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298 Background: A comprehensive chemotherapy informed consent process improves shared decision-making. Additionally, the Oncology Care Model (OCM) emphasizes providing patients with a documented care plan that contains the 13 components in the Institute of Medicine Care Management Plan. Within our health system, we incorporated the care plan into our existing chemotherapy consent process and utilized technology to increase compliance and reduce administrative burden. Methods: Our 2 phase PDSA included: 1) updating our existing paper chemotherapy form with the 13 components of the IOM care plan and then 2) piloting an electronic version of the chemotherapy consent form. We updated our new chemotherapy consent with the addition of Prognosis, Expected Response to Treatment, Potential Effect on Quality of Life, Potential Benefits/Goals of Treatment, and added more options for potential side effects/harm. Given the increased administrative burden, we created and piloted the use of an electronic version of the consent form in our breast oncology program. Results: Baseline, monthly random chart audit of 20-40 patients revealed compliance with completing every question of the paper chemotherapy consent at 30% of all patients receiving IV chemotherapy at our cancer center that month- 7/2018. When the new chemotherapy consent incorporating the IOM elements was rolled out, compliance initially rose to 50% (8/2018), however the following months dropped to 10-20% (9-11/2018) and then back up to 41% briefly (12/2018). The results were low and inconsistent. A pareto chart confirmed that redundancy and too many questions were the reasons for under-completion. By auto-populating fields for certain questions on the paper consent, compliance increased to 75% (2/2019). Finally within our breast cancer pilot group our compliance rose to 100% (3-4/2019), by converting to an electronic form with the maximum options for auto-population and drop-down selections for certain fields. Conclusions: Incorporating regulatory requirements into an existing workflow can reduce administrative burden. The use of innovative technology can further increase clinician and OCM compliance while delivering value to patients.

e18314 Background: The incidence of cancer diagnosed during pregnancy is 0.1-0.2%. The incidence of women who become pregnant while on chemotherapy is less clear. As the initiative to improve awareness about the risks of infertility in premenopausal women receiving chemotherapy improves, it is also important to reinforce the risk of pregnancy during chemotherapy. Treating patients with chemotherapy, especially during the first trimester, is an absolute contraindication and a serious adverse event. Pregnancy testing prior to the initiation of chemotherapy is recommended by the NCCN and ASCO. However, recommendations on how to monitor for pregnancy after an initial screen are inconsistent and lack standardization. Methods: We surveyed five breast medical oncologists and six infusion nurses at a busy urban breast center to determine their baseline practices for pregnancy counseling and testing. We then initiated a quality improvement project over a six month period to routinely screen premenopausal patients ( < 55 years) diagnosed with breast cancer for pregnancy prior to each cycle of chemotherapy. Results: Of physicians and nurses surveyed, 40% and 33% respectively have diagnosed a pregnancy during chemotherapy. All physicians surveyed check a pregnancy test prior to the initiation of chemotherapy, 60% check urine and 40% check serum. Counseling patients on the risk of pregnancy varies with 80% of physicians counseling patients prior to initiation of chemotherapy. Half of the infusion nurses ask patients if they are concerned they may be pregnant intermittently during chemotherapy and 50% do not ask again after the initial screen. During routine screening over a 6 month period no pregnancies were detected. One patient missed a baseline screening prior to initiating chemotherapy. Two patients had a borderline result ( < 1%) on urine pregnancy testing but reflex serum testing was negative. Compliance for testing by nurses was 93%. Conclusions: Results of the survey demonstrate that pregnancy counseling and screening practices vary even within the same institution. We must improve and standardize educating patients and healthcare providers on the risks of pregnancy during chemotherapy in order to prevent unwanted pregnancies, and identify pregnancies in a timely manner. Given the very small risk of pregnancy, we would not recommend routine screening prior to each cycle of chemotherapy, but we do recommend asking all premenopausal patients if there is a chance they may be pregnant prior to each treatment and test based on the individual risk.

71 Background: The safe administration of oral chemotherapy is a challenging yet important process to ensure patient safety. Comprehensive initial and subsequent documentation especially regarding dosage and toxicities in the plan of care for patients receiving oral chemotherapy can be instrumental in improving patient safety by ensuring comprehensive health information is available to all health team members. Methods: We are undertaking a rapid cycle improvement project to improve initial and subsequent documentation of new oral chemotherapy care plans by increasing our compliance with the number of components of an oral chemotherapy care plan (as outlined by QOPI’s 13 standards). We performed a baseline chart audit to confirm our current low level of compliance. We then created a process to use smart phrases that include necessary QOPI elements for progress notes upon new prescription of oral chemotherapy as well as smart phrases for subsequent patient initiated telephone encounters regarding oral chemotherapy, that feed into a universal “med note” location. Post implementation, we will perform a chart audit to determine our updated compliance. Staff satisfaction with the old vs the new process will be compared to verify that we have created a more efficient system to answer patient questions regarding oral chemotherapy. Results: Baseline chart audit revealed the number of components of an oral chemotherapy care plan (as per QOPI standards) documented in the EMR was 43% (i.e contained 5/13 components). A Pareto chart confirmed that underutilization of current EMR resources and lack of knowledge regarding QOPI standards were common reasons for poor oral chemotherapy documentation. Implementation of smart phrases for documentation for initial patient encounters and subsequent telephone encounters is currently in process to determine our new level of compliance with QOPI standards for a sustained and meaningful improvement. Conclusions: This quality improvement initiative was designed to improve patient safety by enhancing documentation of an oral chemotherapy care plan in the EMR and also to create a more efficient system to answer and document patient phone calls regarding oral chemotherapy.

Mud bogging is a sport in which motor vehicles may become trapped in mud that clogs exhaust pipes. Four cases of carbon monoxide poisoning related to mud bogging are described.

A cityscape (or any landscape) can be stratified into environmental units using multiple variables of information. For the purposes of sampling building materials, census and land use variables were used to identify similar strata. In the Metropolitan Statistical Area of a cityscape, the census tract is the smallest unit for which census data are summarized and digitized boundaries are available. For purposes of this analysis, census data on total population, total number of housing units, and number of singleunit dwellings were aggregated into variables of persons per square kilometer and proportion of housing units in single-unit dwellings. The level 2 categories of the U.S. Geological Survey's land use and land cover data base were aggregated into variables of proportion of residential land with buildings, proportion of nonresidential land with buildings, and proportion of open land. The cityscape was stratified, from these variables, into environmental strata of Urban Central Business District, Urban Livelihood Industrial Commercial, Urban Multi-Family Residential, Urban Single Family Residential, Non-Urban Suburbanizing, and Non-Urban Rural.

THE kindergarten visiting program for pre-kindergarten pupils described below was worked out during the past three years under the supervision of Miss Ethel Tucker, principal, and put into practice with splendid results by Miss Fitzpatrick who prepared this account so that all kindergarten teachers in the system might consider it for adoption. Besides the evident soundness of the idea in so far as it permits pupils to make a better start in their school life, there are two reasons which make the plan have much more than local appeal. In the first place, this improvement for the pupils does not call for an increase in the school budget. Furthermore, the plan is one which tends to ease the load of the teacher, particularly during the first week of school, rather than adding to the load.-S. M. Brownell, Superintendent of Schools, Grosse Pointe, Michigan.