2022 Statewide Campus System Scholarly Activity Poster Day

Background: It is a widely held belief that the boarding of patients in the Emergency Department, especially those of high acuity, is generally a suboptimal plan of care as referenced by many previous articles (3, 5, 8). Boarding occurs secondary to a multitude of reasons: critical staffing shortages on various hospital floors, lack of beds available, shift change and otherwise occupied staff delaying giving or receiving report.

One explanation for the suboptimal care that has been reported may lie in the fact that ED staff are trained to be accurate and efficient stabilizers and triagers of the hospital system rather than focused on continuity of care. Additionally, with regards to staffing, most staffing models assign ED nurses a patient to nurse ratio of either 3:1 or 4:1, whereas ICU nurse to patient ratio is 2:1. There are countless small cumulative factors that may contribute to the negative impact on ICU boarded patients in the emergency room such as the ED nurse to ICU provider communication system may be less robust than that at the disposal of the ICU nurse and often the physical distance from the in-house ICU provider to the ED vs the ICU. This undoubtedly is a multifactorial issue that is worth attending to (2, 3, 5, 8).

This hypothesis that longer boarding time of ICU patients in the ED may have negative effects on the patient has been studied in other settings in various ways with special attention to an array of variables but with the constant of ED boarding of ICU patients (2, 3, 5, 8). We have decided to take a unique look at the effect of ED boarding time of ICU patients with Sepsis, Severe Sepsis, and Septic Shock in a MidWest community teaching hospital via a retrospective study. According to the UpTo Date, mortality rates in sepsis are high and range between 10-40 percent (1, 6). Sepsis is also a condition that requires attentive care and close monitoring with tightly goal directed therapy, so much so that the Surviving Sepsis Campaign was rolled out in 2016 with the hopes of improving care given in this high acuity patient (7). Therefore, the concern is that these patients may be at particular risk when boarding in the ED and even more so when requiring ICU level care.

Results: Of the 392 patients studied, 195 (49.7%) are male and 197 (50.3%) are female. In regards to race, 350 (89.3%) are White/Caucasian, 36 (9.2%) are Black/African American, 1 (.3%) are Alaskan/Native American, 4 (1%) or other.

Overall, age ranged from 21-101 years old with a mean of 69.33 and standard deviation of 16.0. ED LOS ranged from 1:18 to 23:17 with a mean of 7:18 and a standard deviation of 3.3. Boarding time in the ED ranged from as little as 8m to a maximum of 264 and 40 with a mean of 5.84 and a standard deviation of 23.6. Hospital length of stay ranged from 1.93 to 1331.37 with a mean of 154.31 and a standard deviation of 180.1. In hospital mortality was found in 165 patients (42.1%) whereas 226 patients (57.7%) survived to discharge.

It was found that boarding time as well as hospital LOS were not correlated (r= 0.121; p=0.17). In the group of patients that survived to discharge, the hospital LOS was 3.12-897.15 with a mean of 152.16 and standard deviation of 158.5. Similarly for the survival group, the boarding time was 0.40-264.4 with a mean of 8.73 and a standard deviation of 35.0.

Meanwhile, in the mortality group, the hospital LOS was 1.93-806.17 with a mean of 146.09 and standard deviation of 161.4. Similarly for the survival group, the boarding time was .08-35.38 with a mean of 3.60 and a standard deviation of 5.5.

A T-test was used to see if there was a significant difference between boarding time and mortality. It was calculated that boarding time did not differ between those who died (3.60) and those who survived (8.74) (p=0.28).

An extreme outlier was identified, one patient in the survival group who had a boarding time of 264.4 while all others were < 20 in that group. The decision was made to rerun analysis with the outlier removed. Boarding time was thus changed as follows, 0.08-35.38 with a mean of 3.81 and a standard deviation of 4. It was found that precision improved. The recalculated boarding mean time of inhospital survival was 4.08 with a SD of 4.2 and of in hospital mortality mean time was 3.59 with a SD of 5.5. Therefore, the boarding time difference became even less significant (p=0.58).

A bivariate (controlling for boarding time and mortality) regression analysis was performed to control for age. It is found using this regression analysis that again, boarding time is not a significant predictor of mortality (OR= .29; p=0.58).

Using multiple regression controlling for age, it is further extrapolated that boarding time becomes even less significant when age is added (OR= .008; p=0.93). It is found that age, itself, is a significant, independent predictor of mortality (OR= 7.04; p=0.008).

Discussion: Multiple past studies have concluded that an increase in ED boarding of ICU patients is correlated with increased hospital mortality. This study, on the other hand, suggests otherwise. Without controlling for age, boarding time did not differ between those who died (3.60) and those who survived (8.74) (p=0.28). Though age was found to be an independent risk factor for mortality (OR= 7.04; p=0.008), when controlling for age, it is found again that boarding time is not a significant predictor of mortality (OR= .29; p=0.58).

There are a number of contributing factors that may have resulted in these variant findings from the robust literature available. This study was performed in a small community hospital system where policy/procedure dictates that though ICU nursing staff does not assume care of the ICU patient boarding in the ED, the ICU attending/resident team does assume care of the patient at and/or very near the time of admission to the ICU regardless of patient physical location. In some hospital systems, the ED provider continues to care for the ICU patient while the patient is in the proximity of the ED. This leads to the conflicting attention of an attending/resident provider as the ED continues to deal with influx of critical and non-critical patients that the team remains responsible in caring for in an ideally timely fashion. Perhaps, additionally, nursing staff at this particular institution where the study was performed have additional experience or training in critical care medicine. Another notable consideration is that this institution's staffing model in the ED largely has a nurse to patient ratio of 3:1 whereas staffing models in many other EDs allow for 4:1 or greater.

This study was able to take a unique look at a midwest community hospital that serves both rural and urban populations alike. It is advantageous to this particular hospital system to know and understand the effects on outcomes (mortality and hospital LOS) on ICU level sepsis patients. However, this is with the understanding that these findings do not follow general norms found in the robust literature today. It may be beneficial, though incredibly labor intensive, to additionally risk stratify patients and their subsequent outcomes as an extension of this study by controlling for co-morbidities. This hospital system does not have a heavily used ICD-10 code system for past medical, social, and surgical histories that would allow for gathering of these variables in mass. Perhaps additional control with, for example, the widely used Charleston comorbidity index, would allow for additional findings. Furthermore, it may behoove this hospital system, to look more specifically at nurse to patient ratios and effects on outcomes as this may be a very real positive factor in the outcomes of this particular study.

Sources: 1. Elixhauser A, Friedman B, Stranges E. Septicemia in U.S. Hospitals, 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb122.pdf (Accessed on February 15, 2013).

2. Hirschy R, Sterk E, Dobersztyn R, Rech MA. Time Spent in the Emergency Department and Outcomes in Patients With Severe Sepsis and Septic Shock. Adv Emerg Nurs J. 2018 Apr/Jun;40(2):94-103. doi: 10.1097/TME.0000000000000188. PMID: 29715251.

3. Li Q, Wang J, Liu G, Xu M, Qin Y, Han Q, Liu H, Wang X, Wang Z, Yang K, Gao C, Wang JC, Zhang Z. Prompt admission to intensive care is associated with improved survival in patients with severe sepsis and/or septic shock. J Int Med Res. 2018 Oct;46(10):4071-4081. doi: 10.1177/0300060518781253. Epub 2018 Aug 30. PMID: 30165749; PMCID: PMC6166340.

4. Nicholas M. Mohr MD, MS, FACEP, FCCM Brian T. Wessman MD, FACEP, FCCM Benjamin Bassin MD, FACEP, Timothy Ellender MD, FCCM et al. Boarding of critically Ill patients in the emergency department. First published: 17 July 2020 https://doi.org/10.1002/emp2.12107.

5. Paton A, Mitra B, Considine J. Longer time to transfer from the emergency department after bed request is associated with worse outcomes. Emerg Med Australas. 2019 Apr;31(2):211-215. doi: 10.1111/1742-6723.13120. Epub 2018 Jun 25. PMID: 30129706.

6. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, Hotchkiss RS, Levy MM, Marshall JC, Martin GS, Opal SM, Rubenfeld GD, van der Poll T, Vincent JL, Angus DC. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287. PMID: 26903338; PMCID: PMC4968574.

7. Slade, E., Tamber, P.S. & Vincent, JL. The Surviving Sepsis Campaign: raising awareness to reduce mortality. Crit Care 7, 1 (2003). https://doi.org/10.1186/cc1876.

8. Zhang Z, Bokhari F, Guo Y, Goyal H. Prolonged length of stay in the emergency department and increased risk of hospital mortality in patients with sepsis requiring ICU admission. Emerg Med J. 2019 Feb;36(2):82-87. doi: 10.1136/emermed-2018-208032. Epub 2018 Dec 5. PMID: 30518642.

Abigail House MD resident

Ascension Genesys

Alex Kaechele

Ascension Providence Hospital and MSU CHM Southeast Michigan Campus

Patient and Physician Satisfaction with Telemedicine

Authors: Anton Juncaj, DO

Background: Telemedicine is defined by the Centers for Medicare and Medicate Services as “…the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.” Telemedicine has evolved gradually since the 1970s, with breakthrough technology to help facilitate patient care. The COVID-19 pandemic forced patients and physicians to rely heavily on telemedicine for safety and improved accessibility. As COVID-19 remains a concern after two years, it is a good time to compare in-person vs telemedicine visits, including phone or video visits, in order to ascertain the preferences moving forward for primary medicine.

Project purpose/design/hypothesis/question: The purpose of this study is to determine the satisfaction and preference of telemedicine compared to in-person visits, in order to assess its utility in the future.

Methods: A cross-sectional survey was distributed among both patients and physicians at Downtown Flint Health Clinic in Flint, Michigan and Ascension Genesys Hospital in Grand Blanc, Michigan, respectively. Patients were given a paper copy of a patient-specific survey investigating their satisfaction and preference of in-person, telephone, and video visits to complete during an in-person visit. A similar physician-specific survey was created on RedCap and distributed via email to all resident physicians as well as their faculty physicians. The surveys were based off surveys generated for previous studies. The surveys were anonymous, and data was collected by the principal investigator.

Results: Data was obtained between February 1, 2022 and March 24, 2022. 48 patients surveys and 42 physician surveys were included in the study. Mean patient age was 49.0 and mean physician age was 31.6 years old. 70.8% of patients identified as female, compared to 45.2% of physicians. Patients were significantly more forgiving with telemedicine appointment duration, 93.9% were satisfied, compared to physicians (78.6%). Similarly, the majority of physicians felt that telemedicine can help avoid unnecessary ED visits (82.1%) compared to patients (74.5%), with no significant difference among the two groups. A Likert scale was used to assess the desire to recommend telemedicine to a friend, with 46.9% expressing that they were very likely to recommend, and 26.5% stating that they would likely recommend, for a total of 72.4% in favor of recommending telemedicine to friends. Significantly more physicians had technical difficulties with telemedicine visits (46.2%) compared to patients (12.2%). The majority of physicians felt they were able to address a patient’s main concern with telemedicine (87.2%) compared to patient responses (85.4%). 93.9% of patients were satisfied with in-person visits, with 61.2% stating it as their most preferred visit, compared to 14.3% preference for telephone visits, 6.1% video visits, and 14.2% responding with a combination of the aforementioned.

Conclusion: A large majority of patients surveyed preferred in-person visits compared to telemedicine visits. The value presented in this data may be an underestimation, given that the group of patients that answered with multiple preferences all had in-person as one of the preferences. These results contrast the initial thoughts of a higher preference for telemedicine given the flexibility, convenience, and efficiency benefits. Patients are more forgiving when it comes to length of appointment time with telemedicine, and physicians tend to have more experiences with technical difficulties compared to patients. The majority of patients and physicians agree that telemedicine can successfully be used to address a patients main concern, and that it can be used to avoid unnecessary ED visits. The data shows that in-person visits are still preferred, suggesting there is still a large gap in technology and practicality in order to have telemedicine as a viable alternative to in-person visits.

Anton Juncaj

Ascension Genesys

Prospective, single-blinded study on the use of medical grade honey in the prevention of bone anchored hearing aid associated skin breakdown

Anya Costeloe, DO; Robert Conway, DO; Kylie Smith, DO; Bo Pang, DO; Robert T. Standring, MD; Seilesh Babu, MD

Objective: To demonstrate that postoperative use of medicinal grade honey compared to current post-operative care decreases bone anchored hearing aid (BAHA) associated skin reactions and breakdown and promotes faster healing.

Study Design: Prospective, single blinded, randomized study

Setting: Tertiary referral center

Patients: Adults >18 years old undergoing bone-anchored hearing aid implantation (BAHA) surgery. Patients undergoing revision surgery or with history of radiation to the site were excluded.

Interventions: Participants were randomized to postoperative medical honey (MediHoney) or standard care. The experimental group applied MediHoney to the abutment site daily for 2 weeks post-op. The control group applied bacitracin ointment. Photos were taken of the site for the first 7 days post-operatively, then at 2 weeks, 1 month, 3 months and 6 months. The de-identified photos were sent to 4 blinded otolaryngologists, who graded the abutment site using the Holgers skin classification. Patient’s subjective level of pain and discomfort were assessed.

Main Outcome Measures: The key outcome variables were the differences in the Holgers values, levels of pain at abutment site and infection rates between the 2 groups, which were analyzed using t-test, ANOVA and Post-Hoc tests. A p-value < 0.05 is considered significant.

Results: With n = 17, there were no statistically significant differences in the Holgers scale ratings detected between the two groups at any of the time points. The average level of pain (scale 0-10, 0 no pain) at 6 months was significantly lower in the MediHoney group (0.583 ± 1.021) compared to the control (5.833 ± 4.119, p = 0.013). The overall infection rate was 16.7% (n = 1) and this patient was in the control group.

Conclusions: Skin reactions are the most common complication after BAHA Connect implant surgery. Post-operative use of MediHoney may decrease long term discomfort associated with BAHAs.

Anya Costeloe, DO

Ascension Macomb-Oakland

Arth Patel

MSUCOM

Avneet Avendano M.D., Virginia LaBond M.D. FACEP

Ascension Genesys

Background: Although research has examined disparities in suicidal ideation across multiple groups, few investigations have analyzed such disparities in the context of COVID-19 pandemic. Furthermore, there is limited research on differences within and across countries, further limiting the extent to which meaningful comparisons can be made. Therefore, this study examines risk and protective factors of suicidal ideation during COVID-19 lockdown in adults across five countries.

Method: Adults (N = 2,482) from the United States, Italy, Spain, Saudi Arabia, and India completed a survey to measure suicidal ideation, recent drug use, and sociodemographic factors. Prevalence of suicidal ideation was assessed using simple and multivariable logistic regression models, and severity of suicidal ideation was analyzed via a multinomial multivariable logistic regression. Cohen’s d statistics were reported for all analyses to report effect size.

Results: In all models, Black adults endorsed a significantly greater prevalence (aOR = 3.88, 95% CI: 1.97-7.65, d = 0.75) and severity (aRRR = 7.64, 95% CI: 2.39-24.44, d = 1.12) of suicidal ideation compared to their White peers. Additionally, past 90-day illicit drug use was associated with greater prevalence (aOR = 1.32, 95% CI: 1.01-1.75, d = 0.15) and severity (aRRR = 2.15, 95% CI: 1.27-3.61, (aRRR = 0.42) of suicidal ideation during COVID-19 lockdown

Conclusions: This study further highlights the racial disparities that exist in suicidal ideation in international samples, for which greater medical and mental health interventions are critical. Furthermore, recent illicit drug use is a significant predictor of suicidal ideation during COVID-19. As such, targeted multicomponent interventions that address substance use are important for reducing the rising prevalence and severity of COVID-related suicidal ideation.

Deeshpaul Jadir (medical student)

MSUCOM

INTRODUCTION: Due to the high cost of operating room time, hospitals have been under increasing pressure to optimize operating room (OR) efficiency. One such parameter that has been used to predict OR efficiency is First Case On-Time Start (FCOTS). In this brief report, we identify the rates and causes of first case delay for elective procedures within the orthopedic department at our suburban community hospital. METHODS: This is a retrospective study. We reviewed information from our anesthesia group to identify the rate and causes for delayed FCOTS, as well as observations and employee interviews to map contributing factors of delay. RESULTS: Surgery data on 159 days reviewed indicated that 107 (67.3%) days had first case delays. Of the 398 total first cases during this period, 156 (39.2%) were found to be delayed. We identified surgeons (56.5%) as the main contributor to delay, followed by pre-operative (18.3%), and room-related causes (13.0%). The anesthesia department and the patient were minor causes of delay, representing 6.9% and 5.3% of case delays respectively. DISCUSSION: At our community hospital we found, similar to other studies, surgeons and Preop as main cause for delay. A fishbone diagram revealed patient factors, inefficiency in the pre-operative process, and staff tardiness as some of the causes. CONCLUSIONS: We identified surgeons and pre-operative as accounting for the main factors relating to OR inefficiency within our hospital . We also determined the contributing factors related to FCOTS delay . Future strategies to improve daily OR flow within our institution should target surgeon on-time arrival, streamlining of the pre-operative process to significantly reduce FCOTS delays. Keywords: First case on-time start (FCOTS), inefficiency, surgeon, operating room (OR), orthopedic

Elise Ketelaar OMS-III (medical student)

MSUCOM

BACKGROUND: Antibiotic resistance is a public health problem that worsens the more we prescribe standard dose antibiotics for acne. Regardless of race, acne vulgaris is one of the most common dermatologic conditions among pediatric populations. As such, we can make a large impact by practicing good antibiotic stewardship while still addressing the impact of acne on adolescents’ self-esteem. Subantimicrobial doxycycline maintains its anti-inflammatory effects while eliminating antimicrobial properties and associated risks of drug resistance. Few studies, focused primarily on adults, have shown that subantimicrobial doxycycline is efficacious in treating acne from a physician standpoint. We aim to investigate the patient experience of acne treatment with subantimicrobial dose doxycycline in the pediatric population.

METHODS: 22 adolescents aged 13-17 with moderate to severe facial acne were randomized in a non-blinded, parallel fashion and in equal allocation to receive either the standard 100mg or subantimicrobial 20mg doxycycline dose BID for 12 weeks. Biweekly Qualtrics surveys were administered to identify changes in the self-reported severity of facial acne lesions using a 10-point ordinal Likert-type scale.

RESULTS: Patients in both the 100mg (P=0.002) and 20mg (P=0.018) groups perceived significant improvements in their acne. Between-group analysis of the 20mg vs. 100mg group was non-significant (P=0.677), demonstrating that patient-perceived improvements in acne severity were not statistically different between the two dosage groups.

CONCLUSIONS: Subantimicrobial dose doxycycline may be a promising alternative to standard dosing in acne treatment among pediatric patients although, future larger scale investigations are warranted.

Erika Malana, OMS-IV

MSUCOM

INTRODUCTION: Patient satisfaction is an important metric of quality that can be nationally measured through a Press Ganey survey: Hospital Consumer Assessment of Healthcare Providers and Systems (HCHAPS). At McLaren Bay Region, physician communication has consistently been well below the national average. From August 2021 through January 2022, physician communication was ranked in the fifth percentile (N=156). This non-human subject quality improvement project hypothesized that patient satisfaction could be improved through pictorial handouts and expected to see a measurable increase in the HCHAPS scores in the physician communication from the fifth percentile to the tenth percentile.

METHODS: On February 1, 2022, McLaren Bay Region’s family medicine residency and hospitalist group provided patients with a pictorial information sheet. This contained pictures of attending physicians, resident physicians, and physician assistants on the front and information regarding the role of a resident or hospitalist respectively and a place to write questions on the back. Every patient admitted to one of the two inpatient services was given an information sheet by a provider at admission. HCHAPS surveys were distributed and reported to the hospital using the Press Ganey national survey system.

RESULTS: Preliminary analysis of our results showed that addition of a pictorial information sheet has not impacted McLaren Bay Region’s physician communication based on HCHAPS scores. Comparing the months of December 2021 and January 2022 prior to our intervention, 46 surveys were completed placing physician communication in the fifth percentile for that month. After our intervention in February and March 2022, 50 surveys were completed showing the fourth percentile for physician communication.

DISCUSSION: Many factors have influenced our study. Due to the supply chain shortage, it took 6 months to receive our handouts limiting the length of our study. In addition, as a result of the COVID19 pandemic, the visitor policy frequently changed during the study which impacted patients' ability to recall care. The pandemic also created staffing shortage which likely negatively affected a patient’s stay. In conclusion, due to confounding variables, we were unable to say if pictorial information sheets increased a patient’s perception of physician communication. This study should be repeated after the COVID19 pandemic has ended.

Erin Campau DO, PGY-3

McLaren Bay Region

Introduction: Well child checks, performed from birth to 21 years old, are essential for completing four main tasks: disease detection, disease prevention, health promotion, and anticipatory guidance. However, implementation can be challenging for various reasons, including EMR limitations, time constraints, competing priorities, and physician competence.

Purpose: This project’s aim was to improve residents’ satisfaction with well child checks and increase time spent on anticipatory guidance by implementing consistent documentation templates as well as providing education and resources for anticipatory guidance.

Methods: Fifteen family medicine residents from two mid-Michigan family medicine offices were surveyed before and after the implementation of revised documentation templates. Templates included recommended anticipatory guidance topics, talking points, and reminders for appropriate developmental screening. Surveys were conducted from June to November 2021 and data was analyzed using a paired t-test.

Results: There was a statistically significant correlation and t-score, both with p-values of <0.01, with regards to residents’ satisfaction with well child checks as well as their confidence in delivering anticipatory guidance to parents. However, there was no significant increase in the reported amount of time spent on anticipatory guidance or the frequency of finishing well child checks in the allotted time. Residents’ perceived importance of anticipatory guidance slightly decreased.

Conclusions: Having an easy-to-use, standard approach to documentation of well child checks and providing talking points for anticipatory guidance within documentation templates results in improved resident satisfaction with well child checks and their confidence in providing anticipatory guidance. Further improvements are still needed in regards to understanding the importance of anticipatory guidance and the amount of time spent providing it to parents.

Gina Delp, DO

Sparrow/MSU Family Medicine

Background: Opioids are commonly prescribed after laparoscopic bariatric surgery but have untoward effects including dependence and diversion. Prior investigation revealed that over three-fourths of discharge opioids prescribed to our patients went unused. Objectives: To determine the feasibility of an opioid sparing discharge protocol following laparoscopic bariatric surgery. Methods: A total of 212 opioid naïve patients undergoing laparoscopic bariatric surgery were examined and divided into two groups; 106 prior to (Cohort A) and 106 after implementation of an opioid sparing discharge protocol (Cohort B). Opioids were converted to morphine milligram equivalents (MME) and post-operative consumption was examined. Data was described as mean ± standard deviation. Results: No patients in Cohort B and 54.7% (58) in Cohort A received an opioid discharge prescription (37.5 MME). Of the 154 patients that remained, only 1.3% (2) received one after discharge. Cohort A took greater amounts of opioids than Cohort B after discharge (4.74 ± 11 vs. 0.21 ± 2 MME; p<0.001). During hospitalization Cohort A took greater amounts of opioids (6.92 ± 11 vs. 2.74 "±" 5 MME; p<0.001) but lower amounts of methocarbamol (759 ± 590 vs. 966 ± 585 mg; p = 0.011). No patient requested an opioid prescription refill or presented to the emergency room secondary to pain. Conclusion: Following laparoscopic bariatric surgery, an opioid sparing discharge protocol is feasible with < 2% of patients receiving opioids after discharge and no increase in emergency room visits. Education regarding these protocols may impact the amount of opioids taken during hospitalization.

Haley Lehman, DO

Henry Ford Health System

Han Yu DO (Resident)

Henry Ford Wyandotte

Abdominal pain during pregnancy is quite common; however, surgical pathology such as acute appendicitis as a cause of such pain is not. Shifting abdominal contents in pregnancy can complicate an accurate diagnosis; therefore, diagnostic tests such as ultrasound (US) and magnetic resonance imaging (MRI) are used in addition to history and physical examination (PE) to help identify the causitive pathology. We elected to find the role of these imaging tests in pregnant patients who presented to our emergency department with acute abdominal pain.

Hunter Holsinger, OMS-III

MSUCOM

Introduction: Point of care ultrasound sonography (POCUS) is becoming more popular among many different specialties and practitioners in the medical field. POCUS is the use of ultrasound at a patient's bedside to aid with both diagnostic and therapeutic processes. There has been an increasing amount of interest regarding POCUS and its contribution to education and patient care over the last decade.

Objectives: This project seeks to evaluate the internal medicine program’s comfort with point of care ultrasound in hopes to strengthen resident’s confidence and knowledge regarding POCUS. We will employ a quality improvement focus to plan, do, study, and act (Taylor, 2013) in hopes to improve physician confidence using POCUS.

Methods: The study will consist of a survey using 11 questions based on a likert scale model. Internal medicine resident’s will be given a pre survey that will be used to gauge their baseline confidence and knowledge regarding POCUS. The surveys will be collected and analyzed to determine what percentage of residents feel comfortable with various aspects of point of care ultrasound. Following the analysis, areas of opportunity will be identified and used as a pilot to assist with the incorporation of a POCUS based curriculum for our internal medicine residency program.

Results: Twenty-three Internal Medicine residents participated in the survey. Selecting the appropriate transducer type: 56% very comfortable, 30% somewhat comfortable, 4 %neutral, 8% not very comfortable, 0% not at all comfortable. Adjusting depth and gain: 43% very comfortable, 39% somewhat comfortable, 8% neutral, 8% not very comfortable, 4% not at all comfortable . Capturing and retrieving images: 8% very comfortable, 26% somewhat comfortable, 30% neutral, 21% not very comfortable, 13% not at all comfortable. Discerning imaging quality (adequate vs inadequate): 8% very comfortable, 30% somewhat comfortable, 30% neutral, 21% not very comfortable, 8% not at all comfortable. Procedural Use: 65% very comfortable, 17% somewhat comfortable, 13% neutral 4% not very comfortable, 0% not at all comfortable. Performing focused cardiac exam 8% very comfortable, 39% somewhat comfortable, 13% neutral, 17 not very comfortable, 17% not at all comfortable. Interpreting cardiac findings: 4% very comfortable, 30% somewhat comfortable, 8% neutral, 39% not very comfortable, 17% not at all comfortable. Performing focused pulmonary exam using correct probe placement: 13% very comfortable, 34% somewhat comfortable, 21% neutral, 21% not very comfortable, 13% not at all comfortable. Interpreting pulmonary findings: 8% very comfortable, 39% somewhat comfortable, 13% neutral, 26% not very comfortable, 8% not at all comfortable. Assessing RV strain: 4% very comfortable, 21% somewhat comfortable, 26% neutral, 39% not very comfortable, 13% not at all comfortable. Assessing volume status by measuring IVC diameter and collapsibility index: 4% very comfortable, 30% somewhat comfortable, 13% neutral, 39% not very comfortable, 13 not at all comfortable

Conclusion and Next steps: There are many areas of opportunity to strengthen our internal medicine resident’s knowledge and confidence using point of care ultrasound. There are many aspects of POCUS which Internal Medicine Residents do not feel comfortable with. The areas that seem to produce the most discomfort include: performing focused cardiac exam, interpreting cardiac findings, performing focused pulmonary exam, assessing RV strain, assessing volume status by IVC. Relatively, residents’ feel most comfortable utilizing POCUS in the areas of selecting transducer type, procedural use, and adjusting depth and gain. This QI project successfully identified areas of deficiency noted by residents and will serve as a foundation to implement resident specific didactics and education dedicated solely to point of care ultrasound and its use in routine patient care. The hope is that this dedicated education will lead to and demonstrate improved knowledge, confidence and comfort surrounding the use of POCUS among Internal Medicine Residents. The goal is to implement a POCUS based curriculum for our internal medicine residency program to adequately and properly train our residents on the proper use of POCUS.

Jillian Roberson, MD Resident Physician

Ascension Genesys

Lauren Cole, OMS-III

MSUCOM

The increasing trend of obesity and its association with leading causes of death, such as heart disease, stroke, cancer, and diabetes, has created a need for primary care intervention. Obesity, poverty, food insecurity, and limited access to care are major problems within our region. Data has shown that 85% of Michigan adults and 82% of Michigan youth eat less than 5 servings of fruits and vegetables daily. We utilized a multi-disciplinary team to teach a sample cohort of patients the curriculum from the "Live Best Lesson Spreadsheet for Dinner With Your Doctor Sessions" over a 6-week span afterhours at a family medicine residency clinic. The implications of a structured cooking and food literacy program administered at a residency site were previously unknown. Biometric and survey data were collected over a 1-year period. Participants were incentivized with kitchen equipment to encourage home cooking after completion of the program. Based on pre- and post-study questionnaires, participants were noted to have made positive lifestyle changes and recalled key learning points such as how to read nutritional labels. Biometric data showed BMI and BP were stable to slightly improved. This project demonstrates that it is feasible to conduct a cooking program at a residency site.

Lucas Friedli, DO

Munson Family Practice

Introduction: At the McLaren Bay Region Family Medicine Residency Clinic, it is challenging to see the 16-24-year-old population on a regular basis. This can lead to delayed diagnoses/care, and worse patient outcomes. HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) to objectively measure, report, and compare quality across healthcare plans. From 2020-2021, our clinic’s lowest HEDIS score was annual urine chlamydia screening in 16-24-year-old women. This project aimed to increase the HEDIS measure percentage of annual urine chlamydia screening in our 16-24-year-old women from 27% to 50%, which is the national average.

Methods: In our clinic, all the clinical staff meet for a huddle meeting to discuss every patient coming in and any special needs for that patient. We implemented a change to the huddle process. During huddle, each resident went through their patient list for the day and marks any who are 16-24-year-old women. The resident then checked the patient’s chart to determine if the patient needed an annual urine chlamydia screening. If the patient was due for a screening, then the resident informed the medical assistant, who completed the urine screening while rooming the patient.

Results: This process intervention was implemented from February to April 2022. The huddle process change increased our annual chlamydia screening average from 27% to 31%. This was below our goal of 50% (national average). ​

Discussion: This study did not show an improvement to the national average. Therefore, the intervention will need to be changed before continuing in the clinic. Limitations for the study include only collecting three months of data, potentially limited sample size due timing of the data collection, and potential variability in residents enforcing the urinalysis collections. Future studies could improve on educating patients on the importance of annual chlamydia screening, aim to look at a full year of data, and analyze any differences between physicians.​

Maxwell White DO, PGY-3

McLaren Bay Region

There is currently very limited literature regarding the application of osteopathic principles to the field of dermatology. Furthermore, no current studies discuss medical students’ opinions on how they view osteopathy’s role in dermatology. The integumentary system is the largest organ of the body and is often helpful in guiding diagnoses. A lack of medical students’ perception of how the skin represents overall health may negatively impact future physicians’ ability to provide proper patient care, regardless of their specialties. This study will provide insight into the current medical student’s perception of how osteopathic principles apply to the practice of dermatology. The significance of this study is to highlight the importance of dermatology in the osteopathic profession and demonstrate the vital link between the two. This project involves a survey written listing dermatology-related statements that apply to osteopathic principles. The survey will be sent out to all students at MSUCOM, completed by the students voluntarily. The survey will have five answers on a Likert scale for the participants to select a range of ‘strongly agree’ to ‘strongly disagree.’ Results of the survey will undergo statistical analysis to understand better osteopathic medical students’ relation between the field of dermatology and osteopathy within MSUCOM, one of the few osteopathic medical schools that has dermatology as a separate course in our curriculum.

Meghan Grossmann Med Student

MSUCOM

Project Intent/Background Primary care providers are responsible for many aspects of patient care. Previous research has shown that posted health care information is an effective way of having patients visualize and read information regarding cancer prevention, HIV, and various topics. However, less data is available on the desire for ongoing communication around the posted health care information. Investigators evaluated the effectiveness of a written patient education poster in a Family Medicine Residency waiting room by evaluating visibility, engagement, and desire to receive further information regarding the topic. Methods Participants: Individuals for this study (N = 30) were patients of a Family Medicine primary care residency clinic. Three resident physicians asked standardized questions of adult patients about healthcare information on a poster in the waiting room. Patients were excluded from the survey if they were less than 18 years old, had a visual impairment, or had an accompanying party in the exam room. Measures: An informative poster about hypertension was placed in the waiting room of the Family First primary care clinic for patients to view. Next, the three resident physicians provided a brief survey with a series of questions about the informative poster to the patient after rooming. Once included in the patient sample (N = 30), if a patient answered “no” at any point, they were discontinued from the survey analysis (figure below). Results All data were analyzed using SPSS (v. 28). Prior to hypothesis testing, standard procedures to evaluate data accuracy, normality, and univariate outliers were implemented. No data was missing. Investigators asked a series of Yes/No questions to patients at a primary care clinic. The proportion of patients of saw the poster (n = 13) was not significantly different from those who did not see the poster (n = 17), χ2 (1, N = 30) = 0.53, p = .47. Similarly, the proportion of those who saw the poster and read the information (n = 7) was not significantly different than those who saw the poster and did not read the information (n = 6). Due to the assumptions of chi-square testing, the proportion of those who read the poster and wanted more information versus those who did not want more information could not be tested. However, none of these seven individuals (0% of the sample) wanted more information about the poster’s content. Conclusion Through this quality improvement project, investigators learned that there is no statistically significant data to support the use of educational health care posters in a residency clinic waiting room. However, little is known about the reasons why the participants did not want more information on the topic. Future PDSA cycles could include patients with the specific health condition mentioned on the poster and extrapolate the data to further assist in providing ongoing health care information to patients.

Michelle Egan, DO, Duncan Innes, MD

McLaren Macomb

In a new era of medical training, which includes challenges such as COVID-19, promoting resident well- being has becoming an optimum importance in the medical institutions. Resident wellness is essential to reducing burnout, enhancing professional growth, improving patient care, and supporting the overall healthcare system. Our study is a systematic review on evidence-based peer-reviewed publications of group and systemic level interventions and strategies of medical residency programs (MDs and DOs) in the United States developed and implemented to promote resident well- being since the inception of COVID-19 (December 2019- present). The results of the review will serve as a summary or tool kit of evidence-based strategies to create a culture that focuses on resident and physician wellness. Some examples of the interventions and strategies include developing and implementing a Well- being Committee and Professional Development Discussion Group in residency programs; integrating mindfulness training; destigmatizing mental health issues; and hiring therapists for residents and physicians. Additionally, we will present how we have effectively implemented some of these strategies in our family medicine residency program.

Mikita Patel MD

McLaren Oakland

The overall purpose of this exploratory pre-post-implementation quality improvement project will be to examine for changes in residents’ pre and post-implementation diabetes foot care assessment behavior frequencies in a convenience sample of podiatry residents at a community-based graduate medical education setting. The authors’ primary selected outcome will be changes in sample residents’ pre and post-implementation diabetes foot care assessment behaviors from a standard teaching protocol given to all residents via a presentation. The authors’ overall null hypothesis is that they will be unable to detect statistically significant pre-post diabetes foot care frequency changes when observing a coefficient Alpha of 0.05 to denote statistical significance.

Mohamamd Khan

Henry Ford Wyandotte

Background: Emotional regulation develops during adolescence and vastly differs between adolescents and adults. Development of emotional regulation may also result in adolescents experiencing a different psychological response to injury-related trauma, such as sustaining an ACL injury and undergoing subsequent ACLR, when compared to the response in adults.

Project Purpose/Design/Question: The purpose of this cross-sectional study was to compare psychological readiness for sport, injury-related fear, and knee-related quality of life between adolescents and adults 4-6 months after primary, unilateral ACLR.

Methods: One hundred seventy-seven participants (97 females, 72 males) were recruited from a university-affiliated sports medicine clinic. Participants were included if they were 13-25 years old and had undergone primary, unilateral ACLR 4-6 months prior to recruitment. Psychological response to injury was assessed using the ACL Return to Sport after Injury scale to assess psychological readiness for sport and the Tampa Scale of Kinesiophobia to assess injury-related fear. Participants completed the Tegner Activity Scale to assess pre-injury activity level and the Knee injury and Osteoarthritis Outcomes Scale quality of life subscale. Participants were categorized as adolescent if <18 years old.

Results/Conclusions: Adolescents reported better psychological readiness for sport (adolescent=72.4±20.5; adult=62.1±23.7) when compared to adults. There were no significant differences in pre-injury activity level (adolescent=9.1±1.0; adult=8.8±1.3) injury-related fear (adolescent=20.1±4.6; adult=20.6±5.0) or knee-related quality of life (adolescent=66.5±18.3; adult=60.7±17.4) between age groups. Adolescents had 2.63 (CI95: 1.39, 4.99) and 2.08 (CI95: 1.12, 3.89) times greater odds of reporting acceptable psychological readiness for sport or knee-related quality of life when compared to adults, respectively. Clinicians should include a diverse set of patient-reported outcomes that assess multiple constructs of psychological response to ensure identification of adolescent and adult patients who may benefit from targeted psychological intervention.

Nate Farner

MSUCOM

Background: Anterior cruciate ligament reconstruction (ACLR) is among the most common sports medicine procedures performed on adolescent and young adult athletes in the United States. While 84% of patients expect to make a full return sport (RTS) within 1 year of ACLR, recent studies indicate that as few as 24% of patients succeed. As a result, there is a need to better understand the reasons for the disconnect between patient expectations for reengagement in activity following ACLR and the reality of their experiences. Clinical success post-ACLR is challenging, and many athletes do not RTS while others consistently report reduced physical activity.

Purpose: The purpose of this study is to describe patient responses to a newly developed survey that characterizes patient perspectives for a change in activity level post-ACLR. We hypothesized that fear of injury and knee symptoms such as pain, locking, and tightness would be the most reported reasons for changes in physical activity.

Methods: A team of 3 researchers conceptualized the initial version of the ACL Reasons survey. The purpose of this survey was to allow individuals with ACLR to characterize their activity level and provide a ranking of evidence-based reasons for their perceived change in activity. We then recruited 65 participants, within 6-24 months post-primary, unilateral ACLR. Participants were sent the survey to evaluate their activity level, determine if activity was more challenging, and ascertain their rationale for reported changes in activity. The frequency of each response was recorded, and the percentage of the total sample represented in each group were calculated.

Results: We found that 38.5% of participants reported that they were as active as they were prior to ACLR, 29.2% were as active as they were prior to surgery but it was more mentally or physically challenging, and 32.3% were less active than they were prior. Within the more challenging group, 22.2% reported knee symptoms and 11.1% reported fear of injury versus the less active group of 14.3% and 28.6%, respectively. Our findings support the potential utility of the ACL Reasons survey as a tool to enhance communication between patient and clinician with the goal of enhancing patient-centered evaluation and intervention.

Conclusions: Our results indicate that fear and physical symptoms do not fully characterize the reasons for patient’s decrease in activity. Nearly 62% of patients reported being less active or experiencing mental or physical challenges when engaging in activity after ACLR and among these patients, knee symptoms, fear of knee symptoms or movement, and fear of injury were the most important reasons for change in their activity. Further development and implementation of this survey will give patients the opportunity to report factors impacting their RTS more holistically and give clinicians a tool to measure psychosocial factors involved in recovery post-ACLR.

Nate Farner

MSUCOM

Robert Tacia, DO: Resident

McLaren Oakland

Samantha Barrett, MD, PGY4 EM Resident

Ascension Genesys

Abstract BACKGROUND Section With the rise of lower extremity wounds secondary to diabetes and peripheral arterial disease, introduction of podiatric surgery consultation has shown to improve patient outcomes. There have been limited studies showing how this can affect readmission rates. After a retrospective chart review was performed at McLaren Oakland Hospital, it was found that patients with lower extremity wounds with a podiatric consultation were significantly less likely (p = 0.03) to be readmitted than those without a podiatric consultation.

Background Diabetes mellitus is a worldwide health issue that has reached pandemic proportions. Studies have shown that up to 25% of diabetic patients will develop an ulceration with up to a 50% chance of reulceration. Diabetic foot ulcerations rank among one of the highest causes for 30-day readmissions. Approximately 17-23% of all diabetic foot ulcerations will unexpectedly be readmitted to the hospital within 30 days of discharge from the hospital. Very few papers have shown correlations to whether or not the inclusion of podiatric services into the multi-disciplinary approach to wound care has improved outcomes for patients.

Project Purpose/Design/Research Question /Hypothesis (as appropriate) Previous studies have demonstrated that introduction of podiatric surgery consultation with timely provision of patient care results in positive patient outcomes. However, there are limited studies focused on readmission rates in teaching community hospitals. The main aim of this study is to determine if consulting podiatric services is associated with higher 30-day readmission rates in patients with lower extremity wounds. A cross-sectional descriptive study of admissions between July 2018 to December 2020 at McLaren Oakland was performed with the hypothesis that patients admitted with lower extremity wounds with podiatric consultations will have lower 30-day readmission rates than those without consultation.

Methods, Sample, Measures, Analyses This study reviewed admissions of adults with lower extremity wounds (ICD-10 codes) during the study period. Encounters in geriatric-psychiatric, intensive care, in-patient rehabilitation, and non-admission emergency room visits were excluded. The study sample was 306 index hospitalizations. The main outcome was a 30-day hospitalization readmission rate related to lower extremity wounds. The main explanatory variable was podiatry consultation. Other covariates of interest included socio-demographic characteristics, types of surgeries, comorbidities, and complications. T-test and Chi-square test were performed to identify differences between groups (consulted/not consulted). Multivariate logistic regression analyses were performed to identify factors associated with 30-day readmissions.

Results and Conclusions Demographic data showed: 78% caucasians, 59% males, mean age 62.32±14.86yr, and 46.4% podiatric surgery consultations. The 30-day readmission rate was statistically significant in patients receiving consultations than those that did not (4.2% versus 11.0%, p = 0.03). Patients with a podiatric consultation had a significantly lower likelihood of 30-day readmission (AOR 0.22; 95% CI 0.078, 0.671) than their counterparts after controlling for covariates. Patients with gangrene (AOR 7.61, p = 0.04) or osteomyelitis (AOR 9.07, p = 0.013) had a higher likelihood of readmission than patients with venous ulcers (reference).

Stephanie Behme DPM Resident

McLaren Oakland

T. Halbert D.O

Henry Ford Wyandotte

Victor Wong

Ascension Genesys

Objective: Determine whether adult cochlear implant (CI) users with superior semicircular canal dehiscence or near dehiscence experience clinically significant differences in audiological outcomes when compared to CI users with normal temporal bone anatomy.

Study Design: Retrospective, single institution review.

Setting: Michigan Ear Institute.

Methods: Retrospective review of CI users with radiographically confirmed superior semicircular canal complete dehiscence or near dehiscence. 15 individuals with complete superior canal dehiscence, 28 individuals with near dehiscence and 67 controls with normal temporal bone anatomy. Study participants had cochlear implantation between 2010 and 2020. Preoperative and postoperative AzBio Sentence Test scores and duration of deafness were analyzed.

Results: 938 patients underwent cochlear implantation with 110 patients having met inclusion criteria. Mean AzBio score for normal temporal bone anatomy group improved from 35.2 percent (SD 28.2) preoperatively to 70.3 percent (SD 25.7) postoperatively, an improvement of 35.1 percent (SD 28.6). Mean AzBio score for near dehiscent temporal bone anatomy group improved from 26.6 percent (SD 28.9) preoperatively to 64.5 percent (SD 30.6) postoperatively, an improvement of 37.9 percent (SD 27.9). Mean AzBio score for dehiscent temporal bone anatomy group improved from 26.3 percent (SD 20.4) preoperatively to 65.1 percent (SD 27.6) postoperatively, an improvement of 38.7 percent (SD 26.9). Utilizing the one-way analysis of variance (ANOVA) no statistically significant difference in audiologic outcomes exists between the three groups.

Conclusions: Patients with complete or near complete radiographic superior canal dehiscence at the time of CI surgery have similar speech perception scores compared to non-SSCD adult CI users.

William Kady, DO

Ascension Providence

Introduction

Approximately 87% of all strokes are due to acute ischemic stroke (AIS)1. Currently, intravenous alteplase (tPA) is the only approved medication for the treatment of AIS and is approved for administration <3 hours (and off-label <4.5 hours in select patients) of symptom onset or last known well2. The recommended door-to-needle (DTN) time is ≤60 minutes, as early administration of tPA has been associated with lower mortality rates3. < 1/3 of patients treated with tPA have DTN times ≤60 minutes4. The American Heart Association (AHA)/American Stroke Association (ASA) developed 12 DTN Best Practice Strategies to increase the percent of patients that achieve DTN ≤60 minutes. One strategy is EMS providers notifying hospitals when a potential stroke patient is identified5. The prehospital environment is a unique and minimally explored window of opportunity in which the determination of candidacy for tPA therapy could potentially occur much earlier than previously considered. The main objective of this study was to determine whether gathering and transmitting pre-hospital information can decrease the door to needle time for administering tPA in patients with signs and symptoms of ischemic stroke who are candidates for tPA therapy. Our hospitals current door to tPA time currently exceeds the standard of care, and the goal of this study was to improve door to needle time to under 60 minutes. We predicted this goal will be accomplished by improving communication between pre-hospital care providers and the emergency department providers.

Methods

A single center retrospective chart review was performed at a 360 bed community hospital with an annual ED census of approximately 65,000 visits per year. This hospital is serviced by 9 independent EMS agencies consisting of both public fire departments and private ambulance agencies all under the medical direction of the Wayne County medical control authority. We received IRB approval with an exemption for informed consent prior to any formal data collection. All adult patients who were suspected to have an acute ischemic stroke by EMS personnel between January 2021 and April 2021 and were brought to Henry Ford Wyandotte Hospital for evaluation were identified for inclusion into this study. Patients were included if the EMS pre-hospital Sheet was completed and sent to HFWH prior to patient arrival in the ED. In order to increase the use of pre-hospital evaluation sheets for suspected acute ischemic stroke, education was provided to EMS personnel, handouts were provided explaining the importance of the sheets, and EMS personnel were reminded of the new protocol when seen throughout the department. Data was obtained through a detailed electronic ED chart review and review of EMS pre-hospital sheets that were submitted.

Results

Insufficient data was collected to determine conclusions about the effect of pre-hospital evaluation on door-to-needle times as none of the 6 patients that had a pre-hospital arrival sheet completed received tPA. There was an increase of 300% in the use of the pre-hospital sheets for suspected stroke from pre-intervention to post-intervention.

Discussion

Limitations to this project include small sample sizes and unavailable EMS pre-hospital sheets, inability to determine conclusions due to lack of sufficient data. Areas for improvement include involving more hospital systems and EMS companies, better education of hospital staff/administrators, better education of nurses, EMS companies, and ED physicians.

Study authors have neither perceived conflicts of interest nor any financial relationships to disclose

References

1. Virani SS, Alonso A, Aparicio HJ, et al. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation. 2021;143(8):e254-e743. doi:10.1161/CIR.0000000000000950 2. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [published correction appears in Stroke. 2019 Dec;50(12):e440-e441]. Stroke. 2019;50(12):e344-e418. doi:10.1161/STR.0000000000000211 3. Man S, Xian Y, Holmes DN, et al. Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke. JAMA. 2020;323(21):2170-2184. doi:10.1001/jama.2020.5697 4. Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750-758. doi:10.1161/CIRCULATIONAHA.110.974675 5. Target: Stroke Best Practices. American Heart Association Website. Updated June 13, 2018. Accessed April 8, 2021. https://www.stroke.org/en/professional/quality-improvement/target-stroke/clinical-tools-and-resources.

Zoe Kaps, MD

Henry Ford Wyandotte Hospital