Oklahoma Chapter of the American College of Physicians Virtual Meeting 2020

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Open Access
Improving Utilization of an Internal Medicine Clinic Patient Portal: A Quality Improvement Project
(2020-10) Street, Mark; Jack, Stuart; Drake, Kory; Yarnall, Ryan; Singh, Amritanshu; Vaughn, Kaleb; Gusman, Lindsey; Mullins, Gina; Minton, Vicki; Beasley, Brent; Corbett, Audrey
Background: The University of Oklahoma-Tulsa Internal Medicine Clinic utilizes an electronic patient portal to improve communication and help achieve the healthcare triple aim of reducing costs, enhancing patient experience, and improving health. Our prior quality improvement initiative successfully improved patient portal enrollment and utilization. Our goal for the continued project was to increase the use of secure portal messaging and decrease the patient call-to-visit ratio. The clinic averages ~1800 visits per month and receives ~3.3 calls per visit with each call averaging ~10 minutes, resulting in significant use of clinic resources. Specifically, our aim was to increase utilization of portal secure messaging (both patient to provider and patient to clinical staff) by 10% and decrease patient call-to-visit ratio by 10% by June 2020. Methods: To effect and measure changes, the Plan-Do-Study-Act (PDSA) model was used. Three PDSA cycles were planned and implemented, as well as one unexpected PDSA cycle. The monthly number of secure portal messages and patient call-to-visit ratios (total number of calls to the clinic divided by the number of visits) were measured. These data points were plotted on XmR charts to determine significant trends and averages. PDSA #1: Laminated flyers containing instructions for portal registration were placed at the check-in desk. PDSA #2: Resident physicians were educated in utilizing the portal for communication with patients. PDSA #3: Information about enrolling and portal utilization were included at the top of the clinical visit summary document. PDSA #4: The widespread medical and social effects of COVID-19 began to affect our clinic. Results: After the first three PDSA cycles, our clinic's average call-to-visit ratio decreased 14% (from 3.37 to 2.89). Patient-to-provider messaging increased 27.3% (from 86.6 to 119 messages/month) and patient-to-clinic messaging increased by 38% (from 104.8 to 170.1). Of the planned PDSA cycles, advertising with flyers appeared to have the greatest change. By March and April, COVID-19 resulted in increased messages to clinical staff and a significant increase in the call-to-visit ratio--likely from the drastic decrease of in-person clinic appointments and increased calls to the clinic. Conclusion: Data prior to COVID-19 showed that portal utilization improved through education of medical staff and basic marketing approaches incorporated into the clinical workflow. COVID-19 was an industry disruptor that both demonstrated the need for enhanced clinical communication, but also affected our prior in-person PDSA cycles. Additional data regarding clinical time spent answering portal messages and effectiveness of portal communication will need to be collected. Increased portal utilization can continue to help with improvements in healthcare cost, quality, and effectiveness--and hopefully continued PDSA cycles can aid in developing new strategies to effectively communicate with our patients during this unprecedented time.
Open Access
Selfish Lung Syndrome
(2020-10) Zhang, Xu Jackie; Mundra, Vishal
Introduction: Congenital lobar emphysema (CLE) is a rare congenital developmental anomaly that is characterized by hyperinflation of one or more pulmonary lobes. Although the exact etiology of the disease is unknown, the most frequently identified cause is obstruction of the developing airway. Airway obstruction can be intrinsic or extrinsic, with the former being more common. An example of intrinsic obstruction occurs when there is bronchomalacia or absent cartilage, that creates hyperinflation. As a result, compression atelectasis occurs to the surrounding area and can result in ventilation perfusion mismatch. The left upper lobe is the most affected, as seen in 40% to 50% of cases. This disorder has a prevalence of one out of every 20000/30000 with higher incidence in males. Patients are often diagnosed and treated in the neonatal/infant period but some cases can have a more gradual and insidious onset that require treatment years later. Case: A 55 year old male, with a hx of CLE and tobacco abuse, came to the ED with dyspnea and cough. He was in mild distress, tachypneic, and oxygen saturations were in the 70s. He had a barrel-shaped chest wall and some expiratory wheezes were noted as well. He was not on oxygen at home and did not follow up with a pulmonologist. Pt denied having any surgical intervention for his congenital malformation other than bronchoscopy as a child. CT chest with contrast showed massive bullous emphysema on the left with mass effect on the right lung and deviation of the anterior junction line by approximately 8 cm to the right. Additionally, there were airspace opacities within the left lower lobe with fluid/fluid level within some of the left-sided bullae, raising the possibility of pneumonia. He was started on Zosyn and recovered well. Cardiothoracic surgical team was consulted and they recommended left pneumonectomy. However, the patient wanted to pursue the surgery outpatient. At the time of discharge, he was hemodynamically stable, saturating above 90%, and returned to baseline. Unfortunately, he was lost to follow up. Discussion: This case illustrates that even though the patient was mostly asymptomatic throughout his life, his lungs continued to deteriorate. It may have started in one lobe of the left lung but slowly progressed to involving the entirety of the left lung. It is essential to reinforce in patients the importance of continuous monitoring and follow up regardless of symptom status.
Open Access
Cluster Analysis as More Precise Measure of Burnout Among Healthcare Providers
(2020-10) Stiefer, Auston; Kezbers, Krista; Austin, Tessa; Nguyen, Amy; McIntosh, Heather; Touchet, Bryan
BACKGROUND: The study of burnout among physicians and medical trainees has become a focus of many professional societies, academic institutions, and hospital systems in recent years, given the high prevalence of burnout in these populations and its implications for poor patient outcomes. However, physician burnout, widely assessed via abbreviated versions of the Maslach Burnout Inventory (MBI), has been largely considered a monolithic, syndromic condition, neglecting multidimensional aspects of the psychometric measure. This study seeks to identify the presence of distinct burnout “clusters” among academic medical professionals and trainees based on respondents’ MBI subscores of exhaustion, cynicism, and professional inefficacy, according to the analytic framework of the MBI’s developers. METHODS: This secondary data analysis was conducted using a large dataset from the 2019 OUSCM’s well-being survey, which included the MBI among other social construct measures. Per a new analytic approach recommended by creators of the MBI, we conducted additional cluster analysis on the dataset to better characterize our population. TwoStep cluster analysis via SPSS was utilized to analyze mean scores of the 3 MBI subscales and to understand similarities, differences, and clusters that existed within the dataset. RESULTS: A total of 272 burnout subscores were included in TwoStep Cluster analysis. Sample demographics included: mean age 39.4, 78.0% female, 75.1% white, 57.2% staff. Preliminary results of the cluster analysis indicated 4 distinct clusters, at fair cluster quality, with all 272 individuals included. Four distinct clusters were identified: 1) respondents with high subscores in both cynicism and exhaustion, 105 (38.6%); 2) respondents with high scores of exhaustion only, 62 (22.8%); 3) those with high scores of inefficacy only, 58 (21.3%); and 4) those with low scores in all areas, 47 (17.3%). DISCUSSION: The emergent four-cluster pattern is consistent with preliminary cluster analysis on burnout subscores among mental health professionals, as elicited by the psychologists who developed the MBI. This method identifies individuals who share similar patterns of burnout subscores, previously considered outliers. Identifying specific dimensions of burnout within a population provides greater understanding of how individuals experience burnout and how their environments contribute to burnout. Our sample restricted to the OUSCM limits assessment of burnout clusters among medical professionals and trainees at large. Extending cluster analysis to samples from multiple academic medical institutions would validate the identification of burnout clusters and provide evidence for the development of more precise interventions to mitigate burnout among medical providers and trainees. Media Link: https://youtu.be/-SnGGFsZFQQ
Open Access
When Lightning Strikes Twice in the Case of Anemia
(2020-10) Reddick, Matthew; Mundra, Vishal
Vitamin b12 deficiency anemia in the general population is 1.4% with an even higher incidence in the elderly and hospitalized reported up to 10-15%. Other causes of anemia such as warm autoimmune hemolytic anemia have an incidence of around 0.017% with a rate as high as 10% with conditions such as chronic lymphocytic leukemia or lupus. This is the case of a 65 year old female patient who presented for fatigue and dyspnea on exertion with an insidious onset. She denied bleeding from any orifices. She denied being a vegetarian and she denied any recent, unexplained weight loss. She mentioned she had a history of anemia that had never been worked up. Her past medical history also included well controlled insulin dependent type II diabetes and hypothyroidism. Patient denied smoking, drinking or illicit drug use. Her medications included insulin and Tresiba. The patient’s vital signs were stable. Physical exam was benign. No noticeable pallor. No glossitis. No tachycardia. No murmurs. No hepatosplenomegaly. Initial laboratory studies revealed pancytopenia with a WBC of 2,900/mm3, hemoglobin of 4.8 g/dL, platelet count of 101 x109/L. MCV was 110.4 fL/cell. B12 levels were also low at 146 pg/mL and methylmalonic acid levels were elevated at 18.72 nmol/L. The patient was admitted for B12 deficiency anemia with plans for transfusion of 2 units of pRBC’s for symptom control. The immunoassay for anti-intrinsic factor was negative. In trying to further understand what could be contributing to the severity of the patient’s anemia peripheral smear and hemolysis labs were performed. The peripheral smear showed hyper segmented neutrophils with macrocytic red blood cells. The absolute reticulocyte count was low at 0.13%, low haptoglobin of 8.0 mg/dL, and an elevated LDH at 5,561 U/L. This prompted a direct combs test and direct antigen test that both revealed the presence of IgG to confirm the concomitant presence of AIHA. She also had EGD done which showed atrophic gastritis with negative H. Pylori test. She was discharged home successfully with a close hematology follow up. While each individual cause is uncommon in the general population, the chance of both occurring is even rarer. There are few case reports of pernicious anemia and AIHA described in the literature. Transient antibody positivity for hemolysis has also been reported with pernicious anemia. Our patient did not have anti-IF antibodies which is seen in about 80-90% of cases of pernicious anemia. Atrophic gastritis can be autoimmune as well. She needs further work up for both of these entities. This case provides a unique look at a possibly non-autoimmune B12 anemia with concomitant AIHA.
Open Access
First Bite Syndrome After Parapharyngeal Surgery
(2020-10) Pruthi, Asheema; Siemens, Chris; Kempe, Paul
Introduction: Most schwannomas, other than those associated with neurofibromatosis, occur in the para-pharyngeal space often originating from Cranial nerves (CN) 9-12 or the sympathetic chain. Although cervical sympathetic chain (CSC) schwannomas are uncommon, they are known for their ability to mimic the physical and radiologic findings of carotid body tumors. Treatment is surgical resection. Post-operative complications involved with removing the CSC include Horner’s syndrome (almost inevitable) and First Bite Syndrome. Case Description: An 80-year-old female presented with a 7-year history of an enlarging right neck mass followed serially over time with moderate growth. The patient complained of locally compressive symptoms including bilateral neck pain, dizziness, dysphagia and hoarseness. The mass was non-tender and firm with a 4-5 cm diameter oriented vertically. Flexible fiber-optic laryngoscopy revealed R vocal cord (VC) sluggishness with poor abduction. CT demonstrated the mass as measuring 3.6 x 3.5 x 4.9 cm with close adherence to the right carotid artery. Biopsy was non-diagnostic. The patient consented to mass excision and right neck dissection that was performed by an otolaryngologist and cardiovascular surgeon. The right-sided mass was free from the jugular vein, carotid artery, and CN 10. It measured 5.7 cm in the largest dimension and was attached to a nerve bundle, possibly the CSC. Histopathologic examination revealed the mass to be likely consistent with a schwannoma. On post-operative day #1, the patient had normal tongue mobility, intact CN 7 function, slight ptosis of the right eye and symmetric pupils without miosis. Fiber-optic laryngoscopy revealed subtle right VC weakness that improved by post-operative day #5. Approximately one month later, the patient complained of discomfort in her mouth and jaw on initiating a meal. Following right parotid gland ultrasound examination, the patient was diagnosed with First Bite Syndrome. Botulinum toxin was injected within the parotid gland for symptom management. Discussion: In First Bite Syndrome, pain in the parotid area can be severe with the first bite of food. With subsequent bites, the pain often decreases. It is currently thought this is likely due to sympathetic denervation of the parotid gland due to severing of the CSC resulting in hypersensitivity of the sympathetic receptors. A majority of these symptoms resolve over time. There is evidence that Botulinum toxin type A injection causes improvement of symptoms by inducing parasympathetic nerve paralysis of the parotid gland. This can also minimize salivation by reducing the hyper-stimulation and exaggerated myoepithelial cell contraction.
Open Access
Increasing Colon Cancer Screening in the OU-Tulsa Internal Medicine Outpatient Clinic
(2020-10) Harris, Audrey; Quaye, Eugene; Tran, Elizabeth; Smith, Tristan; Eslam, Mohammed; Albin, Dru; Corbett, Audrey; Sullins, Lindy
Introduction: Colorectal cancer is the fourth most common cancer and the second leading cause of cancer death in North America. Annually, approximately 53,000 people die of colorectal cancer, yet it is largely preventable through screening. Our quality improvement initiative was to attempt to increase colon cancer screening in United States Preventative Services Task Force (USPSTF) eligible patients in the OU IM clinic by 10% by April 2020. Methods: All patients seen in the OU Internal Medicine clinic were screened for eligibility of colon cancer screening using the USPSTF criteria. If the patients were found to be eligible they were offered several screening possibilities to include colonoscopy, FIT testing, and cologuard screening. The necessary means to undergo testing was then arranged for the individual patient in order to attempt to increase the amount of colon cancer screening by 10% by April 30, 2020. Several PDSA cycles were planned but unfortunately, with the onset of the SARS- CoV2 pandemic only one was able to be implemented throughout the year. The first PDSA cycle consisted of drafting a standardized letter which was added to the clinic EMR that would allow patients to bring a guest with them via SoonerRide to their colonoscopy appointment. Lack of appropriate support to appointments had been a barrier to patient’s ability to keep their screening appointment. The clinic providers and nurses were educated on how to locate and complete the letter. Results: The patient population studied included all eligible adults for colon cancer screening, as defined by the USPSTF guidelines, at the OU Tulsa Internal Medicine clinic. Our data showed that following the implementation of the first PDSA cycle the percentage of patients out of total qualifying patients in the OU IM clinic who have documented colon cancer screening done or had reason why deferred remained at 65.1%. There were no significant increases or decreases in the total percentage. Following the onset of COVID-19 pandemic, the percentage decreased to as low as 62.7%. Conclusion: There was neither a significant increase or decrease in colon cancer screening in the five months following implementation of the first PDSA cycle. However, in March 2020 the American Cancer society recommended that all routine (non-diagnostic) cancer screenings be suspended in the wake of the COVID-19 pandemic. As a result, screening rates decreased by 86% relative to the average before January 2020. Going forward, a focus on FIT like testing may be beneficial during these times to reduce rates of missed cancers.
Open Access
Factors Associated with the Maintenance of Colonic Insufflation During Colonoscopy
(2020-10) Bader, Nimrah; Yohannan, Bryce; Corredine, Thomas; Madhoun, Mohammad
Colonoscopy is a diagnostic and therapeutic procedure performed for several indications including colorectal cancer (CRC) screening, adenoma surveillance, and investigation of gastrointestinal symptoms. Insufflation of the colon with gas allows for adequate visualization of the mucosal tissue and advancement of the endoscope; however, it can cause pain and discomfort. Thus, the majority of colonoscopies are performed with sedation in order to mitigate discomfort and enhance the colonoscopy experience for both the patient and the endoscopist. We hypothesized that deeper levels of sedation would lead to more difficulty in maintaining insufflation. We aimed to evaluate factors associated with difficulty maintaining insufflation. Methods: We performed a prospective study of all patients who underwent outpatient colonoscopies at the Veteran Affairs Medical Center in Oklahoma City between November 2019 and March 2020. Colonoscopies were performed by gastroenterology fellows and attending gastroenterologists. Indications for colonoscopies were CRC screening, positive fecal immunochemical test, symptomatic, and adenoma surveillance. Procedures were done under Monitored Anesthesia Care (MAC) with propofol or moderate sedation with fentanyl, midazolam, and diphenhydramine. Insufflation was done with carbon dioxide. Data collection involved two parts. Firstly, baseline demographic information was obtained from the electronic medical record (EMR) along with colonoscopy details including type and doses of sedatives; total number of polyps, size of polyps, and specific location in colon; and total procedure times including insertion and withdrawal. Secondly, a post-procedure questionnaire was completed by the endoscopists and recorded the bubble score, endoscopic maneuvers, and difficulty maintaining insufflation. Results: A total of 542 participants underwent colonoscopies during this period. Twelve participants were excluded from the study and 37 participants did not have completed questionnaires. We found that difficulty maintaining insufflation was reported in 129 (26%) participants compared to 364 participants where no difficulty was reported. Multivariate analysis showed that patients who had difficulty maintaining insufflation were more likely to be of an older age (P=0.003), had undergone MAC sedation (P=<0.0001), were more likely to have longer procedure times (P=.0025) and fellow involvement (P=0.0002) with the procedure. Discussion: We observed that difficulty in maintaining insufflation during colonoscopy was reported in over one-quarter of the colonoscopies done. We found four factors associated with difficulty maintaining insufflation: use of propofol sedation, older age, fellow involvement, and longer procedural times. We could not find literature that explored maintenance of insufflation. Further investigation into these factors and their relationship with maintaining insufflation is warranted as this may improve the colonoscopy experience.
Open Access
Name the Syndrome: Cytokine Release Syndrome or Toxic Shock Syndrome in a Patient on Avelumab for Ependymal Tumor
(2020-10) Bader, Nimrah; Ul-Haq, Aejaz
Introduction: The use of immune checkpoint inhibitors (ICIs) has dramatically changed the outlook of cancer therapy. As a result, their use is becoming prevalent and a more diverse range of clinicians will encounter patients on immunotherapy and their immune-related adverse events (irAEs). Our objective is to describe a case of suspected cytokine release storm in a patient enrolled in a phase I trial on combination therapy with PDL1 inhibitor Avelumab and oral DNA PK inhibitor who was initially treated as toxic shock syndrome. Case: A 38 year-old-woman with an ependymal tumor on a phase I trial with PDL1 Inhibitor Avelumab and oral DNA PK inhibitor presented with fever and rash a few hours after receiving Avelumab infusion. On exam, vitals were Temperature 39.2 C, HR 148, BP 87/45, RR 30, Pulse Ox 98% on ambient air. Examination was significant for an alert and conversant woman with macular erythema which involved the face, upper extremities, chest, and thighs. Indwelling lines were noted: a peritoneal catheter and a PICC line. There were scattered areas of desquamation on her chest and upper extremities. She was treated with broad-spectrum antimicrobials including clindamycin but her clinical status remained unchanged after 12 hours. It was decided to start methylprednisone for a possible adverse reaction to Avelumab. Given the concern for cytokine release syndrome, she was also given a single dose of Tocilizumab 800mg. Her condition improved dramatically in the next 24 hours; she was transferred out of the ICU on Day 3 of hospitalization and discharged home on Day 7 with a prednisone taper. On a follow-up appointment, her therapy was changed to an alkylating agent. Discussion: We present a case of CRS induced by Avelumab which resulted in rapid improvement of the rash and hemodynamic status of the patient after Tociluzimab. Our differential diagnosis included septic shock, including toxic shock syndrome. These circumstances are likely to be encountered by clinicians who are not primarily practicing in oncology.CRS is a systemic inflammatory disease characterized by a massive release of cytokines. By increasing the activity of the immune system against cancer cells and subsequently the host’s non-cancer cells, ICIs can lead to cytokine-mediated toxicity among which IL-6 plays a key role. CRS has now also been recognized to occur with ICIs, especially PD1 and PDL1 inhibitors. To our best knowledge, seven case reports have described CRS after pembrolizumab and nivolumab; however, none have specifically described this reaction to Avelumab. Rash was described in two case reports. Notably, our case is the only one that an ICI was used for an ependymal tumor. Two of the case reports described using tocilizumab and two used Mycophenolate. Corticosteroids were used in all cases and all patients recovered. Due to the increasing use of ICIs, more clinicians need to be aware that they can trigger CRS.
Open Access
Trust But Verify, Don't Disregard the Simplex Answer: An Uncommon Presentation of Herpes Simplex Encephalitis
(2020-10) Albin, Dru; Gordon, Errol
Introduction: Herpes simplex virus type 1 encephalitis is the most common cause of sporadic fatal encephalitis worldwide. Typical presentation includes fever, altered mental status, focal cranial nerve deficits, and seizures. Diagnosis is confirmed by polymerase chain reaction of CSF with very high sensitivity of 98% and specificity of 94% .Atypical symptoms include urinary and fecal incontinence, aseptic meningitis, Guillan-Barre syndrome, amnesia, Kluver-Bucy syndrome, and hypomania. This case demonstrates syncope secondary to sinoatrial dysfunction as an atypical presenting symptom. Case Description: A 50 year old male with a past medical history of childhood traumatic brain injury and hepatitis B on Entecavir presented to the hospital after new onset syncopal episodes. On exam he was afebrile and tachycardic. WBC count was 14,000, , K+ 2.8, and lactate 3.7. Antibiotics were briefly initiated but not continued due to lack of source. Potassium was replaced and patient was preparing for discharge when another syncopal event occurred. Telemetry showed sinus pauses greater than 10 seconds. Electrophysiology was consulted and performed heart catheterization and pacemaker placement. The next day he developed fever of 39.2 C, altered mental status, and seizure. He was transferred to the ICU and started on broad spectrum antibiotics and acyclovir. Electroencephalography showed left frontotemporal epileptogenicity and CTA and CT head were noncontributory. Lumbar puncture had normal cytology, negative PCR for herpes and echoviruses, and negative antibodies for flaviviridae. Acyclovir was discontinued, antiepileptic medication started, and antibiotics were changed to rule out drug fever. Fevers up to 40 degrees continued despite thorough source investigation and advanced cooling efforts. A second lumbar puncture was competed which showed lymphocytic pleocytosis and a CT head with contrast showed a new enhancing focus of the mesial left temporal lobe. Despite negative culture data, our clinical suspicion remained very high for herpes encephalitis so acyclovir was then restarted. Several days later culture data from both spinal fluid samples became positive for herpes simplex 1. His fever broke, he showed clinical improvement on antiretroviral therapy, and he was discharged home several days later in stable condition. Discussion: In this case, the patient presented with syncope and then developed typical findings of HSV1 encephalitis but the misleading negative HSV PCR led to disregarding the correct diagnosis. This resulted in a delay in care until unsurmountable evidence forced a clinical diagnosis which was then later reinforced by corrected objective data. Herpes Simplex Virus 1 has been known to precipitate encephalopathy and seizures but significant viral load causing sinoatrial conduction abnormalities is less described. It is thought that SA node dysfunction is secondary to autonomic dysfunction in the central nervous system rather than myocardial involvement evidenced by autopsy examination. Be aware of atypical presentations of HSV encephalitis as well as the potential for clinical and laboratory disparity in order to not miss this life-threatening illness.
Open Access
PDSA Cycles Increase Screening for Smoking Cessation
(2020-10) Abdelmonem, Ahmed; Baab, Kelsey; Cerqueira, Oliver; Corbett, Audrey
Introduction: Smoking represents the leading cause of preventable disease, disability and death in the United States, disproportionately affecting lower-income populations1. Smoking cessation has been shown to reduce the associated health risks and to lead to a decrease in early mortality. Due to the significant impact of smoking on our patient population, the students at OU’s student-run, free clinic, Bedlam Clinic, decided to implement a series of Plan-Do-Study-Act (PDSA) cycles to address this issue. PDSA cycles are widely used for quality improvement in healthcare systems and have been shown to improve outcomes2. Our aim was to improve tobacco screening and counseling in OU Bedlam student-run clinic by 20% by June 2020. Methods: From September 2019-May 2020, teams of third-year medical students, PA students, nursing students, social work students, and faculty attendings implemented PDSA rapid improvement cycles. The goal was to increase smoking screening and cessation education above the current baseline of 49.4% by the end of the year. Each individual team created a plan, which they implemented in the clinic. The number of screenings, counseling sessions, and smoking cessations were recorded per team. The teams met bi-monthly to discuss and improve upon the plan. By the third PDSA cycle, the entire clinic agreed to implement the protocol of the team with the largest increase in tobacco screenings. The protocol chosen involved an interdisciplinary approach: the nursing student initiated the screen, the Medical/PA student provided counseling for those interested, and the social work student provided resources for those motivated to quit smoking. Results: At the first PDSA cycle, 49.4% of eligible patients at Bedlam Clinic had a tobacco screening completed, with an upper and lower confidence level of 53.6% and 45.1%. Monthly data points following the initial PDSA cycle were consistently above average. By July, 2020, after 4 PDSA cycles, the average tobacco screening rose from 49.4% to 59.8%. Conclusion: Implementing a multidisciplinary, quality improvement project to increase smoking cessation screening at the OU Bedlam student-run clinic was successful. Tobacco screening at the Bedlam Clinic improved by 20.1% from its baseline. The PDSA cycles elucidated that documentation of the tobacco screening process was being recorded incorrectly in the EMR. Once this was established, we implemented a protocol ensuring that this important step was not forgotten. Specifically, nursing students documented the screening in the EMR at the beginning of the visit. This step was implemented across the entire clinic by February 2020, significantly improving tobacco screenings. This project demonstrates that a student-led, annual, QI project using simple rapid cycle improvement leads to improved patient care. These projects should continue to be implemented at the Bedlam Clinic and further expanded to the remaining OU clinics.
Open Access
Improving Outpatient Follow-Up After Hospitalization
(2020-10) McGinn, Addison; Hurst, Caleb; Blasdel, Jacob; Bordelon, Brian; Abdelmonem, Ahmed; Sharwani, Fahad; Lesselroth, Blake; Cerqueira, Oliver; Corbett, Audrey
Introduction: Hospital readmission is costly, in both patient quality of life and healthcare expenditures. Timely post-discharge follow-up has shown to reduce preventable readmissions. Efforts should be aimed at improving coordination of follow-ups. The aim of this quality improvement project was to increase post-hospital discharge follow-up by 20% for academic primary care patients admitted to a local tertiary care hospital by June 2020. This QI project was conducted at St. John Medical Center and the OU Internal Medicine Clinic utilizing Plan-Do-Study-Act methodology (PDSA). Patients admitted to OU inpatient teams who also designated OU Internal Medicine as their PCP were included in the study. An EMR query was utilized to measure follow-ups completed within 14 days of discharge. A process map was made, showing intervention points. Gap Analysis/Scatter Diagram was used to show points of largest impact. Methods: PDSA #1: Senior residents were given access to AllScripts (the clinic EMR scheduling program) to directly schedule patient follow-up appointments within 14 days of discharge. Follow-up appointments were included in patients’ discharge paperwork.    PDSA #2: Prior to discharge, patients were screened by care managers for a follow-up home visit. If appropriate, a multidisciplinary team of providers conducted an onsite follow-up visit within 14 days of discharge. Results: After PDSA #1: Residents surveyed after the first PDSA cycle admitted feeling overwhelmed with additional tasks and inconsistently scheduled appointments in AllScripts. In addition, EMR review demonstrated a high no-show rate for patients with follow-up appointments. Due to these results, we sought alternative options. After PDSA #2: Three patients were visited in their homes for an onsite 14-day follow-up appointment. Unfortunately, this process was put on hold given the COVID outbreak. At baseline, 31.6% of patients discharged from the hospital attended post-discharge follow-up visit within 14 days. This percentage declined to 29.2% after our interventions. Conclusion: The low rate of hospital discharge appointments within two weeks of discharge indicates that many patients are lacking crucial follow-up care. This project found that having residents enter appointments directly into AllScripts and performing home visits within 14 days of discharge made no difference in the overall rate of successful post-discharge follow-up visits. Weaknesses of this study include but are not limited to the gap of data between July 2019 and March 2020 and the small number of home visits that were performed. This project confirms the concern that unless new approaches to significant post-discharge follow-up barriers are considered, increasing the percentage of successful follow-up appointments will remain a difficult task.
Open Access
Filamentous Actin in the Role of Diagnosing Seronegative Type 1 Autoimmune Hepatitis
(2020-10) Hall, Mallory; McGinn, Addison; Smith, Kevin
Introduction: Autoimmune Hepatitis (AIH) is an inflammatory liver disease, which without adequate diagnosis and treatment, can progress to cirrhosis. There are no distinguishing clinical features to discriminate this from other liver pathology; therefore, diagnosis is made by the presence of circulating autoantibodies, elevated serum globulin levels, and histologic examination. Initial treatment is with immunosuppression by glucocorticoid monotherapy or by combination of glucocorticoid with azathioprine. Case: We present the case of a 65-year-old female with no PMH and non-specific abdominal complaints who was found to have unexplained liver cirrhosis. There was no evidence of past or present alcohol abuse. Transaminases were greater than 10x the upper limit of normal, while IgG was greater than 3x the upper limit of normal. Viral hepatitis panel and hemochromatosis mutation gene were negative. AIH was strongly suspected due to exclusion of other etiologies. Subsequently, ELISA for filamentous actin (FA) was tested and resulted positive; however, reflex to smooth muscle antibody (SMA) was negative. Autoantibodies including antinuclear, liver/kidney microsomal, soluble liver antigen, and antimicrosomal were negative. Without adequate evidence of autoantibodies, treatment was withheld until liver histopathology confirmed Type 1 AIH (AIH-1). Prior to discharge, the patient was started on oral prednisone with plans to taper immunosuppression based on therapeutic response (i.e. transaminase levels). Unfortunately, the patient was readmitted roughly 10 days later with severe complications of cirrhosis and ultimately passed away. Discussion: The subset of SMA with specificity for FA, SMA-T, is the prototype autoantibody correlating with AIH-1. Testing for SMA-T is done by immunofluorescence staining, which can be difficult to visualize when titers are low. FA is detected by ELISA; however, this test has not been fully standardized leading to varying cutoff values depending on assay/laboratory, as well as inability to directly correlate with immunofluorescence titers. In addition, false positive results have been reported in which FA is instead linked to SMA-V, which is seen in a variety of viral illnesses, and not SMA-T. Several factors ultimately contributed to the outcome of this case including hesitation from the patient to pursue invasive measures resulting in a postponed biopsy, and thus diagnosis. However, FA levels were significantly elevated early in the course of illness, indicating the need for standardization of FA assays, as well as correlation between assay and immunofluorescence results. Development of reliable testing for FA has the potential to provide earlier diagnosis and treatment of AIH-1 in patients where SMA titers are negative.
Open Access
Extensive Bioprosthetic Aortic Valve Annual Abscess
(2020-10) McGinn, Addison; Cha, Heather
Case Introduction: Infective endocarditis (IE) is a relatively common, usually subacute infection involving heart valves. IE is often preceded by bacteremia in patients with prosthetic hardware, artificial heart valves, vascular access catheters, or in patients with risk factors such as intravenous drug use. Normally, IE is found during work-up for bacteremia and is best evaluated with echocardiography. Prolonged IV antibiotics are the treatment of choice unless the patient has an indication for surgery such as a large vegetation or signs acute heart failure, among others. Case Description: A 75-year-old male with a past medical history of aortic stenosis status-post bioprosthetic aortic valve (AV) replacement presented with back pain. At the time of admission, labs were notable for acute kidney injury, transaminase elevation, leukocytosis, and lactic acidosis. Subsequent blood cultures grew Enterococcus faecalis. Transthoracic echocardiography confirmed endocarditis with a mobile mass involving the tricuspid valve (TV). Transesophageal echocardiography further demonstrated a large bioprosthetic aortic valve annular abscess extending into the ascending and descending aorta. Direct visualization in the OR confirmed native TV endocarditis and an AV annular abscess eroding into the atria and left ventricular outflow tract (LVOT). He underwent AV/LVOT abscess debridement, repair of aortic root using autologous pericardium with coronary reimplantation, and TV debridement and repair. His postoperative course was complicated by ventricular tachycardia and refractory cardiogenic shock secondary to right ventricular failure. He was transferred to an outlying facility for extracorporeal membrane oxygenation (ECMO) support, but ultimately passed away. Just two weeks prior to this aforementioned admission, the patient underwent transthoracic echocardiography for new onset atrial fibrillation which demonstrated a bioprosthetic aortic valve with normal pressure gradients and without vegetation. Case Discussion: The incidence of perivalvular abscess among patients with bioprosthetic valve endocarditis is between 30% to 40%. What makes this case interesting is not only the impressive local extent of abscess, but also the aggressive nature of the infection given negative imaging just weeks prior. This case illustrates the need for rapid identification, early initiation of treatment, and availability of post-operative mechanical support for patients with bioprosthetic valve abscess from endocarditis. Ramos Tuarez FJ, Yelamanchili VS, Law MA. Cardiac Abscess. [Updated 2020 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459132/