Vision and Hearing Screening Broadway ACN PDSA 2007

Vision and Hearing Screening Broadway ACN PDSA 2007 -2008

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

Why hearing and vision? n Vision disorders: n n n 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: n n 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

Guidelines

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

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

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 d. B at any of these frequencies 4 yo onward: each ear tested at 500, 1000, 2000, and 4000 Hz.

PDSA Cycles

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)

Didactic Stephanie Marion

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)

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

Katie Mc. Guinn 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)

Erik Jensen cycle January n What: n n Eliminated need for provider and PFA involvement Established age-based guidelines as to which patients would be pre -screened: n Vision: Any pt 4 -18 years in clinic for regular appointment (no walk-ins) unless pt/guardian admits to testing within past 6 months. n 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)

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

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)

Summary Baseline Post-didactic Final chart review N 43 18 72 Vision screen 91% 94% 89% Hearing screen 91% 84% Average cycle time 3 h 4 min N/A 2 h 29 min Vision referral when abnormal 25% 70%

Future Plans n n n 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

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

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

Thank you n The ACN Broadway residen. CE: n n n Katie Mc. Guinn, 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

a i l e C n ly M i r a a l e g n A F e p i l e