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Broadway Clinic 2008-2009 PDSA Project

Broadway Clinic 2008-2009 PDSA Project. Lipid Screening and Promoting Healthy Lifestyles Participants MAs : Blanca Cordero, Celia Mendez, Felipe Joaquin and Maritza Estrada RN : Sally Ortiz, Haydee Bayon and Anna Zeleft CPNP : Renie Eis

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Broadway Clinic 2008-2009 PDSA Project

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  1. Broadway Clinic 2008-2009 PDSA Project Lipid Screening and Promoting Healthy Lifestyles Participants MAs: Blanca Cordero, Celia Mendez, Felipe Joaquin and Maritza Estrada RN: Sally Ortiz, Haydee Bayon and Anna Zeleft CPNP: Renie Eis Residents: Brooke Davey, Steph Marion, Lisa Nowell, Cyril Sahyoun, Taryn Wiley-Rio, Corinna Moore, Meg Sullivan, Jen Louis-Jacques, Stu Holzer, Deena Blanchard, Tom Hooven, Anne Abbott, Emily Rothbaum, Erik Jensen and Gabe Rama Faculty: Nan Salamon, Mariellen Lane, Pran Saha, Laura Robbins, Heidi Beutler and John Rausch

  2. AIM Statement We aim to screen 90% of children age 4-12 years with a BMI ≥ 85% and/or a positive family history of dyslipidemia or premature cardiovascular disease (CVD) with a random fasting lipid panel AND provide counseling regarding healthy lifestyles choices using the 5-2-1-0 recommendations. Lipid Screening Protocol: random lipid panel will be ordered for children with risk factors (overweight or obesity, positive family history) at ages 4 years and 11 years when they are in the clinic for blood work or vaccines.  -for those patients with positive screen: intensive nutritional and exercise counseling using 5-2-1-0 message and retest with fasting panel in 3 months -if fasting panel still elevated, refer to Dr. Starc

  3. Pending Return Orders Pending Lipid Return Orders Pending PPD Return Orders • Checked rate of return for pending orders placed for both PPDs and fasting lipid panels • Results supported decision to choose RANDOM lipid panel as screening test for project

  4. Cycle 1(Deena Blanchard, Taryn Wiley-Rio and Stephanie Marion) • Both didactic and systems changes done during cycle • Using provider feedback as well as input from Dr. Starc, Broadway practice guidelines generated (who to screen, positive screen includes values in 75% or higher) • System changes done in form of laminated signs hung in provider rooms and common areas

  5. Cycle 2(Corinna Moore and Meg Sullivan) • Based on data from cycle 1, it was clear that further systems support was needed • Original signs were revamped and new signs detailing abnormal values were hung on EVERY computer monitor • No improvement in rates of lipid panels ordered for patients meeting screening criteria

  6. Cycle 3(Stu Holzer) Adjustment made to definition of positive screen to improve adherence to lipid screening protocol (now only values 95% or above): Total Cholesterol >200 LDL-C >130 HDL <37, TG >120(girls), >110(11yo boys) >85 (4yo boys) Corresponding systems changes made in form of new signs hung on EVERY computer monitor (old signs taken down)

  7. Cycle 4 (incomplete) • Attempted to institute ‘high risk’ lipid screening order set as well as family hx prompt • Orders placed in 2/09, but never completed secondary to insufficient Eclipsys staffing • Represents potential recurring barrier to implementation of EMR related systems changes

  8. Summary of Lipids Data • Baseline Data (Erik Jensen): 66 with increased BMI, 8/66 (12%) screened (no FamHx • recorded) 4yo patients 11 yo patients

  9. 5-2-1-0 Lifestyle Modification Guidelines • Developed in 2006 in New Hampshire after extensive chart reviews of primary care practices • NH Childhood Obesity Panel used this data as impetus to develop practical guidelines to help prevent childhood obesity • Expert panels in these states decided and evidence supports that these messages are the most important to be giving families/pediatric patients • 5 fruits and vegetables a day, 2 hours or less screen time, 1 hours exercise daily, NO soda/sugar-sweetened drinks

  10. 5-2-1-0Supporting Literature • Dietary Guidelines for Americans 2005. United States Department of Agriculture and United States Department of Health and Human Services. • Physical Activity for Children: A Statement of Guidelines for Children Ages 5-12, 2nd Edition.Council for Physical Education for Children (COPEC) of the National Association for Sport and Physical Education, 2004. • Patrick, K. et al. Diet, physical activity, and sedentary behaviors as risk factors for overweight in adolescence. Arch Pediatr Adolesc Med V 158, p. 385-390, 2004. • Gable, S. et. al. Television and frequency of family meals are predictive of overweight onset and persistence in a national sample of school-aged children. Journal of the American Dietetic Association. V 107,1, p. 53-61, 2007. • Dennison et. al. Television viewing and television in bedroom associated with overweight risk among low-income preschool children. Pediatrics V 109, p. 1028-1035, 2002. • Crespo, et al. Television watching, energy intake, and obesity in US children. Results from the third national health and nutrition examination survey, 1988-1994. Arch Pediatr Adolesc Med V 155, p. 360-363. 2001. • Giammattei, J. et. al. Television watching and soft drink consumption: Associations with obesity in 11 to 13 year old schoolchildren. Arch Pediatr Adolesc Med V157, p. 882-886. 2003. • Faith, MS et al. Fruit juice intake predicts increased adiposity gain in children from low income families: Weight status-by-environment interaction. Pediatrics V118(5) p. 2066-2075, 2006. • Wang, YC, et. al. Estimating the energy gap among US children: A counterfactual approach. Pediatrics V118(6) p. e1721-e1733, 2006. • Malik VS et. al. Intake of sugar-sweetened beverages and weight gain: A systematic review. Am J Clin Nutr V 84:274–88, 2006.

  11. 5-2-1-0 Surveys(Stu Holzer, Emily Rothbaum and Tom Hooven) Cycle 1 • Surveys (Spanish and English) were given to all families with children 2-12 yrs presenting for WCC • 70% of potential families received survey and overall liked it • Surveys were trialed over 1 afternoon and parents found it comprehensible Cycle 2 • Literacy was noted to be at 11/12th grade level (based on SMOG and Fry literacy scoring systems) • Surveys were modified with input from the HEAL program (Emelin Martinez), Sally Ortiz (Broadway RN) and MAs Blanca and Celia • Surveys currently at 4/5th grade level with further evaluations pending

  12. Patient Name Place sticker here Yes No Does your child eat 5 or more servings of fruits and vegetables on most days? Does your child eat breakfast every day? Does your child eat dinner at the table with the family at least 2 times per week? Does your child watch TV, videos or play computer games less than 2 hours per day? Does your child have a TV in the bedroom? Does your child participate in some type of physical activity in or outside of school for at least 1 hour every day? Does your child drink juice, soda or punch? Does your child drink mostly skim milk or 1% and not 2% or regular milk? Does anybody in your family have high cholesterol?   5       2   1     0    

  13. Patient Name Place sticker here Sí No ¿Come su niño/a 5 o mas raciones de frutas y vegetales casi todos los días? ¿Come su niño/a desayuno cada día? ¿Cena su niño/a en el comedor con la familia por lo menos 2 veces a la semana? ¿Mira su niño/a television, videos, o juegos en la computadora menos de 2 horas al día? ¿Tiene su niño/a una television en el dormitorio? ¿Participa su niño/a en una actividad física en la escuela o fuera de la escuela por lo menos una hora al día? ¿Toma su niño/a jugo o refrescos regularmente? ¿Toma su niño/a leche baja en grasa y casi nunca de 2% o leche entera (tapa roja)? ¿Hay alguien in su familia que tiene colesterol alto?   5       2   1     0    

  14. FOR ALL PATIENTS: 5At least five fruits and vegetables a day. 2  Spend two hours or less a day in front of a TV, computers, video games. 1One hour of physical activity or exercise every day. 0 No soda, sports or fruit drinks that are high in sugar. Drink water and three to four cups of low fat milk per day.

  15. Para todos los pacientes : 5Coma cinco frutas y vegetales al día 2 Pase dos horas o menos al día delante de la televisión, la computadora, o los juegos de video. 1Haga una hora al día de actividades físicas o ejercicios. 0No tomebebidas alta en azúcar, como refrescos gaseosos, bebidas deportivas, y jugos de frutas. Tome agua o tres a cuatro tazas de leche baja en grasa

  16. Baseline 5-2-1-0 Data -70% of all families with children 2-12 years at clinic for well child visits received survey -76% eat breakfast every day -Parents report that 61% watch only 0-2 hours of TV daily, but 66% have TVs in their bedrooms -Only 6% eat 5 or more fruits and vegetables a day -Fruit juice difficult to assess, as initial survey had number of ounces, many answered 1, 2 or 3 and likely answering servings/day, not number of ounces/day -33% of families indicated having a family history of elevated cholesterol (37/111 surveys handed out)

  17. Conclusions • Overall, we did not meet our goal of screening at least 90% of 4 and 11 yo with random lipid panels. Additionally, assessing and documenting high risk family history remained poor • Possible reasons: 1) inadequate systems support/reminders for providers (not remembering protocol, no where on follow up templates to document family hx) 2) ??insufficient provider consensus?? • Pending future system changes: adding high risk order set to Eclipsys and adding a family hx section to all amb pediatrics follow up templates

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