often mistaken by patients as allergic reactions. These patients are often incorrectly labeled as penicillin-allergic ("just in case mentality") in the electronic medical record. Unverified penicillin allergy has been shown to increase the risk of treatment failure (suboptimal alternative prescribed), healthcare-associated infections (C. difficile and surgical site infections), and adverse events from alternatives that pose more side effects. An objective approach for evaluating penicillin allergy is an important step in optimizing antimicrobial stewardship.

Opportunities for collaboration with learners: The purpose of this pilot project (one primary care clinic pilot) is to develop educational materials for clinic staff to obtain a careful history and an algorithm for ascertaining whether a patient meets criteria to document and/or revise existing erroneous penicillin allergy documentation in Epic.

Expected time frame: 6-12 mo for completion of pilot at one site with potential to expand
Specific skills: Collaborate with Antimicrobial Stewardship Co-Directors (Drs. Amanda Barner and Lou Ann Bruno-Murtha) and multidisciplinary clinic staff (site of your choice) to provide education to improve knowledge, optimize history taking skills, and modify existing erroneous documentation related to pen allergy in Epic. Develop an algorithm for patients who may benefit from referral to Allergy Clinic for formal penicillin skin testing.

If interested, please see Evaluation and Management of Penicillin Allergy: A Review in JAMA 2019;;321:188-199. If this excites, please let me know!

How likely is it that the project will offer trainees opportunities for publication and/or presentation external to CHA? Uncertain


 

Evaluating  Pain/Addiction Curriculum for Family Medicine Residents

Project leader: Randi Sokol, Family Medicine

Project: Over the past 3 years, our Family Medicine residency program has implemented a robust pain and addictions curriculum for our residents. We'd like to formally evaluate it to publish resident feedback/evaluations to make suggestions and share best practices for other programs across the country looking to implement a pain/addictions curriculum.

Opportunities for collaboration with learners: I am looking for learners to help with data collection (survey design and administration and possibly interviews with residents) to understand the value of the curriculum and areas of growth. Learners could also participate in helping write a paper for publication, if they are interested.

How likely is it that the project will offer trainees opportunities for publication and/or presentation external to CHA? Highly likely


 

Tobacco Cessation

Project leader: Adrianne Frankel, Quality Management

Project: This is an on going improvement effort, but it is being re-booted due to recent low performance.

Opportunities for collaboration with learners: This opportunity requires Healthcare Quality Leadership skills, peer education, and collaboration with Quality and Informatics departments at CHA. Our goal is to achieve Massachusetts and National benchmarks for Inpatient Tobacco Cessation Measures. Best practices for achieving these goals include cessation education for all providers, optimization of documentation, and on going analysis and performance evaluation. Participation time would be (estimated) 1-2 hours/week for 1-2 months, and then 2-3 hours/month over a 6 month period.

How likely is it that the project will offer trainees opportunities for publication and/or presentation external to CHA? Uncertain


 

Commit to Sit

Project leader: Adrianne Frankel, Quality Management

Project: This is a new project but will expand on previous performance improvement efforts around improving the patient's experience of care by sitting down while talking with patients in a care area.

"From a patient perspective, 2 minutes of a clinician seated at the bedside feels like 15 minutes of personal attention. Conversely, 15 minutes of a clinician standing and talking over the patient's head can feel like no personal attention at all..." The scope of this project will start in the Inpatient Units and will hopefully expand to the Emergency Department, and Ambulatory Clinics.

Opportunities for collaboration with learners:

  • Collaborate with a multidisciplinary team including, Quality Management, Providers, Nurses, Pharmacists, Interpreter services, and others

  • Research and compile evidence based best practice models and articles on the topic with regards to Improving PEOC Outcomes, (HCAHPS scores)

  • Using PI tools, develop operational processes and workflows which enable providers to sit with patients in the care area

  • Develop and roll out internal learning tools related to proposed workflows

  • Document and analyze current and future state

  • Monitor and supervise implementation and spread of proposed workflows

How likely is it that the project will offer trainees opportunities for publication and/or presentation external to CHA?  Highly likely


 

Effect of Immigration Policies at Primary Health Care Utilization in Two Massachusetts Safety Net Hospitals

Project leader: Lara Jirmanus, Family Medicine

Project: This project is already in progress and I am working with researchers at BMC to look at existing data to evaluate for changes in Healthcare utilization over time before and after immigration policy changes. We will be evaluating the missed appointment rates for patients whose language of care is Spanish, Portuguese and Haitian Creole as compared with English speakers before and after January 25, 2017 when immigration related policies were first changed via a Presidential Executive Order. The project has important policy implications as well as implications for patient health. Should we find a difference it may open the door to possible interventions which can be performed at Cambridge Health Alliance to increase access to care for vulnerable populations at CHA.

Opportunities for collaboration with learners:  The collaborator would help with literature review as well as with writing of an academic manuscript for publication. We are currently seeking funding to subsidize data analysis which would be performed by data analysts at the Institute for Community Health. If a trainee were comfortable performing a difference in differences analysis for a large database of 300,000 patients with approximately 2 million observations, they could also help with the data analysis.

How likely is it that the project will offer trainees opportunities for publication and/or presentation external to CHA?   Highly likely


 

Improving Colorectal Cancer Screening Rates

Project leader: Lorky Libaridian, Primary Care

Project: One of the main measures that primary care has decided to focus on for the coming year is improving colorectal cancer screening rates. There are some plans and projects underway to help improve our rates, but we there is opportunity to join us in working on any of the following areas: further development, implementation, PDSA'ing, work on sustaining and spreading change.

Opportunities for collaboration with learners: Depending on how the project is scoped, it can be done over a shorter or longer period of time. Work will range from understanding clinic workflows and obstacles to screening, to chart reviews, basic data analysis, and talking to and learning from clinical teams in the clinics.

How likely is it that the project will offer trainees opportunities for publication and/or presentation external to CHA? Uncertain


Do you have a learning opportunity for a trainee you'd like to share?

Submit your project here.

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