Approved Projects for Physicians with a Relationship with Nicklaus Children's Hospital

The following projects are currently approved for ABP Part 4 MOC Credit through the Portfolio Sponsorship Program. Unless otherwise stated, these projects are only available to physicians with a relationship to Nicklaus Children's Hospital.


Project Title:
Improving Vaccination Rates in Premature Infant in a Freestanding Children’s Hospital

Project Expiration Date: May 31, 2019
Approving Board: ABP
Project Description:

The AAP/CDC guidelines recommend that at 60 days of age, infants should receive diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine, Haemophilus influenza type b (Hib) vaccine, inactivated polio vaccine (IPV), and hepatitis B virus (HBV) vaccine. The first dose of HBV vaccine is dependent on infant birth weight (BW) and maternal hepatitis B surface antigen (HBsAg) status. Only monovalent hepatitis B vaccine should be used for PT or FT younger than 6 weeks. Administration of a total of 4 doses of hepatitis B vaccine is permitted when a combination vaccine containing hepatitis B vaccine is administered after the birth dose. Because all preterm infants are considered at increased risk of complications of influenza, 2 doses of inactivated influenza vaccine, administered 1 month apart, should be offered for all preterm infants beginning at 6 months of chronologic age as soon as influenza vaccine is available. (Saari, & the Committee of Infectious Disease, 2003; Schillie et al, MMWR 2018; AAP Committee on infectious Disease Red Book, 2018). Suboptimal immunization rates in NICU graduates has been widely reported in the literature. Delayed or non-immunization during hospitalization has been also related to an increased risk for delayed immunizations after discharge. Children who are under immunized at 2 months of age are more likely to remain under immunized at 6 months, 24 months, and 36 mont1 of age. (Macintosh et al. 2017). Improving vaccination rates in NICU setting is a complex process requiring a multidisciplinary approach. A quality improvement (QI) project could be helpful in identifying and overcoming barriers related to real-time recognition of vaccine eligibility, addressing clinician’s perceptions of side effect associated to vaccine, and use of information technology and innovative solutions to improve care. This QI project aims to improve immunization rates in the NICU at Nicklaus Children’s Hospital (NCH NICU). Process and outcome measures will be assessed after various interventions targeting barriers. This pilot targets patients cared by pediatric residents and excluded admission from the emergency department.

Completion Criteria:

To be eligible for credit, physicians must have substantial participation in key activities of the projects from reviewing data, to interventions, or to measurement of outcomes.

To participate, contact the Project Leader: Alejandro Frade Garcia, MD


Project Title:
Improving Time to Antibiotic Administration in Patients with Fever and Neutropenia in the Emergency Department

Project Expiration Date: November 30, 2016
Approving Board: ABP
Project Description:

Patients with fever and neutropenia are at a high risk of developing sever life-threatening infections. Studies have shown that administration of IV antibiotics within one hour of arrival to the ED can potentially abrogate this serious event. Our initial impression was that this was not achieved at our institution due to multiple barriers. In fact our baseline data showed only 3% compliance (97% non-compliance). The aim of this project is to decrease the time to antibiotic (IV) administration in patients with fever and neutropenia presenting to the ED to < 60 minutes and lower the rate of non-compliance by 50% from baseline by tracking the rate Q 3 months for 2 years. This was achieved through multiple stakeholders and interventions including: ER flow, EMR Power Plan, Pharmacy, IV Team, Physicians, Nursing, and ER staff. Project completed with increase in compliance rates. Process was hard-wired into the ED Flow.

Completion Criteria:

Completing 2 cycles, participation in data review, interventions, and / or process implementation.

To participate, contact the Project Leader: Kamar Godder, MD


Project Title:
Work Flow Analysis and Efficiency in a Pediatric Cardiac Intensive Care Unit

Project Expiration Date: January 15, 2016
Approving Board: ABP
Project Description:

The following interventions were implemented Cycle 1: After recording the time spent rounding on each patient for a few weeks, (Baseline data), all stakeholders were gathered for a brainstorming session to decide what items needed to be covered for every patient admitted to the CICU (during and before rounds) and round flow was standardized step-by-step. Intervention 1: Agreeing on the standard process/steps - Then, team members and intensivists realized that there are inputs that were upstream to the Contributors to Quality, which could not be captured by these flow sheets, but that still needed to be addressed to help reduce to a minimum the variation in rounds. Factors were listed Intervention 2: Education & following/adoption of the standard steps: Individual Patient Encounter Work Flow Sheet (Tool Designed) & Daily Rounds Flow Sheet (Tool for Rounds and Pre-Rounds Designed)

Completion Criteria:

To qualify for Credit completion, team members should have contributed to the QI project through attending the educational sessions, team meetings, reviewing the data, implementation of the tools, and revising the tool as needed.

To participate, contact the Project Leader: Darline Santana-Acosta, MD


Project Title:
Initiative to Decrease Length of Stay in the Emergency Department for Patients with Orthopedic Injuries

Project Expiration Date: November 30, 2018
Approving Board: ABP
Project Description:

Implementation of a nursing initiative where a trained group of nurses will place appropriate X-Ray orders for patients with orthopedic injuries before the physician sees the patient. Nurses will have a didactic instruction on orthopedic injuries and will see and examine at least one patient per type of injury. Once checked off by a physician, they will be able to order X-rays.

Completion Criteria:

Participating physicians will complete the project and obtain credit if they: 1) Actively participate in implementation of the intervention(s) - education/ training 2) Collect and/or analyze and review data

To participate, contact the Project Leader: David A. Lowe, MD


Project Title:
Maximizing ED Communication for Ensuring Safe Transition for Admitted Patients to the Floor

Project Expiration Date: October 1, 2018
Approving Board: ABP
Project Description:

Admitted emergency department patients are sometimes sent to the floor by nursing without the knowledge of the treating emergency department physician. Nursing priorities include transferring patients to the floor as soon as a bed is assigned to the patient and this sometimes supersedes appropriate communication between emergency department physicians and nurses. This project aims at improving communication. Through the implementation of a check mark in the electronic medical record to be completed by the physician. This checkmark verifies that the physician is okay with the patient being sent to the floor. Monthly reminders will be given to nurses at their meetings. Physicians working in the ED will be provided with daily reminders to complete the checkmark. The SMART aim includes: Within 6 months 90% of admitted patients will be approved by the treating physician before being sent to the floor by the nurse.

Completion Criteria:

Physicians are eligible for credit if they: 1) Participate in the implementation of the intervention related to the project 2) Actively participated in data collection and/or review and analysis.

To participate, contact the Project Leader: David A. Lowe, MD


Project Title:
End of Life Palliative Care in Oncology Patients with Non-Curative Cancer

Project Expiration Date: June 30, 2018
Approving Board: ABP
Project Description:

The aim of this project would be to involve end of life palliative care upon identification of patients with terminal or advanced cancer, encourage discussions about end of life care and decrease the incidence of ICU deaths in this population in the hopes to reduce aggressive interventions that may not provide reasonable benefit to patient. This is achieved through the planned steps: Development of a screening tool: Using various screening tools that are published or obtained from other hospitals we have reviewed and developed our own screening tool. The screening tool is enclosed. Development of a palliative care consultation form: With inputs from various physicians and palliative care team members we have developed a palliative care consultation form. Involvement of palliative care team nurse: Changes included early consultation with palliative ARNP and referrals on 6T floor admissions by resident scoring system and notifying MD whether palliative consult needed. Periodic education of residents rotating through 6T and 3T (PICU): PL3 and the Chief Pediatric Resident involved in this improvement project have prepared educational materials and have provided education every block with new residents arriving for the rotation in 6T and 3T. Additional educational sessions were conducted when the compliance was lower. Educational material is included. Education of oncology attendings: We have improved awareness of the aim of the project among oncology faculty through presentations in their Division Meetings. In addition, we have presented monthly updates on the progress of the project in their meetings. Presentation of data and education to PICU attending: We have presented periodic updates on the progress of the project in the Critical Care Division faculty meetings.

Completion Criteria:

Completion criteria include physician involvement in the project for 6-12 months as a team participant in either screening, implementation, or review and providing input on the project results.

To participate, contact the Project Leader: Balagangadhar R. Totapally, MB, BS


Project Title:
Depression Screening in Adolescents with Type 1 Diabetes Mellitus

Project Expiration Date: June 1, 2018
Approving Board: ABP
Project Description:

Patients with diabetes mellitus are at increased risk for depressive symptoms and disorders, particularly female patients. About 1 in 4 patients with diabetes suffer from depression. Therefore, there is a consensus on the need for periodic screening for depression in this population. At the same time, it appears that integrating mental and physical health care may improve outcomes. It was noted that formal mental health screening was not part of the visit for diabetic patients. This project aimed at increasing (to >90%) the rates of mental health screening using a validated Quality of Life tool PHQ-9 of adolescents with Type 1 DM and consequently increase mental health referrals to >90% of those who screen positive. Interventions included Education of providers, automated text in EMR for documentation , email reminder to staff. The project was peer-reviewed and accepted for presentation as a poster at the AAP Florida Chapter Annual meeting.

Completion Criteria:

Attend QI Team meetings, participate in data collection, review or intervention.

To participate, contact the Project Leader: Alfonso Hoyos Martinez, MD


Project Title:
Increasing Meningococcal Booster Vaccination in a Primary Care Practice: A Quality Improvement Initiative

Project Expiration Date: May 28, 2018
Approving Board: ABP
Project Description:

Age appropriate MCV#2 (booster) vaccination rates (68%) in the pediatric care clinic are noted to be well below our MCV#1 vaccination rates (94%) resulting in missed doses of MCV#2 vaccinations. This is due to incomplete EMR vaccination schedule and decreased awareness of vaccination recommendations. The aim of this project is to increase the rate of MCV#2 booster vaccination for 16-17 year old patients in our pediatric care clinic with a goal to match our MCV#1 vaccination rates over the course of 1 year. The poster was presented at the Annual Scholarship Day (peer-reviewed) and at the Florida AAP Chapter annual meeting (Peer-reviewed)

Completion Criteria:

Participation in implementation of the interventions, data review or analysis. Attends QI team meetings.

To participate, contact the Project Leader: Raphael Sturm, MD


Project Title:
Pediatric Residents' Knowledge and Proficiency of Epinephrine Auto-injector Administration and Handling: A QI Project

Project Expiration Date: May 31, 2017
Approving Board: ABP
Project Description:

Patients diagnosed with anaphylaxis are often discharged from the hospital with prescriptions for epinephrine autoinjectors (EAI). The purpose of this study was to evaluate the baseline knowledge of pediatric residents regarding proper handling and administration of EAI, and to assess their knowledge after providing them with a formal one-on-one training at the time of discharge. Since education among providers and patients is needed, we believe that efforts to improve the correct use of EAI among providers responsible for training is an essential component to ensuring that patients and families receive the most accurate guidance on how to use this life saving device. The goal of this project is: To increase the percentage of residents who are confident in how to properly use and care for an Epinephrine auto-injector from baseline to 70% or higher over a 3 week period All residents participating on the study will receive one-on-one education by Allergy and Immunology Fellow of the proper administration and handling of Epinephrine autoinjector. Materials and tools Used: Attached can be found the training tool (questionnaire) used for measuring resident’s knowledge on the proper use and handling of epinephrine autoinjector.

Completion Criteria:

Completing of 2 cycles, Participation in meetings, review of the data or implementation of the plan.

To participate, contact the Project Leader: Hanadys Ale, MD


Project Title:
Decreasing Empiric Use of Vancomycin in Late Onset Sepsis

Project Expiration Date: March 30, 2017
Approving Board: ABP
Project Description:

Starting in the 3rd week of October 2016, we educated residents on unit guidelines for LOS at the onset of the NICU rotation and implemented a LOS checklist to assess provider behaviors in the evaluation and treatment of episodes of suspected LOS (see attached checklist and guidelines). The lead resident in the project met with each group of residents at the beginning of their NICU rotation to explain the importance of adherence to LOS guidelines, including the limited indications for the use of vancomycin as well as the adverse effects associated with the overuse of this antibiotic. We then explained the methodology of data collection including the indications to fill out a LOS checklist and where to find it and return it. We engaged the residents by providing reminders in their workstations to fill out the checklist for cases of suspected LOS (stickers on the computers). The residents would then be prompted to bring the checklist to rounds, thus prompting a discussion with the attending about appropriate evaluation for LOS and the choice and duration of antibiotic treatment. The checklist included an area that had to be filled out 48 hours after initiating antibiotics, thus prompting the resident to discuss with the attending if it was appropriate to continue antibiotic treatment depending on whether or not there was a microbial indication.

Completion Criteria:

Completing of 2 cycles, Participation in meetings, review of the data or implementation of the plan.

To participate, contact the Project Leader: Jessica Barreto, MD


Project Title:
Decreasing Antibiotics Use by Standardizing Diagnosis and Management of Ventilator Associated Infection in the NICU

Project Expiration Date: May 31, 2019
Approving Board: ABP
Project Description:

We will target activities related to the primary drivers “hospital ASP and ID consultant participation” and improving “adherence to unit guidelines”.

  • Intervention 1: Develop algorithms for diagnosis and management of VAI The existing literature does not offer specific criteria for the diagnosis and management of VAI in the newborn period. Diagnosis of VAP is based on the definition provided by the Center of Disease Control for infant <1 year, which requires a combination of radiologic, clinical and laboratory criteria. Additionally, we developed an algorithm for the management of infant with suspected VAI adapted from the “Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-Associated Pneumonia” created by the American Thoracic Society Documents.
  • Intervention 2: Education and discussion of algorithm with staff. Conduct an educational campaign with the nursing staff, residents and attending physicians on the appropriate diagnosis and treatment of ventilator associated infection following the developed diagnosis criteria and management algorithm. The educational objective will highlight the difficulties.
  • Intervention 3: Implementation of Guidelines We will use the checklist that was developed in October of 2016 for the iNICQ project. The checklist was modified to evaluate if the presence of a prior ETA positive culture was included in the decision of selecting the empiric antibiotic treatment for infant with VAI.

Completion Criteria:

We anticipate conducting a minimum of 6 PDSA cycles during the 6-months period starting July 1st 2017. Completion Criteria include: - Participation in one of more of the interventions - Attendance of QI meetings to review data and provide feedback - Educating staff and fellows re. the interventions and its tools/checklists/ criteria.

To participate, contact the Project Leader: Adolfo R. Llanos, MD


Project Title:
Improving Accuracy of Location of Peripherally Inserted Central Venous Catheters Using a Tip Locating System (TLS) During Placement

Project Expiration Date: May 31, 2019
Approving Board: ABP
Project Description:

Studies in adults and adolescents of Peripherally Inserted Central Catheters (PICC) found a right atrial malposition rate of 18% and other malpositions at 13.4%. in pediatrics, correction of these malpositions is a time consuming process and involves discomfort to the family and patient. Additional time is needed by the bedside and PICC nurses, ordering physicians, radiology techs and radiologists. Furthermore, additional healthcare supplies are used which leads to increased waste and costs. The PICC line tip termination point is determined by external measures on the patient body (estimates) rather than real time tip location devices during PICC insertion. The aim of the project is to evaluate and compare the rate of malpositioned PICCs on the first attempt after introduction of an Ultrasound-guided Tip Locating System (TLS) compared to the baseline data gathered before its use.

To participate, contact the Project Leader: Dr. Michael Leoncio


Project Title:
Decreasing the Oversuse of CXR in Children (3y-18y) with Uncomplicated Asthma

Project Expiration Date: June 30, 2018
Approving Board: ABP
Project Description:

Preliminary data from 2016 show that there is overutilization of CXR in the Nicklaus Children’s Hospital Emergency Department (ED) and Urgent Care Centers (UCCs). The numbers of ordered CXR in cases of uncomplicated asthma are significantly higher than the national benchmark. This leads to increased exposure of children to unnecessary radiation and increased cost of care. Despite the presence of Asthma national Guidelines, there is lack of adherence to the guidelines. This could be due to multiple factors including: (1) Lack of education of providers (2) Perceived expectations of parents by the providers and (3) other historic practice patterns (4) Fear of missing diagnosis (5) Fear of litigation. This project aims at decreasing the number of CXR ordered for children with uncomplicated asthma.

To participate, contact the Project Leader: Dr. Mario Reyes


Project Title:
Decreasing the Oversuse of CXR in Young Children (1m - 1 y) with Uncomplicated Bronchiolitis

Project Expiration Date: June 30, 2018
Approving Board: ABP
Project Description:

Preliminary data from 2016 show that there is overutilization of CXR in the Nicklaus Children’s Hospital Emergency Department (ED) and Urgent Care Centers (UCCs). The numbers of ordered CXR in cases of uncomplicated bronchiolitis are significantly higher than the national benchmark. This leads to increased exposure of children to unnecessary radiation and increased cost of care. Despite the presence of new AAP Bronchiolitis Guidelines since 2015, there is lack of adherence to the guidelines. This could be due to multiple factors including: (1) Lack of education of providers (2) Perceived expectations of parents by the providers and (3) other historic practice patterns (4) Fear of missing diagnosis (5) Fear of litigation . The aim of this project is to decrease the number of CXR ordered in patients with uncomplicated bronchiolitis between 1m-1year of age. This project is only opened to hospital physicians staff.

To participate, contact the Project Leader: Dr. Mario Reyes


Project Title:
Improving Documentation of Newborn Screen in a Free Standing NICU

Project Expiration Date: December 31, 2015
Approving Board: ABP
Project Description:

Newborn Screening (NBS) is a highly successful public health program that requires timely confirmatory testing, diagnosis, and clinical management so that optimal long-term outcomes can be achieved. NICU population represents a challenge for the eddcative implementation of NBS. Contrary to infants admitted to the regular newborn nursery, who are born healthy, full-term and > 2500g; infants admitted to the NICU are sick and/or premature and/or low birth weight with a prolonged hospital stay. The interventions routinely used in these settings such as blood transfusions, NPO, and TPN solutions have the potential to affect the NBS results and may lead to delay in diagnosis and clinical management. Our analysis of NBS documentation in the NICU in January 2015 revealed a 35% rate of documentation of NBS obtained during hospitalization. The aim of thsi project is to improve the NBS documentation in the NICU to 90% over the next 12 months.
To participate, contact the Project Leader: Dr. Magaly Diaz-Barbosa


Project Title:
Improvement in the Safe and Efficient Management of Acute Scrotal/Testicular Pain

Project Expiration Date: December 31, 2017
Approving Board: ABP
Project Description:

Delays in the definitive diagnosis of testicular torsion can lead to poor outcomes and loss of function. All members of the Emergency Department team may not recognize the acute and emergent nature of this condition. Baseline data indicate that there is room for improvement in the time from presentation to the ED until final U/S read and report. The goal of this project is to improve the time required between presentation to Nicklaus Children's Hospital ED and the time of definitive diagnosis for patients presenting with acute scrotal pain to rule out testicular torsion. An institutional standard pathway is created and the project will aim at increasing adherence to the standard pathway.
To participate, contact the Project Leader: Dr. Jefry Biehler


Project Title:
Severe Sepsis Bundle Implementation at Nicklaus Children’s Hospital

Project Expiration Date: May 31, 2019
Approving Board: ABP
Project Description:
Sepsis is a dangerous systemic infection that often leads to poor patient outcomes, including mortality. Severe sepsis is a significant problem among acutely ill children. A bundle for recognition, initiation and continuation of treatment of severe sepsis based on national guidelines has been created at Nicklaus Children's Hospital but not yet implemented. The goal of the project is to Implement severe sepsis bundle at Nicklaus Children's Hospital thereby improve sepsis-related outcomes.
To participate, contact the Project Leader: Dr. Bala Totapally