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197 Background: Accurate TNM staging of malignancy is essential to quality care of cancer patients but maintaining consistent documentation of appropriate staging remains a challenge. We identified documentation of TNM staging at our institution to be below target levels. We sought to improve documentation of staging in all patients at our cancer center with a diagnosis of malignancy by implementing both automated and manual reminders through our electronic medical record (EMR) software (Epic), as well as by using team accountability. Methods: We defined an expectation that all patients seen at UC San Diego Moores Cancer Center with a billing diagnosis of malignancy would have TNM staging documented in the EMR within 1 month of their initial visit. The project started in 1/2016, with a phased rollout to individual teams, including education and outreach prior to the start of performance tracking. We used the AJCC staging module in Epic and focused on all new patient visits with a billing diagnosis of malignancy. Providers were asked to add this diagnosis to the problem list and then document the stage using the AJCC staging module in EPIC. We tracked compliance by individual provider and by team and emailed performance reports to all providers on a monthly basis. To facilitate compliance, we initiated automatic Epic messages to providers for an unstaged cancer diagnosis on the problem list and followed up with a personal email from administrative staff if documentation was not completed in a timely manner. Results: At the initiation of this project, there was no standardized documentation of cancer staging. The project was phased in with the skin cancer and head and neck cancers teams in phase I. Compliance in the initial month of measurement was 28%. Within 3 months of implementation of the project, compliance was over 50%, and within 27 months, over 90%. Compliance has remained > 90% since. For 3/2020, 368 patients were eligible for staging and 98% were staged within a month of their visit. Conclusions: Documentation of TNM staging of malignancy was significantly improved by both automated and personal reminders with a vital component of team accountability. Further efforts to improve the current practice and culture of documentation for diagnosed cancer patients remains a crucial aspect of quality and safety.

BACKGROUND:: Thrombocytopenia has been considered a relative or even absolute contraindication to neuraxial techniques due to the risk of epidural hematoma. There is limited literature to estimate the risk of epidural hematoma in thrombocytopenic parturients. The authors reviewed a large perioperative database and performed a systematic review to further define the risk of epidural hematoma requiring surgical decompression in this population. METHODS:: The authors performed a retrospective cohort study using the Multicenter Perioperative Outcomes Group database to identify thrombocytopenic parturients who received a neuraxial technique and to estimate the risk of epidural hematoma. Patients were stratified by platelet count, and those requiring surgical decompression were identified. A systematic review was performed, and risk estimates were combined with those from the existing literature. RESULTS:: A total of 573 parturients with a platelet count less than 100,000 mm who received a neuraxial technique across 14 institutions were identified in the Multicenter Perioperative Outcomes Group database, and a total of 1,524 parturients were identified after combining the data from the systematic review. No cases of epidural hematoma requiring surgical decompression were observed. The upper bound of the 95% CI for the risk of epidural hematoma for a platelet count of 0 to 49,000 mm is 11%, for 50,000 to 69,000 mm is 3%, and for 70,000 to 100,000 mm is 0.2%. CONCLUSIONS:: The number of thrombocytopenic parturients in the literature who received neuraxial techniques without complication has been significantly increased. The risk of epidural hematoma associated with neuraxial techniques in parturients at a platelet count less than 70,000 mm remains poorly defined due to limited observations.

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