32. IMPROVING EFFICIENCY OF AUTISM SCREENING

Background Autism is a neurodevelopmental disability appearing before age 3. Children with autism have difficulties in verbal and non-verbal communication, social interaction and play activities. M-CHAT is a 20-question parental survey about a child's social, verbal and emotional development. It is easy to use and validated in primary care settings with 85% sensitivity and 93% specificity. The AAP recommends that all children be screened for autism at ages 18 and 24 months, along with regular developmental surveillance. In Children's Health Center of The Brooklyn Hospital Center, we use Office Practicum with an automated scoring system of M-CHAT. Residents ask 20 questions during the encounter and document answers in the EMR as routine practice at 18 and 24 months visits. We propose a different approach using an M-CHAT paper form to be filled out by the parent before the encounter to improve efficiency of autism screening in a busy primary care clinic. Aim To decrease M-CHAT screening time by 50% and achieve a 100% completion rate at 18 and 24 months visits by May 2018 Interventions PDSA cycle I: Residents ask parent to fill out M-CHAT before the encounter of 18 and 24 months visits. Residents review the answers and input them into the EMR with automated scoring system. Residents address any concerns parent might have. PDSA cycle II: M-CHAT handout is available in front desk with multiple language versions. Educate the front desk staff to distribute M-CHAT to parent at 18 or 24 months well child visit after registration. Measures Autism screen time using M-CHAT-R; Completion rate of documented M-CHAT in EMR at 18 and 24 months visit Results During PDSA cycle I, a significant reduction of autism screen time was noted, with the median time being 1 minute compared to 4.5 minutes without intervention. There were 2 patients with a positive screen result and the screen times were 5 and 10 minutes respectively, which we excluded from data. The average time spent in M-CHAT assessment with negative screen result continued to be 1 minute in PDSA cycle II. In the pre-intervention study from October to December 2017, the documented M-CHAT completion rate was 80% at 18 months visits and 78% at 24 months visits. In January 2018 (PDSA cycle I), the M-CHAT completion rate increased to 100% at 18 months visits and 94.7% at 24 months visits. In PDSA cycle II, the M-CHAT completion rate was 94.6% at 18 months visits and 90% at 24 months visits. Yet, the rate of M-CHAT distribution by front desk staff was 64.5%. Conclusions and Next Steps This quality improvement study demonstrated significant reduction of autism screening time and improvement of workflow, and positive changes in completion of the M-CHAT documented on 18 and 24 months well child visits. Our intervention process excluded child with positive screens due to additional discussion regarding proper follow-up and referral. Use of the M-CHAT handout before the encounter markedly increased efficiency of autism screening, yet adaption to this practice among clinic staff likely contributed to the incompletion rate in quality metrics. Overall, we found the use of M-CHAT paper forms before the encounter helped residents incorporate information faster and assess the risk for autism more efficiently. As a result of this study, the practice leadership decided to continue using the processes introduced in this intervention.