Vision and HearingScreening

Broadway ACN PDSA2007-2008

AIM statement Ensure effective and proper screening of

hearing and vision of 95% of children age 4-18 years in accordance with AAP guidelines.

Ensure proper referrals of 95% of children who require them.

Ensure pre-screening of 75% of patients

Decrease visit cycle time by 15%

Why hearing and vision? Vision disorders:

4th 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:

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?

3 yr.

4yr. 5 yr. 6, 8yr.

10 yr.

11 yr.

12 yr.

13,14 yr.

15 yr.

16, 17 yr

18 yr.

O O O O O S O S O S O

S O O O O S O S O S O

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 S S S S

S S S S S S S S S S S

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 dB at

any of these frequencies• 4 yo onward: each ear tested at 500, 1000, 2000,

and 4000 Hz.

PDSA Cycles

Baseline measurementsBrooke 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)

DidacticStephanie Marion

Didactic cycleA.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

What: provider pre-ordering hearing and vision in Eclipsys the day before patient comes for appointment

Who: one patient and one provider

Result: did not work as “pending return visit” orders not monitored by MAs

Katie McGuinn cycleNovember-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 cycleJanuary

What: Eliminated need for provider and PFA involvement Established age-based guidelines as to which patients

would be pre-screened: Vision: Any pt 4-18 years in clinic for regular

appointment (no walk-ins) unless pt/guardian admits to testing within past 6 months.

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 cycleFebruary

What: Signs placed in MA’s office Signs for provider offices and consultation 4 day retrospective analysis

Who: All providers

Results: Confirmation of improvement Appropriately PRE-screened:

• Vision: 84% (43/51)• Hearing: 84% (43/51)

Emily Kaufman final chart reviewApril – 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% 91% 84%

Average cycle time

3 h 4 min N/A 2 h 29 min

Vision referral when

abnormal

25% 25% 70%

Future Plans 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

Domestic Violence at Newborn, 1 y.o. visits (2006-2007): 45% screening (7/16; 6/10 of newborns screened and only

1/6 of 1 yo)

Blood pressure documentation (2005-2006): 73% of charts (32/44)

Screen time documentation (2004-2005): 0% (0/32)

BMI (5yo-19yo): 14/34 with elevated BMI, 50% documented

intervention

Thank you PFAs:

Evelyn, Kenya, Carlos, Conchita

R.Ns: Haydee, Catherine, Bridget, Sally

M.Ds/N.Ps: Mariellen Lane, Pran Saha, Laura Robbins-Milne,

Renie Eis, Heidi Beutler, Nan Salamon, John Rausch

Thank you The ACN Broadway residenCE:

Katie McGuinn, 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