Improving Hydroxychloroquine Dosing and Toxicity Screening at a Tertiary Care Ambulatory Center: A Quality Improvement Initiative.

OBJECTIVE: Hydroxychloroquine (HCQ) is a commonly used weight-based medication with a risk of retinal toxicity when prescribed at doses above 5 mg/kg/day. The objectives of our study were (1) to characterize the frequency of inappropriate HCQ dosing and retinopathy screening, and (2) to improve guideline-based management by implementing quality improvement (QI) strategies. METHODS: A retrospective chart review was performed to obtain baseline analysis of HCQ dosing, weight documentation, and retinal toxicity screening to characterize current practices. The primary aim was to increase the percentage of patients appropriately dosed from 30% to 90% over a 10-month period. The secondary aim was to increase the percentage of documented retinal screening from 59% to 90%. The process measure was the number of patients with a documented weight in the chart. The balancing measure was the physician's perceived increase in time spent with each patient due to implemented interventions. QI methodology was used to implement sequential change ideas: (1) HCQ weight-based dosing charts to facilitate prescription regimens; (2) addition of scales to patient rooms to facilitate weight documentation; and (3) electronic medical record (EMR) "force function" involving weight documentation and autodosing prescription. RESULTS: The percentage of patients being weighed increased from 40% to 92% after 10 months. Appropriate HCQ dosing improved from 30% to 89%. Retinal screening documentation improved by 33%. CONCLUSION: Dosing charts in clinic rooms, addition of weight scales, and EMR force function autodosing prescriptions significantly improved appropriate HCQ dosing practices. These interventions are generalizable and can promote safe and guideline-based care.

Paging the Right Resident the First Time on General Internal Medicine: A Quality Improvement Project.

BACKGROUND: Interprofessional hospital communication is vital for high-quality patient care. However, staff have reported that nursing pages are often sent to the wrong residents, leading to service delays, interruptions, and safety risks. The aim of this quality improvement project was to reduce day shift pages to general internal medicine (GIM) teams by 25% over 10 months by helping nurses page the right residents the first time. METHODS: This study was conducted at a Canadian tertiary academic hospital and involved three GIM teams on seven inpatient wards. The Model for Improvement was used to explore root causes and redesign how nurses and switchboard operators contacted residents. Multiple change ideas were tested: posting daily resident assignments on digital monitors, redirecting switchboard pages to internal medicine residents, and forwarding pagers in learning sessions. The primary outcome was the average number of pages/team/week to GIM residents. Evaluation was conducted with statistical process control charts and qualitative feedback. RESULTS: A total of 19,925 pages were reviewed from 226 resident shifts over 39 weeks. Average pages/team/week (Monday to Friday, 08:00 to 17:00) decreased by 38.3% (133 to 82) postimplementation. More nurses reported often or always knowing which residents were assigned to patients, increasing from 0% to 38.1%. Fewer residents reported often or always receiving pages about another resident's patient, decreasing from 50.0% to 26.7%. CONCLUSION: Quality improvement methods were used to streamline the paging process on GIM wards, resulting in fewer pages and improved communication efficiency.

London Transfer Project: Reducing Medication Incidents After Discharge From Hospital to Long-term Care.

BACKGROUND: Long-term care (LTC) homes expressed concern that patients had experienced medication incidents after hospital discharge as a result of poor coordination of care. OBJECTIVE: The London Transfer Project aimed to reduce LTC medication incidents by 50% within 48 hours of discharge from general medicine units at the London Health Sciences Centre. DESIGN: This quality improvement study involved 2 hospitals and 5 LTC homes in London, Ontario, Canada. The baseline prevalence of medication incidents was measured and explored for root causes. Two change ideas were tested on general medicine units to improve transfer communication: (1) expediting medication reconciliation and (2) faxing medication plans before discharge. MEASURES: Evaluation involved time-series measurement and a comparison of baseline and intervention periods. The primary outcome was medication incidents by omission or commission within 48 hours of discharge, which was determined by dual chart reviews in hospital and LTC homes. Process measures included medication reconciliation and fax completion times. Hospital discharge times were included as a balance measure of the new communication process. RESULTS: Four hundred seventy-seven LTC transfers were reviewed between 2016 and 2017; 92 transfers were reviewed for medication incidents in participating homes at baseline (January-April 2016) and implementation (January-April 2017). Medication incidents decreased significantly by 56%, from 44% (22/50) at baseline to 19% (8/42) during implementation (P = .006). Medication reconciliation completion by noon increased from 56% (28/50) to 74% (31/42) but not significantly (P = .076). Faxes sent before discharge increased significantly from 4% (2/50) to 67% (28/42, P = .015). There was no significant change in hospital discharge time. CONCLUSIONS/IMPLICATIONS: Medication incidents can be significantly reduced during care transitions by taking a systems perspective to explore quality gaps and redesign communication processes. This solution will be scaled to other inpatient services with a high proportion of LTC residents.

Acute urinary retention secondary to urethral involvement of granulomatosis with polyangiitis.

Granulomatosis with polyangiitis (GPA, formerly Wegener's granulomatosis) is a systemic necrotizing vasculitis of small- and medium-sized blood vessels, primarily affecting the upper and lower respiratory tracts, as well as the kidneys. Urogenital manifestations of GPA are exceedingly rare and usually respond well to systemic immunosuppressive therapy. Here, we present a case of a 36-year-old female presenting with acute urinary obstruction secondary to urethral GPA involvement in the immediate postpartum period. Special consideration should be given to ruling out malignancy in all patients with a history of GPA and urethral lesions, especially when there is a history of cyclophosphamide treatment.

London Transfer Project: improving handover documentation from long-term care homes to hospital emergency departments.

About one-quarter of all long-term care (LTC) residents are transferred to an emergency department (ED) every 6 months in Ontario, Canada. When residents are unable to describe their health issues, ED staff rely on LTC transfer reports to make informed decisions. However, transfer information gaps are common, and may contribute to unnecessary tests, unwanted treatments and longer ED length of stay. London Health Sciences Centre, an academic hospital system in London, Ontario, partnered with 10 LTC homes to improve emergency reporting of their residents' reason for transfer and baseline cognition. After conducting a root cause analysis, 7 of 10 homes implemented a standard minimum set of currently available transfer forms, including a computer-generated summary of resident's most recent interRAI functional assessment. Results were analysed using statistical process control charts and data were posted on a public website (LondonTransferProject.com). The documentation rate of 'reason for transfer' improved from 61% to 84%, and 'baseline cognitive status' improved from 4% to 56% across all 10 homes. These results suggest that transfer communication can be improved by codesigning and implementing solutions with ED and LTC staff, which build upon current reporting practices shared across multiple LTC organisations.

Reducing inappropriate ESR testing with computerized clinical decision support.

Laboratory test overutilization increases health care costs, leads to unwarranted investigations, and may have a negative impact on health outcomes. The American Society of Clinical Pathology, in its Choosing Wisely Campaign, advocates that inflammation be investigated with C-reactive protein (CRP) instead of Erythrocyte Sedimentation Rate (ESR). London Health Sciences Centre (LHSC), a tertiary care hospital organization in Ontario, Canada, set a goal to reduce inappropriate ESR orders by 50%. After developing appropriateness criteria for ESR, we used a series of PDSA cycles to reduce inappropriate ESR ordering and analyzed our results with an interrupted time series design. Our intervention began with an educational bulletin and moved to city-wide implementation of computerized Clinical Decision Support (CDS). After implementation, ESR orders decreased by 40% from 386 orders per week to 241 orders per week. Our results are supported by previous literature on the effectiveness of CDS in reducing overutilization and suggest that provider habit is a significant contributor to inappropriate ordering.

Endometrioid ovarian carcinoma during pregnancy presenting with acute rupture.

BACKGROUND: Endometrioid ovarian carcinoma is rarely diagnosed during pregnancy and is generally asymptomatic. We present a case of endometrioid ovarian carcinoma during pregnancy that presented with acute rupture, and discuss options for management. CASE: A primigravid woman presented at 26 weeks' gestation with severe abdominal pain. At laparotomy, an adnexal mass was found to have ruptured. The mass was identified postoperatively as an endometrioid ovarian carcinoma. The decision was made to perform Caesarean section with fertility-sparing surgical management at 34 weeks to maximize maternal and fetal outcomes. CONCLUSION: To our knowledge, this is the first reported case of endometrioid ovarian carcinoma presenting with rupture in pregnancy. The differential diagnosis of severe abdominal pain during pregnancy should include rupture of ovarian malignancy.

Contexte : Le carcinome endométroïde de l'ovaire est rarement diagnostiqué pendant la grossesse et est généralement asymptomatique. Nous faisons état d'un cas de carcinome endométroïde de l'ovaire pendant la grossesse ayant présenté une rupture aiguë et nous discutons des options de prise en charge. Cas : Une primigravide présentait, à 26 semaines de gestation, de graves douleurs abdominales. Au moment de la laparotomie, nous avons constaté la présence d'une masse annexielle ayant connu une rupture. Cette masse a postopératoirement été identifiée comme étant un carcinome endométroïde de l'ovaire. En vue de maximiser les issues maternelles et fœtales, nous avons pris la décision de procéder, à 34 semaines, à une césarienne au moyen d'une prise en charge chirurgicale permettant de sauvegarder la fertilité. Conclusion : À notre connaissance, il s'agit du premier cas signalé de carcinome endométroïde de l'ovaire présentant une rupture pendant la grossesse. En présence de graves douleurs abdominales pendant la grossesse, le diagnostic différentiel devrait inclure la rupture d'une tumeur ovarienne maligne.

Peroxisome Proliferator-Activated Receptor -ß/δ, -γ Agonists and Resveratrol Modulate Hypoxia Induced Changes in Nuclear Receptor Activators of Muscle Oxidative Metabolism.

PPAR-α, PPAR-ß, and PPAR-γ, and RXR in conjunction with PGC-1α and SIRT1, activate oxidative metabolism genes determining insulin sensitivity. In utero, hypoxia is commonly observed in Intrauterine Growth Restriction (IUGR), and reduced insulin sensitivity is often observed in these infants as adults. We sought to investigate how changes in oxygen tension might directly impact muscle PPAR regulation of oxidative genes. Following eight days in culture at 1% oxygen, C(2)C(12) muscle myoblasts displayed a reduction of PGC-1α, PPAR-α, and RXR-α mRNA, as well as CPT-1b and UCP-2 mRNA. SIRT1 and PGC-1α protein was reduced, and PPAR-γ protein increased. The addition of a PPAR-ß agonist (L165,041) for the final 24 hours of 1% treatment resulted in increased levels of UCP-2 mRNA and protein whereas Rosiglitazone induced SIRT1, PGC-1α, RXR-α, PPAR-α, CPT-1b, and UCP-2 mRNA and SIRT1 protein. Under hypoxia, Resveratrol induced SIRT1, RXR-α, PPAR-α mRNA, and PPAR-γ and UCP-2 protein. These findings demonstrate that hypoxia alters the components of the PPAR pathway involved in muscle fatty acid oxidative gene transcription and translation. These results have implications for understanding selective hypoxia adaptation and how it might impact long-term muscle oxidative metabolism and insulin sensitivity.

The effects of low protein during gestation on mouse pancreatic development and beta cell regeneration.

Beta cells are partially replaced in neonatal rodents after deletion with streptozotocin (STZ). Exposure of pregnant rats to a low protein (LP) diet impairs endocrine pancreas development in the offspring, leading to glucose intolerance in adulthood. Our objective was to determine whether protein restriction has a similar effect on the offspring in mice, and if this alters the capacity for beta cell regeneration after STZ. Pregnant Balb/c mice were fed a control (C) (20% protein) or an isocaloric LP (8% protein) diet during gestation. Pups were given 35 mg/kg STZ (or vehicle) from d 1 to 5 for each dietary treatment. Histologic analysis showed that C-fed offspring had largely replaced beta cell mass (BCM) after STZ by d 30, but this was not sustained over time. Female LP-fed offspring showed an initial increase in BCM by d 14 but developed glucose intolerance by d 130. In contrast, male LP offspring showed no changes in BCM or glucose tolerance. However, LP exposure limited the capacity for recovery of BCM in both genders after STZ treatment.