Malnutrition is exceedingly common in cancer patients, with some of the highest rates seen in gastrointestinal (GI) malignancies. Malnutrition and cachexia in cancer patients is associated with worse quality of life, poor treatment tolerance, and increased morbidity and mortality. The importance of early recognition of malnutrition in cancer patients is key, and numerous screening tools have been validated to aid practitioners in this diagnosis. In this paper, we summarize the importance of identifying and managing malnutrition in GI cancer patients as well as its impact on clinical outcomes. We then focus on presenting our own novel quality improvement project that aims to expand access to dietitian services in a GI cancer clinic at a large safety‐net hospital system. Utilizing evidence‐based quality improvement methodologies including the Model for Improvement and Plan‐Do‐Study‐Act cycles, we increased the proportion of GI oncology patients seen by a dietitian from 5% to 20% from October 2018 to July 2019. In particular, we outline the challenges faced in the implementation process of a malnutrition screening tool built into the electronic medical record in an outpatient oncology clinic. We focus on the tool's ability to capture a greater number of patients with malnutrition and its clinical impact.

PURPOSE: Rates of malnutrition are high in patients with GI cancer, leading to poor outcomes. The aim of our project was to increase the rate of documented dietitian assessment in patients with GI cancer at Parkland Health and Hospital System from 5% to 25%. METHODS: Three PDSA cycles were conducted after identifying barriers to dietitian services. A registered dietitian was assigned to the GI oncology clinic during the first cycle, an adapted Malnutrition Screening Tool was implemented through the electronic medical record during the second cycle, and clinical staff training was performed during the third cycle. New patients with GI cancer seen by the registered dietitian had weight, Eastern Cooperative Oncology Group performance status, and serum albumin recorded at initial visit and 3-month follow-up. Paired t tests were performed. Emergency department visits and hospital admissions were also recorded during this time. RESULTS: Through these interventions, the percentage of patients with GI cancer with documented assessment by the registered dietitian increased from 5.1% in October 2018 prior to our interventions to 21.8% in July 2019 and has sustained in the 15%-20% range thereafter. From May to July 2019, there were 63 new patients with GI cancer seen by a registered dietitian. No significant difference was observed in average difference in weight and serum albumin level at initial visit and 3-month follow-up. CONCLUSION: A nutrition-focused quality improvement project led to a more than three-fold increase in the rate of documented dietitian assessment in patients with GI cancer.

289 Background: Patients with GI cancer have amongst the highest rates of malnutrition, which contributes to decreased quality of life, increased morbidity and mortality, as well as higher healthcare costs. In the GI Oncology clinic at Parkland Health and Hospital System (PHHS), the number of patients with a documented nutritional plan by a registered dietitian was 7%, and there was no standardized screening method for malnutrition in place. Methods: The aim was to increase the rate of documented nutritional assessment by a registered dietitian to 25%. Multidisciplinary sessions involving physicians, registered dietitians, registered nurses, and hospital administration were arranged to identify barriers to nutritional interventions for GI Oncology clinic patients. Results: Prior to QI interventions, between October-December 2018, the total number of GI cancer patients referred to registered dietitian clinic was 11- 30 referrals, which accounted for 7-10.1% of GI cancer patient in the respective month. As part of first PDSA cycle, a registered-dietitian was assigned to GI oncology clinic. The total number of documented nutrition plan after first intervention was 22 GI cancer patient (15% of GI cancer patients). We then developed an adapted-version of the Malnutrition Screening Tool (MST) and implemented it through the institute electronic medical record. The nursing staff and physicians were educated about administering the screening tool and the referral process to a registered-dietitian after a positive MST screen. After the first month during which MST was implemented, the rate of nutritional assessment increased to total of 20.5% of GI cancer patients (total 37 referrals). Twenty out of the 37 referrals (54%) were due to the positive MST screening tool. Conclusions: Through a nutrition focused QI program, we doubled the rate of a documented nutritional plan for PHHS GI cancer patients in a month of starting the 2nd PDSA cycle intervention. Through future PDSA cycles, we plan to further increase patient access to nutritional assessments and then broaden our efforts to the entire PHHS oncology clinic.

e19163 Background: Patients with GI cancer have high rates of malnutrition related poor outcomes. In the GI Oncology clinic at Parkland Health and Hospital System (PHHS), a safety net hospital, the number of GI cancer patients with a documented nutrition assessment by a registered dietitian was 5-7%. The aim of QI project was to increase the rate of documented nutrition assessment by a registered dietitian to 25%. Methods: Three PDSA cycles were conducted after identifying barriers to nutritional interventions. A registered dietitian was assigned to the GI oncology clinic during the 1st PDSA cycle, an adapted Malnutrition Screening Tool (MST) was implemented through the institute electronic medical record during 2nd PDSA cycle, and clinical staff was trained during 3rd PDSA cycle. Patient weight, ECOG performance status, and serum albumin were recorded at initial visit and 3-month follow up from May-July 2019. Paired t Test was performed. Results: Through PDSA cycles, the percentage of GI oncology patients with documented nutrition assessment increased from 5.9% to 21.8% by July 2019 and has sustained over subsequent 6-month period. From May-July 2019, there were 132 new patients seen by the registered dietitian, with 63/132 patients (47.7%) with GI cancer. Between the initial dietitian visit and 3-month follow up, significant average difference in weight -1.14 kg (CI: -2.17, - 0.19; p 0.02) was observed among all patients. However, there was no significant difference observed in average difference in weight in GI cancer patients -0.78 kg (CI: -2.4, +0.9; p = 0.34). Improvement and stability in ECOG performance status was observed in 87.5% of GI cancer patients and there was a non-significant improvement in average difference in serum albumin. Conclusions: Through a nutrition focused QI program on GI cancer patients at high risk of malnutrition, the rate of documented nutrition assessment was doubled. The GI cancer patients maintained weight, ECOG performance status, and serum albumin over 3-months.

259 Background: In April 2021, it was found that 35% of our breast cancer patients seen in the breast surgery and medical oncology clinics had no financial coverage leading to significant financial toxicity at Parkland Memorial Hospital, a safety net hospital for Dallas county in Texas. In addition, only 8% of all our breast cancer patients were financially screened in April 2021. We aimed to increase pre-visit phone calls to financially screen patients within a week of their subsequent visit with a provider from a baseline rate of 8% to 20% for all breast cancer patients in hopes of capturing more unfunded patients and providing appropriate resources. Methods: We used the Institute for Health Improvement (IHI) model as our quality improvement framework. Based on our fish bone and pareto chart analysis, it was discovered that the lack of consistent financial screening was likely due to lack of standardized training across our ancillary staff, lack of standardized processes for financial screening, and lack of education of both providers and patients regarding the financial coverage process. To address these issues, we created a standardized process of financial screening called “pre-visit planning (PVP)” involving a telephone call by our schedulers to breast oncology patients within 1 week of their next visit. Screening included checking financial application status and educating patients on methods of application submission including epic my-chart enrollment. Screening also included checking financial coverage status and if unfunded, a referral to a financial counselor was made. Formal training of staff was performed with mock trial phone calls. We initiated implementation in the breast surgery clinic initially with plans to expand to the medical oncology clinic. Results: At baseline, in April 2021, 300 patients were seen in the breast surgery clinic of which 19 were financially screened (6.3%). Implementation of PVP for all patients in the breast surgery clinic began in May 2021 with data representing 2 weeks of financial screening by our staff. Total number of patients seen over the span of 2 weeks in the breast surgery clinic was 165 of which 59 were financially screened making up 36% of patients. In addition, 8 patients in the breast surgery clinic were screened by a financial counselor increasing the rate of financial screening to 40.6%. Conclusions: We successfully implemented PVP to better assist our patients in several ways including updating their financial coverage, educating them on the financial process, as well as referring them to a financial counselor for additional aid. Increased follow up time is needed to assess the downstream effects of PVP such as increase in financial counselor visits and decrease in unfunded patients.