Hello friends 👋
In this episode, I had the pleasure of speaking with Dr Shayla Percy, who is now a third year Neonatology fellow UPMC Children’s Hospital of Pittsburgh. Shayla described her QI project and the steps she took with her team to improve detection and management of metabolic disease of prematurity. She talked about the team work and the support from her mentors that set her up for a successful project. We also talked about some of the challenges that she experienced and how she tackled it. Shayla completed QI courses during the fellowship and also won the AAP young investigator award for her project. Shayla shared her experience presenting her work at AAP and provided insights to future incoming fellows who might be interested in a similar research pathway.
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Short Bio: Dr Shayla Percy is a third year neonatal-perinatal medicine fellow at UPMC Children’s Hospital of Pittsburgh. She received her medical degree from the Medical College of Wisconsin in 2019 and completed her pediatric residency at UPMC Children’s Hospital of Pittsburgh in 2021. Her research focuses on metabolic bone disease of prematurity; and she recently received the 2024 American Academy of Pediatrics Young Investigator Award for her quality improvement work on this topic. Shayla will be joining the faculty at UPMC after completion of her fellowship.
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The transcript of today's episode can be found below 👇
Srirupa (00:00.75)
Hello, everyone. Welcome to the Fellow Series. My name is Roopa Hari Gopal. I am a first year attending, which seems very interesting. You you're always in this lifelong journey of learning. So I am a new attending who just graduated from fellowship recently. And this is a platform just for you fellows to talk about your research, to talk about your passion and interest in the world, in this beautiful world of neonatology.
So without further ado, my guest for today is Dr. Shayla Percy. She is a third year in unitology, perinatology fellow from UPMC Children's Hospital of Pittsburgh. So up from the North and she is wonderful because she's done so much of work on her quality improvement project. She received her medical degree from the Medical College of Wisconsin.
She's completed her Peds residency from the Children's Hospital of Pittsburgh and stayed on to finish her fellowship there as well. And she is finishing her fellowship, I would say, soon. I cannot believe that it's already six months into my first job, which means it's six months into your third year of fellowship, which is amazing. So welcome, Sheila. How are you doing today?
Shayla Percy (01:16.129)
doing great! Thanks so much for having me on!
Srirupa (01:19.032)
Yeah, so I am excited to know everything about this quality improvement project that you've been doing. And I would say that one of her attendings reached out to me about all the amazing work that she's done in her quality improvement project. And that clearly speaks highly of all the work she's done in her fellowship. So I would love for you to tell in your own words and describe in your own words a little bit about your project.
Shayla Percy (01:42.336)
Yeah, absolutely. So my project started back in my first year of fellowship where we had over the course of a couple years, I mean, this was prior to me starting, but staff in our NICU started noticing that we were seeing more fractures on x-rays without really a good explanation. And our goal was to figure out why that was happening and hopefully decrease the rates of fractures.
So I fell into this project a little bit. It had started in the COVID era and then with the challenges of COVID, it had kind of petered out. And as I was starting my fellowship, they were revamping things. So I had the opportunity to kind of jump on board and start almost from scratch, where we started looking at our rates of fractures and the types of patients that were
were getting these fractures and we especially noticed that it was our most premature babies. So those micro preemies who were a lot of times having more than one fracture. So we put together this really amazing team of a bunch of different people from different aspects of the NICU. We wanted to make sure that we were including people who were both on the medical side of things, but also people who were in nutrition and
who were in physical therapy and occupational therapy. So we put together this amazing team and we delve into all of the data that we could pull from our charts. And we found that we actually had a fairly high rate of fractures, somewhere around 5.57 fractures per 1,000 patient days. Which when you look at the literature, it's in the range of what's reported in the literature.
But the problem with metabolic bone disease of prematurity and fractures is that we don't have great definitions for it. And everyone looks at it a little bit differently. Most people don't specifically do head to toe x-rays looking for fractures on these preemies. So most of the data is incidental. So we still don't have a great sense of what the true incidence of this is. But for the purpose of our unit, we thought that
Shayla Percy (04:03.529)
5.57 fractures per 1,000 patient days was too high. So we looked at our unit and put together kind of what we call on quality improvement as data analysis, where we pulled opinions from different people, talked with lots of people and figured out what about our unit in particular could be contributing to this high rate of fractures.
So in quality improvement, you do this data analysis, and then you put all of those ideas on what we call a key driver diagram, which is kind of an idea map, where it links all of your ideas to possible things that you could change. So we did that. We put together our team, and we came up with our aim statement, which was to decrease our rate of fractures by at least 20 % in infants who are born
under 29 weeks and hopefully maintain that over a period of time. We chose 29 weeks specifically, which I know for some people that's an odd number to choose, but we chose that because we had for our unit, we already had a way to pull information for 29 weeks and below. So it made sense for us to pick that number. And when you look at metabolic bone disease,
Srirupa (05:12.836)
Thank
Shayla Percy (05:24.155)
the people who are most affected or the babies that are most affected are babies born prior to the third trimester. So it's right in that range of 28, 29 weeks, know. So we chose that as our number. And then in terms of our project, what we did is we picked three primary interventions that we wanted to do. The first was something super simple. We put signs in front of the baby's isolettes.
within the first week of life with the goal to just say, hey, my bones are fragile. Please be careful. And it wasn't a way to blame anyone. was just a way to get the conversation started and get people thinking about how delicate these infants are. So that was the first thing we did. The second thing we did is we did not have a standardized process for how we go about metabolic bone disease. So we put together a
essentially a guideline with several flow diagrams for providers to be able to say, okay, I have this baby, they have these risk factors, these are the labs I need, based on the lab numbers, this is what we need to do. So we really standardized our process. And then the final thing we did is we put together a physical therapy protocol. There's actually a lot of really great literature that looks at bone loading. So when an infant is born,
They lose the mechanical load that the uterus provides, which is actually super important for bone strengthening. And then they sit in the NICU in their little danderu wrapped up and they don't do a lot of losing. So by providing physical therapy, once they're born, you can actually provide a lot of strength to the bones. So we wanted to incorporate that as well. So some of my amazing physical therapy colleagues led by Lisa Hennan, who's one of our
physical therapist put together this awesome protocol that are these really short sessions, just five to 10 minutes where they're just doing a little bit of manipulation of the limbs and some joint compression, just gentle squeezing essentially of the joints. And it seems like that has been really helpful for our babies as well. So we did all of these things and we've been tracking a bunch of data. And what we've found is that we've had a really big increase in our fracture rates.
Srirupa (07:45.914)
Okay.
Shayla Percy (07:48.902)
So we started at 5.57 fractures per 1,000 patient days, and we've been able to decrease that down to 1.54 fractures, which was much more than I expected. And it's really exciting that all of this has been working in our unit. We've also seen a decrease in our osteopenia rates. So we started with about 3.8 patients per 1,000 patient days being diagnosed with osteopenia per their x-rays.
And we've also reduced that down to 2.29 patients. So we've seen some really amazing results from it. And it's definitely a credit to all of the amazing people who are working on this project. And we're still working on tweaking things and trying to get the bones of our babies to be in the best spot possible. But it's been a really amazing experience so far.
Srirupa (08:40.45)
No, that's wonderful. It seems like you all worked so much as a team to get this successful. that, I would say that diagram would have been amazing to look at that run diagram. And I did get a copy of that and it looks so beautiful to see how that rate just like dropped and all kudos to all of your efforts to, you know, do all of these interventions together. May I ask amongst the interventions that you did, what was the one that had the most impact to improve your rates?
Shayla Percy (09:10.31)
That's a really great question. I think really standardizing our process was probably the most important thing. We did see quite a bit of a drop after we started putting the bone signs in the rooms. I think some of that is what we call Hawthorne effect or awareness of the problem causes people to focus on it a little bit more. And we had such a big multidisciplinary team that
As we were planning, we had our dieticians who were already suggesting like, let's maybe focus a little more on calcium and phosphorus in the TPN. And we had our physical therapists who were helping our nurses figure out the best way to handle the infants. So we had kind of a little bit of a change right off the bat just because we started thinking about the problem. So we had that drop. And I think what sustained it is having a standardized process.
It's so important for everyone to be doing the same thing.
And I think what our unit fell into, which I think is a really common problem is we would get the labs prior to all of these interventions, we would get the labs, we'd look at them and say, they're high, but they're not super high. And we don't have a specific cutoff. So then we just get labs in a couple weeks. And it would just progress. Whereas now we have, okay, we get labs, they're sort of high, let's make a couple changes based on this whole protocol we have.
and things don't progress as far. So I think that really has been the most important thing.
Srirupa (10:45.688)
Yeah, yeah, no, that's amazing. Tell me a little bit about how you developed your relationship with all of these stakeholders. I see that this is going to be, this is definitely a multidisciplinary effort. You have so many people that have to provide their inputs, have to be hand in hand with your interventions. So tell me a little bit about your experience on how that changed your relationship with the rest of your team.
And how did they take this project in general? Like how was their experience and their reaction to all of these guidelines and the signs and everything?
Shayla Percy (11:26.276)
I think I had a slight leg up because I did my residency at the same location. So I knew a lot of the quote unquote stakeholders that were involved in this project, which in quality improvement work, just knowing people and being able to have a conversation, even if it's just a casual in the hallway conversation is super important. So I think I had a slight leg up because I knew people going into it. That being said,
You know, I think the most important thing is to just have those conversations and make sure that you're transparent and just really casual about it. You know, we're all working towards doing the same thing. We're trying to make the babies feel better. We all have slightly different ways that we can do that because we have different roles. But having just a good relationship is the most important thing in quality improvement. I think
A lot of people were invested in this right off the bat. You know, we don't want our babies to have fractures. It's something that's painful. It's not a good outcome. So it's something that people were invested in, which also was really helpful because I didn't have to do as much work in convincing people that this was an important topic. It inherently is an important topic. And I had some really amazing advocates within the team to help drive things forward.
So I have three primary mentors on this project. So Brianna Bertoni, who is my primary mentor and is kind of the quality guru in my life. She was super key in helping me figure out the best way to go about building stakeholder relationships. So I think that's something that's really important is to find someone who has some experience and also
knowledge of your environment and they'll help you navigate those situations. So she was really key. Burhan Mahmood is another one of my mentors. He was more interested on the medical side of things and he, I consider him my idea man. He comes up with the best ideas.
Shayla Percy (13:40.7)
Sometimes too many ideas and I need to rein him in, but having someone on your team who's going to push you forward and suggest things that you wouldn't think of is also an amazing thing to have. And then my last primary mentor is a beer azucca, who's also a little more on the medical side. She particularly is interested in nutrition. And she is someone who
is one of the medical directors in our unit, so she knows the system really well. And that, again, is super important to just have different members of your team to be able to help you in different aspects. So having those primary mentors was amazing. I think one of the things I learned about this project is you can have those mentors that are kind of top down. But in quality improvement, there's a lot of peer mentorship as well.
So I learned so much from people who do quality improvement who are not necessarily physicians. Lots of people do quality improvement and just having conversations with nurses and physical therapists and our dieticians, you can learn so much in how they do things, which is not inherently how physicians tend to think about things. That just really drives things forward.
So I'm not totally sure if I answered your question or if I went off on a huge tangent, but that's where I went.
Srirupa (15:12.054)
No, but I think that was amazing that you had that you built that relationship as you went through sort of part of your residency going into fellowship. And that just like, would say flourished as you did this project seems like, and I cannot emphasize enough on personal experience that good mentors make such a huge impact in your career. And so I'm so glad that you were able to figure that out during your fellowship. I see that all of this.
started in residency, the interest started in residency. And you know, sometimes with quality improvement projects, you want to do something and it ends up being something else because of lots of challenges that come in your way. And quality improvement project can surprise you slash shock you in a lot of ways. I think you would agree with that in a way, but I would love to understand what were some of the challenges that you faced while implementing this and how did you tackle them?
Shayla Percy (16:06.808)
Sure. You know, I think probably the biggest challenge, and this is going to be anyone who does quality improvement work is going to say the same thing, is just human nature. People don't like to change what they're doing, and it has nothing to do with your project and how good it is or how detailed it is. It's just people don't like to change. And that's okay. And that's part of the process of a quality improvement project is you need to slowly...
introduce the idea and get that buy-in and kind of work through it. So I said earlier I had a lot of buy-in and a lot of support from the people who were involved in the project and fractures inherently are an issue that we don't want. So it's a little easier to push that through. But one of the big interventions was
changing everything that we did in the unit. So doing this guideline where we introduced a new lab marker that we didn't do before. So we started using a urine test called the tubular reabsorption of phosphate. We didn't do that before. And it took a little bit of time for people to get used to it, to understand how to use it. And a lot of it was just reinforcement. know, like if people had questions,
I made myself available via text or email or if they saw me in the hallway they could grab me. Whatever you need to do to make sure that people are comfortable and understanding. So I think it's important when you're looking through challenges like this to make sure you're talking about it beforehand. So most problems can be avoided or most challenges in terms of human nature can be avoided if you talk to the people beforehand.
So in our unit, we kind of talked about the guideline in a division meeting before it went live. There was some feedback from the medical team and we made those changes. And I think that process made the implementation a little smoother. But yeah, I think in all quality improvement, human nature is the most challenging thing.
Srirupa (18:21.166)
For sure, for sure. I totally agree with that. Throughout your fellowship, I'm pretty sure the quality improvement initiative that you took sort of led you to different directions of sort of adding additional courses and training. Could you tell me a little bit more about how your fellowship program supported this quality improvement interest in you and how you're exploring your future in quality improvement?
Shayla Percy (18:45.279)
Absolutely. So here at Children's Hospital of Pittsburgh and UPMC at large, we have a kind of adjacent center. So it's called the Wolf Center that is focused on quality improvement. And I recognize that that is a blessing and not all institutions have that kind of built in quality improvement support. So I was very fortunate to have that. And one of the things that this center does is they offer
courses throughout the year. So they have a basic education series that gets you started with quality improvement and then you can apply into the advanced series. And the goal of these series is to bring in kind of quality improvement experts throughout the country to do lectures probably every one to two months. And then you also are assigned a mentor who is specifically a quality improvement person who will help you
kind of take a project from the beginning stages through. So that's been a really amazing experience and it's been incredibly helpful where I have both my mentors on the quality side of things, or sorry, on the medical side of things in the NICU, and then I also have this quality side of things. So Stephanie Nock and Katie have been amazing in...
helping me from a quality side of things bring this project the whole way through.
Srirupa (20:17.37)
That's amazing. And I think through fellowship, I feel like fellowship is the best time of your career just because you get to explore what you truly, truly desire in your most favorite area of interest. And so it's just amazing that you took your quality improvement interest to another level and got these courses done and are pursuing them. That's amazing. I would also like to sort of highlight that you won the AAP's Young Investigator Award for this project.
That is amazing. Congratulations. Tell me a little bit about how that happened and how your experience had been at AAP.
Shayla Percy (20:48.657)
Thank
Shayla Percy (20:55.622)
Yeah, so I, to be totally honest, did not know that this Young Investigator Award was a thing prior to going through the process.
Srirupa (21:07.896)
Like most of us, like most of us. think we just come into fellowship, just doing fellowship, and then we try to learn all of these things in the background. So like all of us.
Shayla Percy (21:15.418)
Exactly. Exactly. So yeah, so I had sat down with my kind of mentorship team and we had figured out what conferences I had wanted to apply to. Mostly did have some deadlines for, you let's get to this point in my project by this date so we can submit to this conference. And the AAP conference was one of those deadlines. So I, you know, I think I got my project started early enough in my first year to really have
a good result by the deadline kind of end of second year, early third year, which I think is probably important for any type of award like that. need a finished, almost finished product.
Srirupa (21:59.482)
Absolutely.
Shayla Percy (22:00.412)
So I applied to the AAP conference. I got an email at some point that I had entered the category of the top 10 abstracts that were submitted for TCAN members, essentially, which also was a shock. I didn't know that was a thing, but it was super exciting. And then I went to the AAP conference where I had a platform presentation.
And I went through the platform presentation. I practiced a ton, probably an insane amount. I can probably do that presentation in my sleep now. And then I went through the rest of the conference, which was amazing. It's a really fantastic place to kind of network and meet people and just have conversations about neonatology. And then one of the Sunday sessions, they asked all of the individuals who had
had those top 10 abstracts to make sure they attended that session. And I attended, I had listened to all of the other abstracts, they were fantastic. There were tons of really amazing scientific explorations that were going on. So I was not expecting anything. And then they announced it. And it was very shocking because I typically don't think of quality improvement work as kind of these things that go up for awards. Like you think of these really amazing
basic science or clinical translational research that they're making these huge impacts. So it was really surprising, but it was really exciting as well.
Srirupa (23:37.614)
That's amazing. think that's, that's unfortunately the way people think of quality improvement is, it's simple, but in all honesty, it's probably the most difficult research to conduct because you, as you rightly pointed out, have to get not just one individual to agree to do a quality improvement. It's such a big teamwork that it takes a whole village to improve things in the NICU and neonatology as we know has.
tons and tons of opportunities for quality improvement at so many levels possible. And so it's great that you got onto this project. It's amazing that the work that you're doing has such significant impact on something that we tend to not know obviously, right? Like I feel like fractures are something that we think about, but it's not so obvious. Like we think about respiratory depression. We think about cardiac dysfunction. We think about nutrition so much, but then
Fractures are so important too, and we tend to not think about it as much, which is very important. And your study clearly highlights that we have to make every effort to do it, even if it means a simple sign at bedside that says, okay, my bones are fragile. That's amazing. So we're coming to the end of our interview, and I would love for you to give one good teaching point out of your experience doing this quality improvement project.
Shayla Percy (24:44.524)
Mm-hmm.
Srirupa (24:57.646)
for any potential incoming fellows who might be interested in taking the quality improvement pathway.
Shayla Percy (25:04.511)
Ooh, okay, one thing. So I think the most important thing, particularly if you're moving to a new institution, is to just talk to people. People already know what the issues are, and you can very easily get this running list of possible projects. I have on my phone this quality improvement projects to think about. So just talking to people.
And it doesn't have to be a targeted conversation of, I'm looking for a project. Just talk about like, hey, I noticed this is different from the unit that I was at. What do you guys do here? And it's super easy for these things to pop up. You don't need to have a huge issue. You can start with something super small and build it into a really amazing project and have huge impact on your patients.
So I think the most important thing is just be curious, talk to people. Things are going to work out even in ways that you're not expecting, but just talk to people.
Srirupa (26:12.13)
Awesome. So Shayla, one final question. What are your next steps in your career? I see that you're almost six months into your 30 or so. I'm presuming that you're probably interviewing or completed interviewing process. So tell us a little bit about that. Share if you'd love to.
Shayla Percy (26:27.977)
yeah, so I'm super excited. I get to stay on as faculty at Pittsburgh. So I am seemingly going to be a lifer and do all of my training and stay on as an attending at Pittsburgh, but I'm really excited to be able to stay.
Srirupa (26:45.434)
That's wonderful. think Pittsburgh would be really lucky to have you on. And I'm pretty sure that you're going to continue your lifelong journey of improving the quality of our amazing patients. And you'll have so much of impact to give to our quality improvement in neonatology. Congratulations. And thank you so much for being on the show and sharing your experiences as a fellow doing a quality improvement project. I'm so glad you were able to make it today.
Shayla Percy (27:01.589)
Thank you.
Shayla Percy (27:11.051)
Thank you so much for having me.
Srirupa (27:13.368)
Awesome, thank you, bye.
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