Rangel PDSA TB Didactic TB or not TB?

AIM Statement In order to improve care at the Charles Rangel Clinic, we will implement a tuberculosis screening protocol in order to identify high risk patients aged 1-11 years old who require PPD placement according to the guidelines set forth by the AAP Committee on Infectious Disease.

AIM Statement Our goal –≥95% of our patients will have documented screening for tuberculosis risk factors at least yearly –≥95% of patients with documented risk factors will have a PPD placed AND read – follow those in whom treatment is warranted

Why pediatric TB is important: 30% of global TB cases; 7% in U.S. Age 0-4 more likely to develop active TB once infected and more vulnerable to disseminated TB Public Health Standpoint: Pediatric TB = Sentinel Event Worldwide, 500,000 children die annually from TB

Tuberculosis rates by neighborhood 2005

Routine pediatric care: No more universal testing Not cost-effective to routinely skin test healthy children without risk Up to 85% of positive results will be FALSE positives in areas of low TB prevalence Preferred strategy: “targeted testing” –Focuses testing children with risk factors –Screen all children for risk factor(s) –Test only if > 1 risk factor(s) present

PDSA Cycle 1: TB screening questions To be asked once yearly at well child visits in children between the ages of 1 and 10: –Was your child or any household member born outside the United States? –Has your child or any household member traveled outside the United States? –Has your child been exposed to anyone with TB disease or a positive PPD? –Does your child spend time with anyone who has been in jail (or prison) or a shelter, uses illegal drugs, or has HIV?

Cutoff PPD values 5mm is positive when –close contact with known or suspected contagious tuberculosis –suspicion of disease based on clinical factors, or radiologic abnormalities 10 mm is positive when –risk for dissemination, including those younger than 4 years or those having medical conditions such as HIV diabetes renal failure or solid tumors –increased exposure such as frequent exposure to HIV infected persons, drug users, incarcerated persons, or nursing home residents –areas endemic for TB and those who have contact with adults from those areas (Asia, Middle East, Africa, Latin America) 15 mm is positive when –4 years of age and over without any risk factors

PDSA Cycle 2: Baseline Measures Chart review of all well child visits on 2 consecutive Tuesdays 19 patients were screened for tuberculosis risk factors 8 (42%) of the patients screened had at least one risk factor –3/8 (38%) did not have PPD placed –2/8 (25%) had PPD placed: 1 patient did not return for the reading. 1 patient had positive read and was referred for CXR and started on INH –1/8 (13%) had a documented negative PPD in the chart and was not retested –2/8 (25%) could not be followed due to missing charts

All the screening questions, in one nice neat little box – oh the joys of modern medicine!!

PDSA Cycle 3: Old Projects revisited

PDSA Cycle 4:

PDSA Cycle 5 Assessed return rate for PPD readings in January –15 PPDs placed –12 (80%) returned for reading in the appropriate amount of time All 12 were read as negative –1 (7%) did not return –2 (13%) still pending at the end of the cycle

The Rangel Clinic’s state of the art Mead Composition Book has a 0% “system shut down from 1-3am” rate!

page from 7/2007 page from 4/2008 Over the course of the year – increased messiness possibly correlating with increased activity!

PDSA Cycle 5: Keeping Track of PPD Placement Implemented a “PPD placement note” into Eclipsys –Started by the nurse at the time of placement and kept “incomplete” –Note completed when the patient returned for PPD read Unfortunately, this did not completely solve the issues: –Unable to filter PPD notes in Eclipsys –Difficult to keep track of outstanding PPD and results

PDSA Cycle 6: Improving Tracking Organized with the nurses that PPD notes in Eclipsys should include the ordering MD as a co-signer for the note. –MD and nurse share the responsibility of following up on results Talked to Eclipsys administrators to create a filter for patients who have PPDs placed in a given time

PDSA Cycle 6: Reviewing Positive PPDs Review of positive PPDs over 3 years ( ) 6 patients with positive PPDs documented 4 of these patients had charts available for review 2/4 (50%) had documented CXR and INH treatment

PDSA Cycle 7: Progress of PPD Tracking Chart review January 30-February 17 94% of PPDs placed had a PPD placement note in Eclipsys 70% returned for PPD read, 100% negative 17% of these were co-signed to a physician –When a note is updated in Eclipsys, all co-sign data gets erased and must be reassigned –Our head nurse reminded staff to reassign a co-signer each time the note was accessed

PDSA Cycle 7 Reassess TB Screening Chart review of patients presenting on 1 day of clinic 75% of the charts had documentation of TB screening during a WCC over the past year 100% who screened positive had PPDs placed 100% of the patients who returned for their read were read as negative

PDSA Cycle 8: Positive PPD requirements 100% of PPDs placed were read as negative Induration >10mm was always read as postive. Unclear what to do with induration >5mm. Nurses and physicians re- educated about definition of positive PPD Red Bood guidelines posted in nursing office

The Future of TB at Rangel TB screening is sustainable, as there is a prompt within the Eclipsys ambulatory note Once screened, placing a PPD is also simple Issues still lie with improving return rate for PPD reads –Reminder phone calls to families regarding visit –Implementation of Televox system

PDSA Cycle 3: Old Projects Revisited 25 charts (8/07-9/07) coded “WCC” for ages 6 months to 4 years were reviewed for documentation of dental screening and and lead risk. 5/25 had documentation of dental screening (20%) 8/25 had documentation of lead risk factors (32%) 3/25 had documentation of both (12%)

PDSA Cycle 3: Old Projects Revisited A presentation reviewing our previous projects was given on each clinic day To improve documentation rates utilized Eclipsys: –“Dental” check box should be added to the Eclypsis note with a free text box –The lead risk factors check box, which existed in the “Social” portion of the note should be in its own separate drop box.