1. Vision and Hearing Screening Broadway ACN PDSA 2007-2008

2. AIM statement Ensure effective and proper screening of hearing and vision of 95% of children age 4-18 years in accordance with AAP guidelines. Ensure proper referrals of 95% of children who require them. Ensure pre-screening of 75% of patients Decrease visit cycle time by 15%

3. Why hearing and vision? Vision disorders: 4 th most common disability among US children Leading cause of childhood impairment conditions Only 21% of all preschool children are screened Only 14% receive a comprehensive vision exam Hearing loss: Most common congenital condition in the US - 33 infants born daily Congenital deficit may only become evident in childhood Can be acquired during infancy or childhood Post trauma to the CNS, noise pollution, ototoxic drugs

4. Guidelines

5. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for preventive pediatric health care. Pediatrics.2000; 105 :645 –646

6. AAP Guidelines: When do I screen? 3 yr.4yr.5 yr.6, 8yr. 10 yr.11 yr.12 yr.13,14 yr. 15 yr.16, 17 yr 18 yr. OOOOOSOSOSO SOOOOSOSOSO Newborn1 mo. 2 mo. 4 mo. 6 mo. 9 mo. 1 yr.15 mo. 18 mo. 21 mo. 24 mo. OSSSSSSSSSS SSSSSSSSSSS S: Subjective screen at every routine visit (i.e.: history) O: Objective testing

7. Referral Vision: 3-5 yo: 20/50 or worse (repeat in 6 months if uncooperative) 6 yo and older: 20/40 or worse Any age with two-line difference between eyes, even within the passing range (i.e., 10/12.5 and 10/20 or 20/25 and 20/40) Hearing: Air conduction hearing threshold levels of >20 dB at any of these frequencies 4 yo onward: each ear tested at 500, 1000, 2000, and 4000 Hz.

8. PDSA Cycles

9. Baseline measurements Brooke Davey Average visit time: 3 hours 4 minutes Appropriately screened: Vision: 91% (39/43) Hearing: 91% (39/43) Abnormal results referred: Vision: 25% Hearing: N/A (no abnormal screens)

10. Didactic Stephanie Marion

11. Didactic cycle A.k.a Eclipsys crash cycle, Tom Hooven Appropriately screened : Vision: 94% (17/18) Hearing: 91% Abnormal results referred: Vision: 25% (1/4) Hearing: N/A (no abnormal screens)

12. Tom Hooven cycle What: provider pre-ordering hearing and vision in Eclipsys the day before patient comes for appointment Who: one patient and one provider Result: did not work as “pending return visit” orders not monitored by MAs

14. Katie McGuinn cycle November-December What: Effective identifying of patients in need for pre-screening: Identification of eligible patients by providers, marked on tallies for PFAs to see Eclipsys orders entered Pink box on cover sheet attached to front of chart for MAs to recognize Who: Resident clinic (half a day) Result: Did not work – Labor intensive Appropriately PRE-screened : Vision: 40% (4/10) Hearing: 60% (6/10)

15. Erik Jensen cycle January What : Eliminated need for provider and PFA involvement Established age-based guidelines as to which patients would be pre-screened: Vision: Any pt 4-18 years in clinic for regular appointment (no walk-ins) unless pt/guardian admits to testing within past 6 months. Hearing: Any pt 4-10 years in clinic for regular appointment (no walk-ins) unless pt/guardian admits to testing within past 6 months Who: Resident clinic (2 half days) Results: Improved results but not at goal yet Appropriately PRE-screened: Vision: 67% (4/6) Hearing: 67% (4/6)

16. Meg Sullivan cycle February What : Signs placed in MA’s office Signs for provider offices and consultation 4 day retrospective analysis Who : All providers Results : Confirmation of improvement Appropriately PRE-screened: Vision: 84% (43/51) Hearing: 84% (43/51)

17. Emily Kaufman final chart review April – over 2 weeks, all providers n = 72 Average visit time: 2 hours 29 minutes Appropriately screened: Vision: 89% (64/72); 98.5% pre-screened Hearing: 84% (36/43); 97% pre-screened Abnormal results referred: Vision: 70% (18/26) Hearing: 0% (0/1)

18. Summary BaselinePost-didacticFinal chart review N431872 Vision screen91%94%89% Hearing screen91% 84% Average cycle time 3 h 4 minN/A2 h 29 min Vision referral when abnormal 25% 70%

19. Future Plans Staff education planned with Ophthalmologist Michael Chiang M.D. to review vision screening methods Find ways to decrease cycle time even more (i.e.: redesign, pairing M.A with provider, etc) Ensure that providers are actually looking at results of screen by importing flow sheet into note

21. Chart review of past projects Domestic Violence at Newborn, 1 y.o. visits (2006-2007): 45% screening (7/16; 6/10 of newborns screened and only 1/6 of 1 yo) Blood pressure documentation (2005-2006): 73% of charts (32/44) Screen time documentation (2004-2005): 0% (0/32) BMI (5yo-19yo): 14/34 with elevated BMI, 50% documented intervention

22. Thank you PFAs: Evelyn, Kenya, Carlos, Conchita R.Ns: Haydee, Catherine, Bridget, Sally M.Ds/N.Ps: Mariellen Lane, Pran Saha, Laura Robbins-Milne, Renie Eis, Heidi Beutler, Nan Salamon, John Rausch

23. Thank you The ACN Broadway residenCE: Katie McGuinn, Brooke Davey, Stephanie Marion Lindsey Tilt, Cyril Sahyoun, Taryn Wiley-Rio Sangita Patel, Meg Sullivan, Jennifer Louis- Jacques Emily Kaufman, Deena Blanchard, Tom Hooven Eva Cheung, Emily Rothbaum, Erik Jensen