LEND Training and Quality Improvement: Building Leadership Skills While Enhancing Patient and Family-Centered Care

BACKGROUND
The Problems
The CDC created a new ICD-9 Code for Wandering and Elopement (V40.31) based on the interest and high rates reported by major autism groups (2012). AWAARE and IAN , for example, reported wandering rates from 50% to high as 92% (2012). Only 14% of patients said they received information from medical professionals (IAN, 2012). The Golisano Childrens Hospital Kirch Center serves a large population with Autism Spectrum Disorders and wants to become proactive in using the CDC Codes and promoting understanding about wandering. Other key autism related safety issues associated with wandering were also identified and incorporated into the study to see if they were being reported and discussed. Notation in a Medical Center/Community-wide Electronic Medical Record alerts providers in multiple settings of risks Unsafe Behaviors Elopement: Nearly half of children with an ASD elope, and more than half of these go missing. Elopement is associated with autism severity, and is often goal-directed. (Pediatrics 2012) Drowning: Children who wander are often drawn to water sources. Accidental Drowning was identified as one of the leading causes of death among children who have a diagnosis of ASD (AWAARE, 2012) Pica: Prevalence: 25-30% of children who have a diagnosis of ASD Pica can lead to: Lead Poisoning, Bowel Problems, Intestinal Obstructions or Perforations, Dental Problems, and Parasitic Infection Aggression: Many children who have a diagnosis of an ASD exhibit aggressive behaviors towards those close to them. This can be challenging to emergency providers who come across a person with ASD. Self-Injurious Behavior : Children who have a diagnosis of ASD are more likely to engage in SIB (Schroeder, et. al, 2002) This includes Head, face, or body slapping, banging, biting, chewing, pinching,

Claire Beers, Katherine DiNicola, Marjorie Dobra, Robin Gardner, Carrie Goodberlet, Jed Nordfelt, Johanna Stump Lisa DeLucia, Michelle Casey, Mark Orlando, Stephen Sulkes

DESIGN/METHODS
Five Chart Reviews / PDSA Cycles were conducted in the Kirch Clinic Four reviews conducted of all practitioners during followup visits One review conducted of practitioners who volunteered to use behavioral template Chart Selection Criteria: First two patients over age three seen during that week by each practitioner with diagnosis of ASD or PDD-NOS

RESULTS
PDSA Cycle Results: Percent Documented
Risk Area PDSA #1 % n = 22 9 5 50 50 18 0 PDSA #2 % n = 22 18 0 23 50 23 0 PDSA #3 % n =20 32 0 32 47 32 0 PDSA #4 PDSA #5 % % n = 19 n = 19 39 17 56 50 17 22 84 11 36 63 47 21

DISCUSSION AND CONCLUSIONS

Initial clinical team resistance Practitioners tend to focus on what they feel is important during patient visits. Their time is very limited and they like to address the immediate concerns of the patient, leaving less time for documentation of other screening Needed resources to implement changes eRecords was not live during at start of project and AllScripts did not have an easily accessible template. With implementation of new system, quality markedly increased Practitioners, recognized the importance of the risk-areas and given the right tools, change how their practice Produced a safety resource list (paper and Kirch Center Safety Resource List Wandering Safety:electronic) Spread awareness across the Kirch Developmental www.AWAARE.org Center of Autism Risk www.Autism_Risk_Management.com Areas www.Project_Lifesaver.org www.UNYFEAT.org (Autism Risk and Safety section) Drowning Prevention and Water Safety: www.warnonline.org/english/index.html autism.fsu.edu/documents/DrowningBrochureDRAFT.pdf Pica Prevention: www.healthguideinfo.com/autism-treatment/p114419/ SIB and Aggression www.autism.com/ind_self-injurious_behavior_treat.asp http://Autism-help.org/behavior-intro-autism.htm

Elopement Drowning Pica Aggression Self-Injury Emergency Communication

PLAN-DO-STUDY-ACT (PDSA) Cycles A Tool for Incremental Improvement

Implementing Safety Templates in Electronic Health Records for Children with ASDs
90 80 70 60 50 40 30 20 10 0
84 63 50 39 32 18 9 5 0 0 17 23 11 32 56 37 18 23 50 50 47 50 32 17 0 0 0 22 21 47

PDSA 1 PDSA 2 PDSA 3 PDSA 4 PDSA 5

Cycle Descriptions:
Cycle 1: Baseline One Randomly selected week in October, 2011 22 charts reviewed Cycle 2: Providers Informed of Activity; no specific intervention proposed After informal presentation to Kirch Practitioners of QI project One randomly selected week in December, 2011 OBJECTIVES This study Cycle 3: Small Group Template Implemented 5 Practitioners volunteered to utilize a Template called Symptoms Reviewed from week of January 30, 2012 19 charts reviewed total Cycle 4: Template Presented to Full Team Formal presentation to Kirch Practitioners in February First week in April, 2012 Total of 20 charts reviewed Cycle 5: New Electronic Medical Record in Place with Adjustable Templates

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References
Anderson C, Law JK, Daniels A, Rice C, Mandell DS, Hagopian L, Law P. Occurrence and Family Impact of Elopement in Children With Autism Spectrum Disorders. Pediatrics 11/12; 130(5):1-8, 11/12. AWAARE Collaboration. (2012). Become Aware. Retrieved from http://www.awaare.org/index.htm Centers for Disease Control and Prevention. (2012). New Data on Autism Spectrum Disorders (ASDs). Retrieved from http://www.cdc.gov/Features/CountingAutism/ Interactive Autism Network (IAN). (2012). Challenging Behaviors. Retrieved from http://www.iancommunity.org/cs/challenging_behavior/

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LEND FELLOW LEARNING OUTCOMES

Literature Review Skills Understand Quality Improvement Process and Use of PDSA Cycle Approach to Incremental Change Presentation and Interdisciplinary Team Engagement Skills Quantitative Skills Negotiation and Conflict Resolution Systems Change to Achieve Family-Centered Care Advocacy with Medical Center to add codes to electronic medical record system