Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation

Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation

Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission SHOULD RESECTED FEMORAL HEADS ROUTINELY BE SENT TO PATHOLOGY FOLLOWING FEMORAL NECK FRACTURES? Department: Orthopaedic Surgery CRMC Collaborating Department(s): Department of Pathology, Finance Department Presenter Name(s): Geoffrey Rohlfing, DO,

Maximino Brambila, MD, Jason Davis, MD. 3 TITLE/PROBLEM STATEMENT The purpose of this study is to determine the incidence of positive findings, specifically neoplasia, in FH specimens sent for PATH after arthroplasty for femoral neck fracture, and to determine the cost effectiveness of this practice. In the process we will discover the percentage of FH specimens that were sent for PATH and elucidate the patient characteristics and demographics of those whose FH were sent to pathology versus those not. We hypothesize that many femoral head specimens, resected from hip fracture surgery, undergo pathologic examination that would otherwise not be indicated based on the patients history, physical exam, or radiographic findings. We also hypothesize the overwhelming majority of these examinations are negative resulting in little to no alteration of care, but with an increase cost.

4 SOLUTION New innovation or technology used: none Benefits Standards being adopted: Only sending femoral heads to pathology when medically indicated, not on every case. Benefits: Cost savings for the patient, hospital, and insurance company. Improved efficiency in hip fracture care. Standards specifically being ignored (if applicable): none Drawbacks & benefits 5

IMPLEMENTATION State assumptions about resources allocated to this project People: Resident, faculty, research coordinator, Summer Biomedical Intern, CRMC Finance Department, Pathology Department Equipment: Computers Locations: CRMC Support & outside services: None 6 RESULTS 1,595 Hip Fractures Exclusions: Exclusions:

745 745 Elective Elective THA THA 850 HA/THA Exclusions: Exclusions: 384 384 Femoral Femoral Heads Heads not not Sent Sent to to Pathology Pathology

466 Femoral Head Specimens Examined Concordant 464 (99.6%) Discrepant 0 (0.0%) Discordant 2 (0.4%) 7 RESULTS Sent to Patholo gy

# of Patien ts (%) Age in Year s (sd) Gender (%) Yes 466 (54.8) 78.2* Male-150 (51.0)

(11.8 Female-316 ) (56.8) No 384 74.5 Male-144 (49.0) (45.2) (13.7 Female-240 *indicates significant difference at p<0.000 ) (43.2) 8 RESULTS Patients with Femoral Head Specimen Positive for Neoplastic Process Patient Gender Age Mechanism of Injury Cancer History Antecedent Hip Pain Pathology Treatment 1

Female 49 Tripped None Yes Multiple Myeloma Proximal Femoral Replacement 2 Female

68 GLF None Yes CLL/SLL Hemiarthroplasty 3 Male 49

Walking Lung Cancer with metastasis Yes Adenocarcinoma of Lung Hemiarthroplasty 4 Male 73

GLF CLL No CLL Hemiarthroplasty CLL = Chronic Lymphocytic Leukemia 9 CURRENT STATUS High-level overview of progress against schedule On-track in what areas: Data collection is completed and manuscript preparation is underway

Behind in what areas: none Ahead in what areas: none Unexpected delays or issues: None 10 Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Extra Corporeal Membrane

Oxygentation: Why A Dedicated Team Improves Outcomes Department: Internal Medicine CRMC Collaborating Department(s): Pulmonary/Critical care Presenter Name(s): Deepti Mundkur; Chirag Rajyaguru; Faye Pais; Karamjit Dhaliwal-Binning; 12 Increased Mortality With Ecmo ECMO as a procedure independently increases mortality rate. A 50% mortality rate has been reported by the ECLS registry. This is especially important in critically ill patients in whom this procedure is frequently

employed. The mortality in patients undergoing ECMO at CRMC was suspected to be higher than the national. 13 Importance of an ECMO team Successful outcomes in patients undergoing ECMO is largely dependent on the collaborative support from an inter-disciplinary team. Identifying appropriate patients who would benefit from ECMO should be decided by this team 14 STANDARDS BEING ADOPTED

Physicians trained in ECMO (who can provide 24-hour coverage) Critical care specialists Thoracic or trauma surgeons ECMO coordinator who can be ICU nurse, registered RT with strong ICU background On staff biomedical engineer for technical support Palliative care specialist ECMO transport team: to transport patients while on ECMO 15 STANDARDS BEING IGNORED Patients continue to receive ECMO without the consultation of the ECMO team There are only 2 ECMO trained physicians and 1 ECMO trained fellow at CRMC to meet the

demands of this high acuity, high volume, tertiary care, level I trauma center, covering the 6.5 million people of central California 16 IMPLEMENTATION State assumptions (false) about resources allocated to this project People Sufficient critical care physicians and ICU support staff required to provide 24/7 patient care Equipment Adequate number of ECMO machines are available Location Readily available ICU beds for emergent patients Support & outside services A biomedical engineer on call for mechanical support

17 RESULTS % Survival 50 45 40 35 30 25 20 15 10 5 0 % Survival

Pre-ECMO Team Post-ECMO Team 18 RESULTS Before ECMO Team 28.00% 5.33% Expired Discharged Transferred 66.67% 19

CURRENT STATUS Ongoing efforts: Continued collection of data for patients undergoing ECMO with and without the consultation of the ECMO team. Setbacks: Data acquisition on specific patient parameters like ventilator data, procedure related complications and long term outcomes including post-ECMO quality of life Analysis of secondary outcomes including predictors of poor outcomes in patients undergoing ECMO, ventilator-free days, length of hospital stay and long term survival Dedicated team personnel and sufficient equipment Ensuring all ECMO candidates go through a dedicated ECMO team 20 Second Annual CRMC/UCSF

Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission CURRENT OUTCOMES OF BLUNT OPEN PELVIC FRACTURES: HOW MODERN ADVANCES IN TRAUMA CARE MAY DECREASE OVERALL MORTALITY Department: General/Trauma Surgery CRMC Collaborating Department(s): Orthopaedic Surgery, Interventional Radiology Presenter Name(s): Sammy S. Siada, DO, James W. Davis, MD, Krista L. Kaups, MD, MSc, Rachel C. Dirks, PhD,

Kimberly A. Grannis, MD 22 INTRODUCTION Open pelvic fracture, caused by a blunt mechanism, is an uncommon injury with a high mortality rate In 2008, the Western Trauma Association (WTA) published an evidence-based algorithm for managing pelvic fractures in unstable patients The use of massive transfusion protocols (MTP) has become widespread, as has the availability of pelvic angiography The aim of this study is to evaluate the outcome of open pelvic fractures in association with related advancements in trauma care 23

METHODS A retrospective review was performed of all patients who sustained blunt open pelvic fractures from January 2010 to April 2016 The WTA algorithm, including MTP (1:1:1 ratio) and pelvic angiography were uniformly used during this time Data collected included age, injury severity score (ISS), transfusion requirements, use of pelvic angiography, length of stay (LOS), and disposition Patients with penetrating injuries and closed fractures were excluded Data were compared to a similarly designed study from 2005 Dichotomous variables were compared using Chi square tests with significance attributed to a p value < 0.05. 24 RESULTS During the study period, there were 1505 patients with pelvic fractures, 87 (6%) were open. Of these, 25 were due to blunt mechanisms and made up the study population. Use of angiography was higher (44% vs 16%; p=0.011) and mortality was lower (16% vs 45%; p=0.014) than in the 2005 study Fourteen patients (56%) were hemodynamically unstable, and 12 had MTP initiated. Most deaths (75%) occurred from exsanguination in the first 24 hours. No patients underwent pre-peritoneal packing. 25 BASELINE PATIENT CHARACTERISTICS Stud ISS

y (n) 2005 30 (44) 2016 29 (25) p - 0.87 valu e GCS 12 Age Male LOS s 39 68% 22 11

42 68% 21 0.67 - 0.98 26 CHANGES IN CARE FOR OPEN PELVIC FRACTURES Study

(n) 2005 (44) 2016 (25) pvalue Patients Pelvic Fecal Mortali transfuse embolizati diversio ty d on n 32 (73%) 7 (16%)

17 (68%) 11 (44%) 0.68 0.011 4 (9%) 20(45%) 3 (12%) 4 (16%) 0.70 0.014 27

CONCLUSIONS The care for patients sustaining open pelvic fractures by blunt mechanism has evolved in recent years Changes include the use of an evidence-based algorithm, treatment of coagulopathy including massive transfusion protocols, and increased use of angioembolization The overall mortality for open pelvic fractures has decreased with these advances. 28 Second Annual CRMC/UCSF Fresno Quality Improvement &

Innovation Symposium Thursday, May 4, 2017 2017 Submission TITLE OF STUDY: PULMONARY EMBOLISM RESPONSE TEAM Department: Pulmonary Disease and Critical Care Medicine CRMC Collaborating Department(s): Cardiology, Cardiothoracic Surgery, Critical Care, Emergency Medicine, Hospitalist Medicine, Interventional Radiology, Pulmonary Disease Presenter Name(s): Kirat Gill MD, Ednann Naz MD, Timothy Evans MD PHD 30

TITLE/PROBLEM STATEMENT Pulmonary embolism (PE) is the third most common acute cardiovascular event after myocardial infarction and stroke with over half a million cases annually in the United States. The estimated annual incidence of PE is 23 to 69 cases per 100,000 persons resulting in 676,000 inpatient hospital days and an annual cost of 7 to 10 billion dollars per year in the US. The reported mortality is up to 30% resulting in more than 100,000 deaths per year. Currently, the major treatment modalities for acute PEs involve systemic anticoagulation, systemic thrombolysis, catheter-directed interventions, and/or surgery. 31 TITLE/PROBLEM STATEMENT (CONTINUED)

Although the treatment of low-risk PE is generally straightforward and requires relatively little collaboration, treatment of intermediate and high-risk PE is more complex. The treatment of PE has historically been inconsistent. In addition, there is a paucity of data supporting specific therapeutic strategies. Add to this the ever expanding and increasingly complex nature of modern treatment modalities and the importance of expertise in the diagnosis, risk stratification, choice and implementation of treatment becomes increasingly critical. 32 SOLUTION The Pulmonary Embolism Response Team (PERT) model allows for multidisciplinary input to optimize clinical decision making, risk stratification and efficient resource utilization. Our PERT team would be composed of specialists in Cardiology, Cardiothoracic Surgery, Emergency Medicine, Interventional Radiology, Hospitalists, and Pulmonary Disease and Critical Care

Medicine. An activation system would be created wherein an on call PERT fellow responds to an activation and immediately convenes a conference among the specialists after ascertaining the appropriate data. Team members would then review the case and accompanying radiographic and laboratory data. A consensus decision would be made in regards to treatment and the appropriate team would be mobilized. Additionally, a PERT conference could help decide when a patient may benefit for transfer for an invasive therapy not available at the sending facility. 33 IMPLEMENTATION State assumptions about resources allocated to this project People: Involvement of aforementioned specialties for treatment, education of hospital housestaff and

clinicians Equipment: Activation system, alerts within EMR and software necessary for conference call Locations: Hospital-wide Support & outside services: 34 RESULTS Data from the Massachusetts General Hospital (MGH) PERT team showed that in 30 months, there were 394 unique PERT activations, 314 (80%) for confirmed PE. PERT activations increased by 16% every 6 months. Most confirmed PEs were submassive (n = 143, 46%) or massive (n = 80, 26%). The PERT treated a relatively large proportion of patients with PE and systemic or catheterdirected thrombolysis (n = 35, 11%), though the most common treatment was anticoagulation alone (n = 215, 69%). Hemorrhagic complications were rare overall,

especially among patients treated with catheter-directed thrombolysis. The all-cause 30-day mortality of PERT patients with confirmed PE was 12%. Chest. 2016 Aug;150(2):384-93. doi: 10.1016/j.chest.2016.03.011. Epub 2016 Mar 19. 35 CURRENT STATUS On-track: -Discussed with specialties involved -Presented at Quality Committee Meeting Forth-coming: -Implementation of software and alerts within EMR -Promulgation of concept within the hospital -Expansion of concept to surrounding hospitals

36 Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission STRENGTHENING MEDICAL HOMES FOR CHILDREN WITH DOWN SYNDROME IN THE S AN JOAQUIN VALLEY Department: Pediatrics

Community collaborators: CVRC, EPU, DSACC, VCH Presenter Name(s): Rachel Manalo, DO, Denise Der, MD, Bonnie Singh, MD, Michael Smith, 38 PROBLEM STATEMENT Approximately 100 babies with Down syndrome (DS) are born each year in the San Joaquin Valley Children with DS are at high risk for developing chronic physical, developmental, and behavioral problems requiring long-term management Per survey results from 2015, only 7% of children with DS in San Joaquin Valley received all the recommended services specified by the AAP (American Academy of Pediatrics)

39 SOLUTION Focus groups Designed to investigate barriers to health care access facing children with Down syndrome in the San Joaquin Valley. Met with groups of parents of children with Down syndrome and their primary care providers Benefits of the focus group format Open and guided discussion to explore parental and provider perceptions of social support, expectations, and barriers to health care access for Down syndrome patients Helped to identify problems areas and brainstorm ways to improve care for Down Syndrome patients 40

IMPLEMENTATION/METHODS A list of questions was developed based on a literature review of attitudes and behaviors of parents and providers who care for children with Down syndrome Groups of 3 to 8 participants (caregivers and health care providers) were recruited via various local community partners to participate in focus groups Locations: EPU, CVRC, CHC, VCH Support & outside services: funded by American Academy of Pediatrics Resident Community Access to Child Health (CATCH) grant 41 RESULTS: DEMOGRAPHICS Children with Down Syndrome in study (n= 10)

Community Providers (n=10) 3 Female Male Attendings Number 13% 2 29% 1 Nurse

Practitioners 58% Residents 0 <1 1-3 3-5 5-12 12-18 18-21 Age (years) 21+ 42 RESULTS: PARENT FOCUS GROUPS

Primary care physician strengths Our son is 3 years old and we did not have a pre-delivery diagnosis. Our pediatrician said we need to sit down and I have something to tell you. She has been a champion for us. She talks to my son directly and shows respect for him. Ideas to improve care A one-stop shop clinic to make sure if there is anything my pediatrician is missing. OT, Speech, PT and all specialties under one roof to talk to each other. There needs to be a clinic for children and adults with Down syndrome. I was 14 weeks pregnant and home alone getting ready for work. The geneticist called me at home and told me that the baby was 99.9% positive for Down syndrome. Support Group Participation Unless a parent contacts DSACC, there is no way for them to contact you. I truly believe that contact with other parents is the most important thing so they dont feel isolated. And to get

medical information. 43 RESULTS: PROVIDER FOCUS GROUPS Access to Subspecialists Referring is easySometimes it is an issue with access. It may take 3 months to get into GI. Many kids with Down syndrome tend to have problems with their behavior and need psychiatric intervention and that is extraordinarily difficult in terms of access For behavioral therapy, Im embarrassed to say I have no idea [where they go] Barriers for families to keep appointments Financial ability to afford transportation Their behavior sometimes can be a [physical] barrier Other obligations that come up. Other children Dissatisfaction with care

Limitation of what you can do in one visit. One feedback we get is I wish we could see all the subspecialties at once instead of coming out here on three different occasions in a week for appointments. They tried to have a California Childrens Services (CCS) Down syndrome clinic but they need more of a variety of things. 44 NEXT STEPS Improving access to various subspecialties, most importantly behavioral and mental health programs Seamless transitioning of care to adult providers Improving the delivery of the diagnosis of DS to families (working with OBGYN and Genetics colleagues)

Research on creating one-stop shops for DS patients 45 THANK YOU 46 Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission

DAY VERSUS NIGHT LAPAROSCOPIC CHOLECYSTECTOMY: A COMPARISON OF OUTCOMES AND COST Department: Surgery CRMC Collaborating Department(s): Trauma Program, emergency department Presenter Name(s): SS Siada, SM Schaetzel, HD Hoang, AK Chen, FG Wilder, RC Dirks, KL Kaups, 48 IS IT SAFE TO OPERATE AT NIGHT? Early laparoscopic cholecystectomy (LC) for acute cholecystitis has been advocated to reduce morbidity, hospital length of stay (LOS), and risk of complications

Acute care surgery (ACS) model has been developed to improve outcomes, maximize resources, and reduce cost Several studies have shown that performing LC at night has an increased rate of complications and conversion to open cholecystectomy 49 HYPOTHESIS Compared with day LC, patients undergoing night LC have Decreased hospital LOS Decreased cost of hospitalization No difference in complication rate No difference in conversion to open rates 50

METHODS Retrospective review was performed Tertiary-level safety-net hospital (650 beds) 10/2011 - 7/2015 Acute cholecystitis from ED Exclusion criteria: Elective/incidental cholecystectomy Planned open cholecystectomy Gallstone pancreatitis Choledocholithiasis Admission to medicine 51 METHODS Day LC = 7am 5pm

Night LC = 5pm 7am Patient variables included: Age BMI SIRS ASA class Pre-operative hypotension Severity of gallbladder disease Complications within 30 days 52 METHODS Primary outcomes of interest: Overall hospital length of stay Conversion to open cholecystectomy Rate of complications Cost of hospitalization

53 Acute cholecystitis n = 1553 Excluded patients n = 687 Day LC n = 647 Study population n = 866 Night LC n = 219 BASELINE CHARACTERISTICS

Group (n) Day (647) Night (219) P value Age 41 16 42 16 0.87 BMI 32 7

32 7 0.42 Female gender 464 157 (72%) 0.99 (72%) SEVERITY OF DISEASE Symptomatic

cholelithiasis Acute cholecystitis Chronic cholecystitis Gangrenous/ necrotizing cholecystitis Gallbladder perforation/abscess Day (647) Night (219) pvalue 16 (2%)

4 (2%) 0.50 131 (60%) 0.43 52 (24%) 0.47 79 (12%) 29 (13%) 0.70 6 (1%)

3 (1%) 0.70 408 (63%) 138 (21%) OUTCOMES Group (n) Day (647) Night p-

(219) value 35 (16%) 0.07 Cholangiograph y Length of case Conversion 140 (22%) 1:42 0:51 1:42 0:43 57 (9%)

9 (4%) 0.38 0.02 OUTCOMES Group (n) Day (647) Night p- (219) value

Cost $4479 $4230 0.15 Cost -SIRS $4304 $3894 0.09 Complications 53 (8%)

14 (6%) 0.41 2 CONCLUSIONS Performing LC at night is safe No increase in complication rate Higher conversion to open rate in daytime LC Night LC have shorter of length of stay No difference in cost 59 SURVEILLANCE OF BACTERIAL CONTAMINATION OF ELEVATORBASED ENDOSCOPES AFTER

REPROCESSING WITH STERIS 1E CHEMICAL STERILIZATION: A SINGLE-CENTER STUDY Department: UCSF Fresno Division of Gastroenterology and Hepatology CRMC Collaborating Department(s): CRMC Endoscopy Unit Presenter Name(s): Adnan Ameer, MD, Umesha Boregowda, MD, Mark Osburn, RN, Lisa Avalos, RN, Ana Araujo, RN, Jayanta Choudhury, MD, Rabindra Kundu, MD 60 S UR VE IL L A NC E OF B ACT ER IAL CONTA MI NAT ION OF E L EVAT ORBAS E D EN DOSC OPES Optimal surveillance of reprocessed elevatorbased endoscopes (EBE) has not been established, in light of recent reports identifying CRE (carbepenam-resistant

Enterobacterericeae) transmission associated with persistently contaminated EBE. Liquid chemical sterilization with standard highlevel disinfection of EBE has not been evaluated. oblem/topic 61 REPROCESSING WITH STERIS 1E CHEMICAL STERILIZATION Comparing the bacterial decontamination of EBE by standard method and using Steris 1E (35% peracetic acid) chemical sterilization (S1ECS) after standard method. 62 IMPLEMENTATION

Single-center study was conducted at Community Regional Medical Center, Fresno, CA between February and May 2015. Bacterial cultures were obtained from 17 elevator-based endoscopes (12 ERCP and 5 EUS scopes). Initially cultures were obtained after reprocessing with standard method as per industry product guidelines. Second set of bacterial cultures obtained after reprocessing with standard method and S1ECS. Data collection and analysis was done using SPSS software version 22. Determining 48 hours bacterial culture results as pass or fail for negative and positive bacterial cultures. Identification of characteristic low concern and high concern bacteria, including CRE. 63 RESULTS Total of 309 cultures were obtained; 105 cultures after reprocessing with standard method and 204 cultures

after reprocessing with standard method and S1ECS. Standard method failed to decontaminate in 33% cases and S1ECS failed in 5.4% cases. It was also observed that decontamination with standard method failed to decontaminate EUS scopes (47%) more frequently than ERCP scopes (26%); no such difference was observed with S1ECS (5%). 64 RESULTS Endoscope Cultures: Pass/Fail Cultures Obtained:

40 30 20 10 0 Pass Fail Total No CRE identified during this investigation 65 CURRENT STATUS

S1ECS is more efficient in decontamination of elevator-based endoscopes (EBE) compared to standard high-level disinfection. Our study is limited by the number of EBE cultured. Current progress: on-going surveillance of reprocessed elevator-based endoscopes (EBE) using Steris 1E chemical sterilization Bacterial cultures obtained from ERCP and EUS scopes Q monthly (expected number of cultures > 1500 Plan for data analysis summer 2017 66 Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation

Symposium Thursday, May 4, 2017 2017 Submission TIMING IS EVERYTHING: OUTCOMES IN TRAUMATIC SUBDURAL HEMATOMAS BASED ON TIME TO OR Department: Surgery CRMC Collaborating Department: Trauma Presenter Name: Rachel J. Caiafa, MD 68 TITLE/PROBLEM STATEMENT Per the American College of Surgeons Committee on Trauma guidelines:

Patients with traumatic subdural hematomas who require operative decompression should go to the OR within 4 hours of arrival Does not consider neurologic exam Does not consider acuity of subdural on CT 69 SOLUTION Patients with mixed (both acute and chronic components) or chronic subdural hematomas can go to the OR less emergently If no neurologic symptoms or signs Benefits Improved resource utilization with the OR, anesthesia, and neurosurgical teams No difference in discharge disposition, mortality, or hospital or ICU length of stay

70 IMPLEMENTATION Current guidelines state that operative decompression should occur within 4 hours of arrival Departments affected: Requires 24/7 availability of: Emergency department Neurosurgeons Operating room Anesthesiologist/CRNAs

PACU Operating room and PACU staff Trauma ICU Trauma/neurosurgical floors 71 RESULTS Acute SDH Mixed SDH Chronic SDH OR4 OR>4

OR4 OR>4 OR4 OR>4 N 154 135 19 58

20 98 Age 51 50 68* 71* 66* 71* GCS

7 10* 10* 14* 12* 14* ISS 27 26*

22* 19* 22* 21* ICU LOS 10 12 6 4* 6*

3* Hospital LOS 15 19* 10 12 12 9* Home or Rehab

27% 42%* 53%* 64%* 70%* 62%* Mortality 44% 21%* 37%

3%* 5%* 4%* *p<0.05 compared to Acute SDH4 p<0.05 compared to OR4 72 RESULTS Patients who present with mixed or chronic subdural hematomas Higher Glasgow Coma Scores Lower Injury Severity Scores Discharged more frequently to rehab or home Lower mortality

If patients with mixed or chronic subdural hematomas present without neurologic symptoms, they do not need to go to the OR emergently overnight or on weekends Improved resource utilization Decreases the likelihood of over-burdening limited OR resources during on-call hours 73 Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission

THE DREADED DISCHARGE SUMMARY; A DAUNTING TASK SIMPLIFIED TO IMPROVE PATIENT SAFETY Department: Internal Medicine VA-CCHCS Collaborating Department(s): - Quality and Patient Safety, Systems Redesign Presenter Name(s): - Matthew White, DO (Resident) - Regina Godbout, MD (Chief of Medicine, VACCHCS) 75 A PROBLEM WITH MANY L AYERS Rules and Regulations Per Veterans Affairs Central California Health Care System bylaws: discharge summaries must be

completed within 48 hours of a patients discharge The Problem Our programs compliance with this regulation was far below goal, with an average of less than 50% of discharge summaries being completed on time Our Goal At least 80% of all discharges accompanied by high-quality discharge summaries within 48-hours from the time of discharge Cause and Effect What is causing our problem? Initial Thoughts: We hypothesized that poor time management complicated by the numerous responsibilities placed on a senior resident are the key barriers to achieving our goal Key Players: Senior Residents: responsible for writing the discharge summary Interns: responsible for daily documentation and discharging the patient

76 AN EFFECTIVE SOLUTION Step 1: Identify the resident-perceived barriers: Resident-focused survey Step II: Reduce the burden and address the barriers: Clinical Navigators: Nurse Practitioners Liaison between social work, physical therapy, and internal medicine to prepare for a safe and efficient discharge from the day of admission. Modification of the daily progress note to include information expected in a high quality discharge summary Hospital Course: A daily update of significant events and changes in management Interns responsibility to update, will help the senior resident quickly summarize a patients hospital course upon discharge. Anticipated Discharge: To help with early discharge planning and preparation Anticipated date of discharge, barriers to discharge, follow up upon discharge, and medication changes upon discharge

Step III: Monitor progress and refine: Collect weekly data regarding percentage of discharge summaries completed on time Promote the 5 Lean Principles through real-time resident feedback to achieve sustainable, resident-centered behavioral change 77 IMPLEMENTATION: A MULTIDISCIPLINARY APPROACH Interdepartmental collaboration VA Fresno/UCSF Fresno Internal Medicine Resident-driven change Clinical Navigators: Nurse Practitioners Three additional positions, one dedicated to each ward team Systems Redesign Modification of progress note templates Quality and Patient Safety Monitoring % discharge summaries completed on time per week

78 RESULTS: WHAT THE RESIDENTS THINK Resident Survey: Q1: What is the biggest barrier preventing you from completing discharge summaries on time? A combination: overworked, burdened by chart review, Q2: In general, on which of the following days is it the most difficult to complete discharge summaries on time? Post-call day after 28-hour shift Q3: What would help you write the discharge summary on time? Multiple free response suggestions Q4: If the hospital course along with medication changes and outpatient follow up plan were updated prior to discharge, would this reduce the burden of writing the discharge summary on time?

Yes: 58% Maybe 33% No 8% Q5: Would you be willing to update the information in Q4? Yes 8% Maybe 66% No 25% 79 RESULTS: WHAT THE RESIDENTS THINK Q6: How important is it to you to complete discharge summaries on time? Very important 8% Somewhat 66% Not at all 25% Q7: Have you encountered a situation where the discharge summary was not completed by the time you evaluated your patient in clinic for a discharge follow up? Yes 75% No 25% Q8: Do you believe that patient care and safety suffers when discharge summaries are not completed in a timely fashion? Yes 75% No 25% Q9: Do you believe your discharge summaries provide other physicians with the necessary information required to provide the safest care for patients

during the discharge follow-up period? Yes 75% Maybe 25% No 0% Q10: The Society of Hospital Medicine has proposed a discharge summary check list to ensure key elements are included in each summary. Would you use such a checklist to improve the quality of your discharge summaries? Yes 58% Maybe 42% No 0% 80 RESULTS: ACTIONS SPEAK LOUDER THAN WORDS Pre-Intervention: 100 Percent of Discharge Summaries Dictated within 24 hours of Discharge (09/2016 - 12/2016) 90 80 70 60 50

40 30 20 10 0 1 2 3 4 5 6 7

8 9 10 11 12 81 RESULTS: ACTIONS SPEAK LOUDER THAN WORDS Post-Intervention: Percent of Discharge Summaries Viewable within 48 hours of Discharge (01/2017 04/2017) 100 90

82 80 70 68 60 61 58 50 68 51

50 44 44 40 35 30 29 21 20 10 0 1 2 2

3 4 5 6 7 8 9 10 11

12 13 82 CURRENT STATUS High-level overview of progress against schedule On-track: Integration of Clinical Navigators Upward trend in % completed discharge summaries within 48 hours Behind: Enforcing changes to daily documentation Unexpected delays or issues Delay in implementing modified progress note 83

Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission RADIATION DOSE REPORTING IMPROVEMENT Department: UCSF Orthopaedic Surgery CRMC Collaborating Department(s): Radiology Presenter Name(s): Daniel Brown, MD; Lisa

85 RADIATION DOSE REPORTING IMPROVEMENT During Orthopaedic Surgery, especially trauma surgery, the patient, surgeon, and OR staff are exposed to radiation from Fluoroscopy. The amount of radiation exposure depends on several factors such as: patient body habitus; fracture location, type, and complexity; surgeon skill and technique; and technologist skill. Some factors are modifiable, some are not. Improvement in modifiable factors to reduce radiation exposure cannot be made unless there is first accurate reporting of the amount of radiation exposure in each case. Currently, the reporting of radiation exposure, by submitting the Dose Report into PACS with the final images, is less than 50%. 86

SOLUTION Current standard set by the ASRT (American Society of Radiologic Technologists) is for the Dose Report to be submitted, but this is not happening at CRMC consistently By ignoring reporting, we are unaware of the amount of radiation we and the patients are exposed to in a specific case, and unable to reduce it With submission into PACS of final fluoroscopic images, the dose report will also be included Each surgeon will be able to see the amount of radiation used in each case No new technology is required No new costs, no extra effort When submitting final images, technologists simply need to check the box to include the Dose Report

87 IMPLEMENTATION Problem first noticed June 2016. It has not changed since then. Implementation will include: Radiation Technologists Fluoroscopes CRMC ORs, both 2C and TCCB Radiation Technologist Supervisors 88 RESULTS We retrospectively examined all Orthopaedic Surgery cases from June and July 2016 to see if they 1.) used Fluoroscopy, and 2.) if they did

use Fluoroscopy, did they submit the Dose Report. We then examined February 2017 to see if the rate had changed. Current Dose Report utilization/submission rate is 45%. This is essentially unchanged from June and July 2016. (P=0.66) 89 RESULTS: PRIOR TO IMPLEMENTATION Jun-16 Flouro Yes No Total

Jul-16 percent percent Dose dose fluoro Report report 145 71.4% 63 43.4% 58 28.6% 82 56.6% 203 145 Flouro Yes

No Total percent percent Dose dose fluoro Report report 112 65.9% 47 42.0% 58 34.1% 65 58.0% 170 112

Feb-17 Flouro Yes No Total percent percent Dose dose fluoro Report report 130 79.3% 59 45.4% 34 20.7% 71

54.6% 164 130 90 CURRENT STATUS Intervention occurred in March 2017 In March 2017, we spoke with the supervisor and select technologists. Still to be completed: Email follow up Fliers in boxes Fliers on Fluoroscopes May also consider: Additional sign in OR

April 2017 At the end of the month we will collect data again to see if the reporting rate has changed 91 Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission PITFALLS OF A NON-ALGORITHM BASED PLEURAL EFFUSION WORKUP IN A

L ARGE COMMUNITY TEACHING HOSPITAL: Department: Pulmonary and Critical Care CRMC Collaborating Department(s): Internal Medicine, Pulmonary, Laboratory Presenter Name(s): Kenneth Juenger, MD PCCM 93 PLEURAL FLUID ANALYSIS Pleural fluid pH measurements are used in the management of exudative pleural effusions and to guide treatment in parapneumonic effusions and empyemas. Inconsistency in sampling and frequency of ordering pleural fluid pH and pleural fluid analysis (PFA) can lead to inaccurate and incomplete workup of

patients with a pleural effusion. This can lead to incorrect treatment and/or additional workup which can be costly and unnecessary to the patient. 94 OBJECTIVE This study will look retrospectively at the ordering and testing of PFA samples to determine the frequency of sampling, timing of processing results, and evaluate the completeness of PFA to assess for variability in practice based on department. Once assessed and analyzed, quality improvement measures can be implemented to improve upon current practices and better patient management.

95 METHODS: Data from 101 consecutive patients who had a thoracentesis performed at a community teaching hospital between April 2016 and September 2016 were reviewed retrospectively using EMR. The data included provider ordering pleural fluid analysis (PFA), thoracentesis operator, timing of pH and glucose results, type of PFA ordered and sample container used for transportation. As a bench mark for quality, we used one hour as the optimal time for pleural fluid pH measurement and 2 hours for all other chemistry testing. Continuous data was analyzed using Student's t-test and proportional data was compared using Chi-square test. 96

RESULTS: A total of 101 patients were reviewed who underwent thoracentesis. 47 patients (46.5%) had pleural fluid pH drawn. 11/47 of these patients (23.4%) had pH resulted within 1 hour. Mean time of pH delay: 112 minutes for Pulmonary Department 210 minutes for Interventional Radiology Department. 28/74 patients (37.8%) who had glucose drawn resulted within 2 hours. Mean time of glucose delay: 157 minutes for Pulmonary Department 199 minutes for Interventional Radiology Department. 97

RESULTS: Proper workup was ordered in 40/101 (39.6%) patients; 15/26 (57.7%) by Pulmonary department 16/44 (36.4%) by Hospitalists 7/18 (38.9%) by Internal Medicine Department 2/13 (15.4%) by others. Thoracentesis was performed by Interventional Radiology in 66/101 (65.3%), 13/101 (12.9%) Internal Medicine Department, and 22/101 (21.8%) Pulmonary Department. Pleural fluid was sent to lab in 6 different sample containers. 98 F I G U R E I : T H E M E A N T I M E D E L AY I N M E A S U R E M EN T F O R P H A N D G LU C O S E .

99 RESULTS: COMPLETE WORKUP? 100 CURRENT STATUS Data collection complete on 150 more patients. Currently being analyzed to assess for further comparison. Will then be able to discuss methods to improve current techniques, protocols, sampling, and measurement of PFA. Quality improvement methods will then be implemented to improve upon the above and better patient care and potentially outcomes as

well as reduce the cost to the healthcare system because of incomplete and/or inaccurate data. 101 Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission Depression Screening in Diabetic Patients

Department of Family and Community Medicine Clinica Sierra Vista Kulraj Dhah, DO; Laura Pierce, DO; Juan Carlos Ruvalcaba, MD 103 PROBLEM STATEMENT Diabetic patients are at an increased risk for depression 1 in 4 patients with type 2 diabetes mellitus has clinically significant depression Depression in diabetic patients is associated with: Worse medication adherence Poor glycemic control

Increased mortality Increased costs 104 SOLUTION Dot Phrase for 2-item Depression Screen Simple, cost-effective Adopted American Diabetes Association Clinical Practice Recommendation 3: Comprehensive Medical Evaluation and Assessment of Comorbidities Annual assessment of depression 105 IMPLEMENTATION

Design: Pre-post Random sample of 20 patient charts before and after the intervention Intervention: Clinic director met with IT to facilitate dot phrase creation Two PGY2 residents instructed to use dot phrase Location: Clinica Sierra Vista Dates: October 13, 2016 to January 31, 2017 106 RESULTS: DIABETIC PATIENTS SCREENED FOR DEPRESSION p < .0001 107 N= N= CURRENT STATUS Overview of progress During the trial period, we found that the screening questions helped identify previously undiagnosed depression in patients with diabetes. This comorbidity may play a significant role in compliance with medications, control of blood glucose and overall risk of complications. Based on our results, our clinic plans to continue with the annual screening questions for our Diabetic patients. We are working to improve our efforts to screen all of our Diabetic patients.

108 Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission INCREASING PNEUMOCOCCAL VACCINATION RATES IN PATIENTS WITH DIABETES Department of Family and Community Medicine ACC Family Health Center

Mohsin Jawed, MD; Navpreet Gill, MD; Ila 110 TITLE/PROBLEM STATEMENT People with diabetes are at an increased risk for pneumococcal infections, including bacteremia that has a mortality rate as high as 50% Evidence supports vaccination against Streptococcus pneumoniae in all diabetics given their immunologic response to the vaccine Vaccination leads to decreased hospitalizations, health care costs, and has morbidity and mortality benefits 111 SOLUTION

Use electronic medical record (EMR) to allow providers to: Track data over time Identify patients due for preventative visits and screenings Quickly identify diabetic patients without proper vaccinations 112 IMPLEMENTATION Goal was to increase immunization rates among patients with diabetes at ACC Family Health Center, October 2016 through February 2017 Baseline and follow up data were obtained from the Epic EMR registries

Utilization of .imm smart phrase under all our diabetic assessment/plans 113 RESULTS All patients in panel 415 All patients with diabetes 118 Patients with vaccine before intervention 87

Patients with vaccine after intervention 99 114 RESULTS Percentage of patients with pneumococcal vaccine 100% 84% 80% 74% 60% 40%

20% p = 0.09 0% Baseline Follow up 115 RESULTS 19 12 87 Baseline vaccinated

Post intervention vaccinated Remain unvaccinated 116 CURRENT STATUS Overall vaccination rate increased 10% 39% of eligible patients were vaccinated High baseline vaccination rate Improvements can be made within the registries to differentiate PCV13 from PCV23 vaccinations. This would ensure proper vaccination status among the different ages in the diabetic population 117

Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium Thursday, May 4, 2017 2017 Submission INCREASING INPATIENT PALLIATIVE CARE CONSULTS Hospice & Palliative Medicine Shane Lieberman, MD & John Thompson, DO 119 EFFECTIVE EDUCATION FOR PROVIDERS

Referring physicians often have preconceived notions of what the palliative care team does Studies demonstrate that inpatient palliative care consults lead to increased patient satisfaction, decreased hospital length of stay and cost savings to the hospital and the medical system 120 SOLUTION Provide education to the internal medicine hospitalist group regarding the role and benefits of palliative care Number of consults will increase Patient benefits will be achieved (i.e. increased satisfaction, decreased length of stay, and better

pain and symptom management) 121 IMPLEMENTATION Hospice & Palliative Medicine Fellows Informal educational conversation with hospitalist 2-minute scripted conversation about when & why to consult palliative services Answer any questions from hospitalist CRMC January 2017 122 RESULTS Provider Palliative Consults 20

Frequency 15 10 5 TBD 0 Baseline Follow-up Intervention TBD

Baseline Follow-up No Intervention 123 RESULTS Baseline Interventi on Follow-up No intervention Group

size 21 33 Number of consults 55 76 Median (Min Max) 2 (0 8)

1 (0 15) No consults 6 (29%) 13 (39%) Interventio No n intervention 15 39 124 CURRENT STATUS

39% of providers have been educated Pending results increase education for providers Pending results change method of education vs. message Unexpected delays or issues Number of providers reached Difficult to directly measure patient-centered outcomes Results available April 15, 2017 125 Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation

Symposium Thursday, May 4, 2017 2017 Submission QUANTITATIVE BLOOD LOSS VS. ESTIMATED BLOOD LOSS Department: ObGyn Presenter Name(s): Lynsa Nguyen, MD; Dr. Subhashini Ladella, MD 127 Q U A NT I TAT I V E B LO O D LO S S V S . ES T I M AT E D B LO O D LO S S : H O W D O T H E Y C O M PA R E ? Obstetric hemorrhage is identified by The California Department of Public Health Maternal Child and Adolescent Health Division as the leading cause of maternal mortality in

California in 2002-2004 (2). The World Health Organization estimates that the US maternal mortality ratio (MMR) increased 136%, from 12 deaths per 100,000 live births in 1990 to 28 deaths per 100,000 live births in 2013 (3). Other estimates of the US MMR are more conservative, but also show an increase in contrast to decreasing MMRs in the majority of developed and developing nations (3). It has been well established that visual estimated blood loss is inaccurate. More commonly, visual EBL most commonly results in underestimation by at least 33-50% (1). Studies have consistently found that large volumes are typically underestimated and small volumes overestimated. No correlation has been found between accuracy of EBL with specialty, age or years of experience. Studies have shown the inaccuracies of EBL; therefore relying on EBL to determine the need to initiate postpartum hemorrhage protocols may be inappropriate. There is potential for interrupting the 128

Q U A NT I TAT I V E B LO O D LO S S V S . ES T I M AT E D B LO O D LO S S : H O W D O T H E Y C O M PA R E ? Currently, at CRMC, both EBL and QBL are recorded. Postpartum hemorrhage is defined by a blood loss of 500cc in a vaginal delivery and 1000cc in a cesarean section. Here at CRMC, supportive treatment with volume resuscitation is not necessarily initialized with postpartum hemorrhage. It is based on the clinicians judgement based on blood loss and the patients status. Typically an EBL is more readily accessible when quick action is needed. There has been a discrepancy observed between reported visual EBL and QBL. Therefore, the goal of the study is to determine the comparative accuracy of EBL and QBL measurements. Is it worth going through the extra work and costs to provide a quantitative blood loss?

129 SOLUTION The specific aims of this study include: Showing a significant increase in the accuracy of quantifying blood loss by using QBL over visual EBL. If shown to be more accurate, physicians and staff on labor and delivery would no longer need to provide an EBL and instead could transition to only assessing QBL. Effecting a significant decrease in maternal morbidity and mortality associated with obstetric hemorrhage in childbirth with the initiation of assessing QBL. The concern with the use of EBL is failure to recognize excessive blood loss and such failure would delay effective intervention. 130

IMPLEMENTATION State assumptions about resources allocated to this project People: Clinicians and RNs have already collected appropriate information per routine on Labor and Delivery. Support & outside services: Previously collected information through retrospective chart review (via EPIC) of patients that have delivered on the Labor and Delivery unit at CRMC from February to present is being conducted. Investigators are pulling the following data: pre-delivery hemoglobin, post-delivery hemoglobin, estimated blood loss, quantitative blood loss, complications, age, BMI, parity, and ethnicity. Investigators are looking at the pre-delivery and post-delivery hemoglobin levels and comparing the drop in hemoglobin to the blood loss given by QBL and EBL. Morbidity and mortality rates from obstetric hemorrhage during the time of QBL collection is also being reviewed. Equipment: Plastic drapes for collection of blood and scale Locations: CRMC Labor and Delivery 131

RESULTS Delivery data from February 2016 to May 2016 have been reviewed. The goal for now is to collect data From February 2016 to June 2016 for analysis. Data being reviewed: date and time of delivery, mode of delivery, gravida and parity, patients weight, initial hemoglobin (prior to delivery), repeat hemoglobin (after delivery), date and time of repeat hemoglobin, EBL, QBL The initial hemoglobin and repeat hemoglobin are used to calculate the blood loss from delivery. This is compared to the QBL and EBL. 132 CURRENT STATUS

High-level overview of progress against schedule On-track in what areas: Data collection instrument and pregnancy episode list have been secured. Behind in what areas: : Chart reviews. Unexpected delays or issues Members of the research team have not been able to access QBL values due to their limited EPIC access. This has slowed down the progress of chart review completion. 133 REFERENCES 1. The Association of Womens Health, Obstetric and Neonatal Nurses. Quantification of Blood Loss: AWHONN Practice Brief Number 1. Nursing for Womens Health 19.1

(2015): 96-98. Web. V9.14.2016 2. California Department of Public Health. The California Pregnancy- Associated Mortality Review. Reports from 2002 and 2003 Maternal Death Reviews. California Department of Public Health, Maternal Child and Adolescent Health Division. Sacramento. 2011. 3. World Health Organization. Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. 2014. 134 Second Annual CRMC/UCSF Fresno Quality Improvement & Innovation Symposium

Thursday, May 4, 2017 2017 Submission SYPHILIS DURING PREGNANCY: ONEVERSUS THREE- DOSE BENZATHINE PENICILLIN G REGIMEN, AND SUBSEQUENT DIAGNOSIS OF CONGENITAL SYPHILIS Department: OBGYN Presenter Name(s): Andrea Seid, DO; Anubhav Agrawal, MD 136 S Y P H I L I S D U R I N G P R E G N A N CY: U N C E RTA I N T Y A BO U T T H E O P T I M A L T R E AT M E N T R E G I M E N Congenital syphilis in the Central Valley, California is increasing. Here in

Fresno County, the total number of syphilis cases in adults is the highest in the state, and has dramatically increased from <20 cases 2010 to approaching 120 cases in 2014, and now >150 cases in 2015 (Rutledge, 2014). Syphilis during pregnancy can result in vertical transmission and is deleterious to the fetus. The rate of congenital syphilis in Fresno County more than triples that of the state of California rate. (Rutledge, 2014). Currently guidelines for the treatment of maternal syphilis vary on the timing and duration of disease. Women with early syphilis (primary, secondary or early latent) should be treated with a single dose of 2.4 million units of benzathine penicillin G. Late latent syphilis (>1 year without treatment/nonreactive within past year) is 2.4 million units weekly x 3 weeks for a total of 7.2 million units (Centers for Disease Control and Prevention, 2016) (Berman, 2004). However, while penicillin has proven effective in treating syphilis in pregnancy and in preventing congenital syphilis, uncertainty remains about the optimal treatment regimen (dose, duration and preparation) (GJA, 2004). 137

S Y P H I L I S D U R I N G P R E G N A N CY: U N C E RTA I N T Y A BO U T T H E O P T I M A L T R E AT M E N T R E G I M E N The CDC indicates that some evidence suggests that additional therapy is beneficial for pregnant women. Congenital syphilis can be prevented if the mother is diagnosed and treated appropriately and without delay, and the baby is evaluated and treated per CDC STD guidelines (Kidd, 2016). In this study, our goal is to determine if a 3-dose regimen of PCN, specifically for early latent syphilis is an acceptable alternative during prenatal/antepartum care in high-risk areas. 138 SOLUTION

The specific aims of this study include: Determination of the number of newborns with congenital syphilis at CRMC and correlate with maternal penicillin treatment received. Evaluation of maternal syphilis after 1- and 3-dose regimens of penicillin. The purpose of these aims are to evaluate that regardless of diagnosis timing, congenital syphilis of the newborn is less if a three-dose regimen of penicillin is used rather than a single-dose regimen. 139 IMPLEMENTATION Medical Charts of CRMC patients identified as being pregnant and with syphilis between January 2010-December 2016 will be reviewed for penicillin regimen received (1- or 3-dose) and incidence of congenital syphilis. State assumptions about resources allocated to this project

Data will be collected from the CRMC hospital electronic record system, EPIC, using ICD9 and ICD10 codes for syphilis complicated pregnancy, congenital syphilis, maternal syphilis. Health Information Management (HIM) will be assisting in the data collection for this study. To secure dates of treatment not available in EPIC, we will call the Fresno Department of Public Health and contact Dr. Lichtensteins office where most CRMC patients are treated for syphilis. From each patient and neonate we will be reviewing known history of syphilis, gestational age at diagnosis, gestational age at treatment, number of treatments, maternal RPR titer levels, placental pathology, treatment for congenital syphilis given, and evidence of congenital syphilis identified by neonatology/pediatrics. 140 RESULTS Preliminary data shows that for all patients treated adequately (>1 mo prior to delivery) with unknown duration (3 doses PCN), there

was no congenital syphilis in neonates Of the neonates who had 2 doses PCN with congenital syphilis, three had 1-2 doses just prior to delivery, and two had >3 weeks prior to delivery with 1-2 doses. Of the neonates who did not have congenital syphilis, and got 2 doses PCN, all three were treated inadequately (did not complete recommended doses >1mo prior to delivery) 141 RESULTS Preliminary data from n=18* 2 doses PCN PCN Congenital Syphilis

3 doses + 5 0 - 3 10 *Data collection is currently on-going. From HIM review, expected n>200 142 CURRENT STATUS

High-level overview of progress against schedule doses On-track in what2 areas: IRBPCN approval and Patient list for review have been secured. Behind in data collection Data analysis has taken a significant amount of time, expected to be complete within the next couple of months 143 REFERENCES Berman, S. (2004). Maternal syphilis: Pathophysiology and treatment. Bulletin of the

World Health Organization , 82, 433-438. CDC. (2016, 09 19). Sexually Transmitted Diseases. Retrieved 10 23, 2016, from Syphilis: http://www.cdc.gov/std/syphilis/default.htm CDC*. (2016, 06 27). 2015 Sexually Transmitted Diseases Treatment Guidelines. Retrieved 10 23, 2016, from Syphilis in pregnancy: http://www.cdc.gov/std/tg2015/syphilis-pregnancy.htm Centers for Disease Control and Prevention. (2016, 07 27). 2015 Sexually Transmitted Diseases Treatment Guidelines. Retrieved 10 23, 2016, from Syphilis: http://www.cdc.gov/std/tg2015/syphilis.htm GJA, W. (2004). Antibiotics for syphilis diagnosed during pregnancy (Cochrane Review). (Chichester, Ed.) The Cochrane Library (4). Kidd, S. (2016, 07 18). Medscape. Retrieved 10 23, 2016, from Congenital Syphilis Is on the Rise? Reviewing Prevention Steps: http://www.medscape.com/viewarticle/865770 Rutledge, J. (2014). The 2014 Fresno County Department of Public Health Annual Report. Fresno: Fresno County Department of Public Health. 144

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