Broadway Clinic Broadway Clinic 2008-2009 PDSA 2008-2009 PDSA

ProjectProjectLipid 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

AIM AIM StatementStatement

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

Pending Return OrdersPending Return Orders

# order

ed

# complet

ed

%

Review 1

8 4 50

Review 2

9 3 33

• 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

Pending Lipid Return Orders

# ordere

d

# placed

# read

July-Nov. 2008

42 17 (40%)

15 (88%)

Pending PPD Return Orders

Cycle 1Cycle 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

Cycle 2Cycle 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

Cycle 3Cycle 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)

For all patients age 4 with at least one:1.BMI> 85% (>17)

2.+Fm Hx: - Dyslipidemia - CVD in women <65 yo - CVD in men <55 yoOrder a Random Lipid PanelIf High:1.TC >2002.LDL >1303.HDL <374.TG >120(girls), >85(boys)Repeat Fasting Lipid Panel in 3 monthsIf still High Refer to Cardiology

For all patients age 11 with at least one:1.BMI> 85% (girls>21, boys>20)

2.+Fm Hx: - Dyslipidemia - CVD in women <65 yo - CVD in men <55 yoOrder a Random Lipid Panel If High:1.TC >2002.LDL >1303.HDL <374.TG >120(girls), >110(boys)Repeat Fasting Lipid Panel in 3 monthsIf still High Refer to Cardiology

Cycle 4 (incomplete)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

Summary of Lipids DataSummary of Lipids Data

# pts with incr BMI

# pts with

+ FamH

x

# pts screen

ed

%

Cycle 1 3 0 2 66.7

Cycle 2 4 1 0 0

Cycle 3 7 1 0 0

Final Review(Anne Abbott

)

16 1 4 25

Total 20 3 6 30

# pts with incr BMI

# pts with

+ FamH

x

# pts screen

ed

%

Cycle 1

1 0 0 0

Cycle 2

2 1 1 50

Cycle 3

4 0 4 100

Final Revie

w(Anne Abbot

t)

5 0 0 0

Total 12 1 5 42

4yo patients 11 yo patients

• Baseline Data (Erik Jensen): 66 with increased BMI, 8/66 (12%) screened (no FamHx recorded)

5-2-1-0 Lifestyle 5-2-1-0 Lifestyle Modification GuidelinesModification 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

5-2-1-05-2-1-0Supporting LiteratureSupporting 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.

5-2-1-0 Surveys5-2-1-0 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

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

0

1

Yes No

Patient Name

Place sticker here

¿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

0

1

Sí No

Patient Name

Place sticker here

5  At least five fruits and vegetables a day.

2  Spend two hours or less a day in front of a TV, computers, video games.

1  One 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.

FOR ALL PATIENTS:

5  Coma 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.

1 Haga una hora al día de actividades físicas o ejercicios.

0 No tome bebidas alta en azúcar, como refrescos gaseosos, bebidas deportivas, y jugos de frutas. Tome agua o tres a cuatro tazas de leche baja en grasa

Para todos los pacientes :

-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)

Baseline 5-2-1-0 DataBaseline 5-2-1-0 Data

ConclusionsConclusions

• 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