The Georgia Academy of Family Physicians offers both practice and community-based initiatives providing myriad opportunities for its members to be catalysts to improve the quality and access to healthcare.
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GAFP Annual Research Poster Competition Winners Announced
The GAFP Annual Research Poster Competition was held during the GAFP Annual Meeting and Scientific Assembly November 9-12, 2016 in Atlanta. Posters were displayed in the GAFP registration area of the Westin Buckhead Atlanta Hotel for all attendees to view, and were evaluated by Dr. Oguchi Nwosu, Dr. Yuan-Xiang Meng, and AAFP Representative Dr. Lynne Lillie. Pre-Med, Medical Students, Residents and Practicing Physicians from throughout the state participated in the competition. Results were as follows:
Pre-Med Category Winner:
1st Place – Language Nutrition in Action: The Impact of the “Talk with Me Baby” Program in Georgia Public Health District 2
Author/Presenter:Max Muldoon – Foothills Area Health Education Center, Gainesville, GA
David Westfall, MD, MPH, CPE – Gainesville, GA
Deenene Chandler, MPH, CHES, ATC – Special Projects Coordinator, Foothills Area Health Education Center (AHEC), Inc.
Hailey Clark – Gainesville, GA
A 30-million word gap—this is the difference between children (up to age 3) from families of lower and higher socioeconomic statuses. The existing body of research attributes this gap to children’s interaction with language (being spoken to) and connects increased interaction with language (seen more frequently in the higher socioeconomic group) to future academic and financial success. The Georgia Department of Public Health instituted the “Talk with Me Baby” program in 2014 to target factors influencing the literacy and cognitive function of infants and children. The aim of the program, facilitated in WIC clinics, is to reinforce the importance of language nutrition in underprivileged families through education and informational resources.
This study was conducted to assess effectiveness of the “Talk with Me Baby Program” in GA Public Health District 2. Data collection was achieved through two surveys, one designed for clients and another for WIC employees. The patient survey was distributed to 13 clinics in the District 2 region; the employee survey was administered in the Gainesville WIC clinic. The authors designed the patient and employee surveys to measure client application of language nutrition skills and employee opinions regarding program effectiveness, respectively. Results suggest that language nutrition principles are being utilized by nearly 50% of clients, that improvements and updates to program tools may enhance client interest and engagement, and that further education is needed with respect to the role of electronics in language development
Medical Student Category Winner
Clarkston Community Health Center Quality Improvement Initiative: Optimizing Patient Flow
Authors/Presenters: Joyce Kim – Emory University School of Medicine, Atlanta, GA and Gina Papa – Emory School of Nursing, Atlanta, GA
Introduction: The Clarkston Community Health Center (CCHC) is a non-profit 501c(3) organization founded in 2013 to provide affordable primary and preventative healthcare to the uninsured refugee and indigent population of the Clarkston community, a major refugee resettlement area located outside the city of Atlanta. The Institute for Healthcare Improvement (IHI) Emory Chapter partnered with CCHC in Spring 2016 to improve clinic processes and subjective experiences at this quickly-growing clinic staffed by volunteer health professionals and students. Specifically, this partnership aimed to reduce patient wait and total time at the CCHC by 25 percent by May 1st, 2016.
Methods: After two weeks of initial observations of current processes, the IHI Quality Improvement (QI) Team identified three core areas to improve clinic processes: patient flow, volunteer coordination, and patient forms. Process flow maps and spaghetti diagrams were utilized to better understand clinic flow. The QI team used the Plan-Do-Study-Act (PDSA) approach to test interventions in the three core areas and used average patient clinic time per clinic day gathered every week to measure the impact of each intervention. For patient flow, the team implemented four PDSA cycles; interventions included moving the physical location of check-in desk area for staff to better monitor flow of patients, designing a checklist to better monitor flow of patients, and strategically placing signs and arrows to better assist new patients. For volunteer coordination, the team conducted three PDSA cycles to develop an organized task list of various volunteer roles. For patient forms, the team conducted two PDSA cycles to simplify and revise patient and staff forms to streamline new patient intake process as well as to better reflect essential information needed for documentation at the clinic. The number of patients who did not check out was evaluated as a balancing measure of an unintended consequence due to the physical changes implemented. Also, surveys were conducted to evaluate the subjective experiences of CCHC staff and volunteers after QI interventions.
Results: Although target goal of reducing clinic time by 25% was not achieved, the average total clinic time decreased by nine minutes after QI implementations. Overall, CCHC staff and volunteers saw a subjective improvement in clinic experience after interventions. Of those surveyed, 78% believed that the checklist stickers on the patient forms improved the process of managing charts and 67% found the revised forms to be easier to understand than previous forms. Those surveyed noticed improvements in communication, a faster process, and better organized flow of patients. The volunteers subjectively perceived a less hectic clinic overall. One unintended consequence of changing the check-in location was an increase in number of patients who left the clinic without checking out. This was resolved with the implementation of the checklist sticker, successfully bringing the number of patients who did not checkout to zero.
Conclusion: Interventions to optimize patient flow were successfully made through the rapid feedback obtained via the PDSA cycles as well as engagement with the key stakeholders at CCHC. Future directions for the IHI QI Team at CCHC include further optimization of the checklist sticker and volunteer task-list, adjusting the exam room spaces to better adapt to where bottlenecks form, and translating revised patient forms to main language represented at the clinic to better serve its patients.
Resident Category Winner
A Case for Post-Operative Prophylactic Cardiac Monitoring in a High-Risk Patient
Author/Presenter: Hillary Dowdall, MD – Emory University Department of Family and Preventative Medicine, Dunwoody, GA
Advisor/Coordinator/Contributor: Isabell Lowell, MD
Case Description: An elderly African American female with multiple medical comorbidities presented to the emergency room with right upper quadrant pain. Imaging was consistent with acute cholecystitis, and she underwent laparoscopic cholecystectomy. On post-operative day 2, the patient’s family noted persistent lethargy and generalized weakness since surgery. The patient denied symptoms and physical exam was non-focal. A broad work-up was initiated due to persistent familial concern. A new right bundle branch block and grossly elevated troponins led to diagnosis of non-ST elevated myocardial infarction (NSTEMI). Cardiac catheterization showed multi-vessel disease and the patient underwent percutaneous intervention (PCI) with stent placement as she was deemed not a surgical candidate for coronary artery bypass graft.
Peri-operative physiological changes place patients at higher risk for cardiac events, and identifying acute coronary syndrome (ACS) is particularly challenging in the post-operative period. Initial literature suggests that monitoring troponin levels and ECGs daily during the first three days after surgery may help identify patients at high risk of major cardiac events and improve prompt diagnosis of perioperative myocardial infarction. A reasonable threshold for choosing whom to monitor is to obtain troponin levels and ECGs for patients with established atherosclerotic disease who are undergoing surgery requiring hospital admission. In addition, patients who have other risk factors for perioperative cardiac events, such as diabetes, renal insufficiency, history of heart failure cerebrovascular disease could be screened. The patient in this case study meets criteria for both suggested surveillance groups. Routine ECGs and troponins post-operatively would have led to earlier detection of ACS and more rapid intervention.
This case emphasizes the importance of having a high index of suspicion for atypical presentation of ACS in high risk patients, particularly in women and in the post-operative period. A review of the literature supports prophylactic post-operative cardiac monitoring in high risk patients such as this one, which may lead to earlier detection of ACS. Further research is needed to quantify a mortality benefit and to determine optimal testing frequency and modality.
Practicing Physician/Fellow Category Winner
Nails: A Window to Systemic Diseases
Author: Viktoria Nurpeisov, MD – Atlanta Medical Center, Atlanta, GA
Despite the enormous involvement of imaging tools in medicine, a focused physical examination still plays a pivotal role in all medical fields. During and after taking history, a detailed inspection and examination of the patient will direct to further key diagnostic tools. A wealth of information can be gained from examining the hands. This part of the examination, especially the examination of the nails, is often neglected, although it is simple to notice if the hands are warm and well perfused and to examine the color of the nails. This short case report describes a patient with different systemic diseases which were diagnosed based on patient’s nail changes. The early recognition of this nail abnormality led to earlier treatment.
An 85-year old gentleman with a history of hypertension, hyperlipidemia, and tobacco use presented to the geriatric clinic with a history of craving ice chips for several months and a twenty-pound weight loss over the previous six months. He denied any noticeable change in stool habits, hematemesis, abdominal pain, or vomiting. He did not use alcohol and had smoked cigarettes for the past 60 years. His medications were: Lisinopril 5 mg daily, Aspirin 81mg daily, and Hydrochlorothiazide 12.5 mg daily. He was compliant with his medications. On examination, he was a thin and cachectic. His vitals were stable. There was no noticeable jaundice. His lungs were clear and heart exam was unremarkable. His abdominal exam didn’t reveal any palpable masses but revealed an enlarged liver. There was no palpable lymphadenopathy. Lungs were clear and cardiac exam was unremarkable.
His nails revealed spooning, evidence of nicotine staining and changes consistent with Terry’s nails. His labs showed normal chemistries and urinalysis. TSH and vitamin B12 levels were normal. He had a microcytic anemia, hemoglobin of 9 g/dl.
This patient was admitted and by CT colonoscopy, diagnosed with colon cancer with metastasis to the liver. He and his family elected for him to receive hospice care. His Terry’s nail changes were consistent with hepatic disease. These are usually seen with cirrhosis but in this case we felt these changes were the result of hepatic metastasis. His nails also revealed spooning consistent with an iron deficiency anemia as well as nicotine staining on the second and third finger nails. Based only on this gentleman’s history and nail changes as described, colon cancer with liver metastasis was a leading diagnosis before getting any diagnostic studies. Subsequent CT colonoscopy confirmed this diagnosis. To our knowledge, this is the first case of association of Terry’s nails with hepatic metastasis without hepatic cirrhosis.
Terry’s nails were first described by the British physician Richard Terry, who investigated this nail-bed abnormality in 82 of 100 consecutive patients with hepatic cirrhosis. The biochemical circumstances leading to Terry’s nails are usually related to the underlying disease and not causally associated to the nail disorder. Other disorders that have been associated with Terry’s nails include: diabetes and tuberculosis.
In this age of growing technology getting back to the bedside and taking the time to listen, as well as look for subtle but important physical exam findings, still remains an important art and skill which should not be overlooked. Nail changes are easy to observe and often are associated with important clues to underlying systemic illness in older patients. This case report emphasizes Sir William Osler’s quote that ” every patient you see is a lesson in much more than the malady from which he suffers.” This poster will show pictures of this gentleman’s hands and nail findings as well as other diagnostic nail changes in systemic disease.
Congratulations to the GAFP 2016 Research Poster Winners! We wish them continued success in their research efforts!