Infectious Disease Screening and Vaccinations Guidelines for Patients Initiating Immunosuppression for Dermatologic Conditions: A Multidisciplinary Design and Quality Improvement Initiative.

INTRODUCTION: Gastrointestinal (GI) complications in patients undergoing orthopedic surgery are common but underreported. Prolonged immobility and the use of post-operative narcotics can increase the risk of GI complications which include: constipation, ileus, bowel obstruction, stercoral colitis, perforation, and death. In 2017 we observed an increase in GI complications among patients undergoing orthopedic surgery at our orthopedic hospital. This prompted a multidisciplinary quality improvement (QI) initiative to reduce GI complications among patients admitted after joint or spine surgery. METHODS: Following a surge of GI complications at our university-affiliated tertiary referral orthopedic satellite hospital in early 2018 we created a multidisciplinary QI program. The first component was a didactic lecture delivered by a GI attending to the orthopedic trainees, attendings, physician extenders, nurses and staff. The 1 hour lecture discussed an effective GI history, exam and reviewed the symptoms and treatment of common GI conditions affecting post-operative patients. The second component was the development of a post-operative constipation and bowel assessment algorithm focused on early identification, escalation and treatment of GI conditions (Figure 1). The third component was a redesign of the electronic medical record post-operative constipation order sets in order to facilitate implementation of the aforementioned bowel algorithm. This new order set changed laxative orders from “as needed” to standing with an option to be held for diarrhea. These QI initiatives were implemented on a rolling basis from 1/31/2018 to 5/31/2018. Cases of ileus, obstruction and perforation were determined based on coding for admitted orthopedic patients. RESULTS: The proportion of patients admitted with each diagnosis was compared from the first quarter (1/1 to 3/31) of 2018 to 2019 corresponding to 6 months after the implementation of all QI components (Figure 2). We achieved a 71% reduction in overall bowel complications (P < 0.05). The greatest reduction was achieved in post-operative ileus by 81% (P < 0.05). Following the QI initiative there was only 1 perforation corresponding to a 50% reduction. CONCLUSION: We created a multidisciplinary QI program that successfully reduced GI complications in patients hospitalized following orthopedic surgery. The greatest impact was in the reduction of post-operative ileus and serious adverse events such as perforation.

BackgroundPenicillin (PCN) allergies are reported in up to 10% patients and are associated with adverse clinical and antimicrobial stewardship outcomes. Here we describe a multidisciplinary quality improvement (QI) initiative to facilitate PCN delabeling at a large urban hospital.MethodsStarting in August 2020, the departments of Allergy and Infectious Diseases (ID) began a joint QI effort to employ a part time allergist nurse practitioner (ANP) for PCN allergy assessment and delabeling. The ANP used a daily system generated list to identify and assess adult patients with PCN allergy and contact teams to request a consult. An ID fellow also assisted with identifying patients and contacting care teams. The ANP then offered skin/oral PCN challenge or direct label removal based on history after discussion with an allergist physician. Baseline, clinical, and allergy characteristics were compared between patients delabeled and not delabeled using Chi-square and Mann-Whitney U test. Primary endpoints were antibiotic utilization outcomes from index admission post ANP assessment to 30-days post discharge. Secondary endpoints included readmission, length of stay (LOS), mortality, and sustained removal of the PCN allergy at 30-days.ResultsBetween 30 August 2020 and 6 May 2021 (250 days), 139 PCN allergic patients were assessed (81 delabeled versus 58 not delabeled) (Figure 2). Some patients (37%) were delabeled via history alone, while 63% had further skin/oral testing. Baseline characteristics were similar between groups (Table 1). In the delabeled group, we observed increased narrow-spectrum PCN use (p< 0.001), and decreased vancomycin (p< 0.001), fluoroquinolone (p=0.013), carbapenem (p< 0.011), and overall restricted antimicrobial use (Table 2). Rates of 30-day readmission, LOS, and mortality were comparable. Four (5%) of delabeled patients had had PCN allergy re-entered in the chart at 30-days.Patients were similar between groups on all baseline clinical and allergy characteristics except for more patients with infection classified as “other” in the non-delabeled group.In the delabeled patients, we observed increased narrow-spectrum PCN use and decreased vancomycin, fluoroquinolone, carbapenem, and overall restricted antimicrobial use. Use of first and second generation cephalosporines was comparable between groups. Rates of 30-day readmission, LOS, and mortality were comparable.ConclusionThis QI effort between the departments of Allergy and ID to employ an ANP increased narrow spectrum antibiotic use and reduced use of restricted antimicrobials. Challenges included the part time position of the ANP unable to see every patient, reemergence of allergy in the chart, and clinical or other exclusions for delabeling (Fig 3).DisclosuresAll Authors: No reported disclosures

e18640 Background: Delays in diagnosis and treatment have been identified as practice gaps in lung cancer management. At our large safety-net hospital, 2016-2018 data provided by the Commission on Cancer (CoC) indicated that 58-66% of lung cancer patients began treatment &gt; 30 days after their diagnosis, compared to a median of 30 days for CoC-accredited hospitals. A quality improvement (QI) project was performed to identify causes for treatment delays, and to implement changes to reduce the median time from diagnosis to treatment to &lt; 30 days. Methods: Root cause analysis was performed on a cohort of lung cancer patients identified and abstracted by the CoC Registry with diagnosis in October 2018-September 2019, to provide more recent data on treatment delays and to identify actionable interventions. Subsequently, a multidisciplinary QI initiative through Thoracic Surgery, Hematology Oncology, and Radiation Oncology was implemented using the Plan-Do-Study-Act (PDSA) tool. The initiative was tracked for 6 months starting in August 2020, with time from referral to consult and time from diagnosis to treatment calculated via chart review. Results: For the root cause analysis, 36 patients were identified. Eleven cases were excluded as they did not receive treatment at our institution. For the remaining 25 patients, the median time from referral to consult across all three oncology specialties was 13 days. The most common barriers to initiating treatment were appointment scheduling delays (37.5%), patient factors including synchronous malignancies or insurance, geographic or cultural barriers (31.3%), and multiple factors including appointment scheduling delays (25%). Median time from diagnosis to treatment was 31 days, with 36% (N = 9) starting treatment in &lt; 30 days. While appointment scheduling delays included both work-up (imaging, procedures) and consults as well as follow-ups, multidisciplinary discussions identified time from referral to consult as the most actionable QI initiative. With support from Patient Navigation, the three oncology specialties jointly implemented a system whereby suspected or confirmed new lung cancer patients were scheduled for consult ideally in &lt; 7 days, and no more than 14 days from the referral date. Of 28 new lung cancer patients who started treatment after the QI intervention, median time from referral to consult decreased to 7 days. Median time from diagnosis to treatment decreased to 26.5 days, with 53.6% (N = 15) of patients starting treatment in &lt; 30 days. Conclusions: By decreasing time from referral to consult, this multidisciplinary QI intervention facilitated earlier initiation of treatment for lung cancer patients. Similar actions to decrease other scheduling delays and mitigate the impact of social determinants of health could further promote improvements in timely patient care.

Geriatric Recovery and Enhancement Alliance in Trauma (GREAT) multidisciplinary quality improvement initiative: improving rates of successful resuscitation, rehabilitation and reintegration of geriatric trauma patients across the trauma spectrum of care. Sandy Widder, Kristin E. Morch, Nori L Bradley, Lauren Ternan, Ni Thuyen Lam Background: Traumatic injuries are a significant cause of morbidity and mortality in the elderly, with the risk of poor outcomes increasing with advanced age. Using a multidisciplinary geriatric trauma care approach, led by a dedicated nursing coordinator, standardized order sets were implemented to reduce in-hospital complications and screening tools applied early to identify patient specific care needs. Specifically, early trauma consult, identification of injuries, appropriate opioid ordering, polypharmacy avoidance, delirium prevention, mental health issues, and mobility needs were addressed The goal was to improve geriatric trauma awareness, decrease in-hospital complications and improve the likelihood of return to home and baseline function Implementation: Through stakeholder consultation process, it was recognized that the hospital needed a coordinated, geriatric trauma team process. The geriatric trauma navigator (GTN) role was created to lead these quality improvement initiatives. This included the development of educational strategies for frontline staff and physicians to highlight the unique challenges of trauma patient management and to introduce the GREAT study for optimized patient care. Patients 65 years of age or older with a traumatic mechanism were enrolled. GREAT patients then followed a protocol designed for tracking and implementing standardized processes, including early ED and in-patient order sets, engagement of trauma services, and the application of screening tools and specialty consultations. Screening tools (Identification of Seniors At Risk (ISAR), Confusion Assessment Method (CAM), Mini-Cog, Patient Health Questionnaire (PHQ-2), Geriatric Depression Scale (GDS-15), Alcohol Use Disorders Identification Test- Concise (AUDIT-C), Canadian Nutrition Screening Tool (CNST), Clinical Frailty Scale, ADL/IDLs) were administered to identify at-risk patients and to inform consultation with geriatrics and psychiatry, and allied health services (occupation therapy, physical therapy, nutrition services, pharmacy). The study team evaluated data on a monthly basis and met quarterly to evaluate and implement changes. Evaluation Methods: Data was prospectively collected and compared to control data from the Alberta Trauma Registry and Trauma Quality Improvement Program (American College of Surgeons). Data tabulation and statistical analysis was performed using Stat59 (STAT59 Services Ltd, Edmonton, AB, Canada). Outcome measures-provision of timely and comprehensive care: rates of trauma team activations, emergencydepartment and in-hospital length of stay-reduction of hospital complications: UTI, DVT/PE, pneumonia, pressure ulcers, ICUadmission, unexpected readmission to hospital-improvement of functionality upon discharge: in-hospital and 30 day mortality rates,return to function, disposition (home versus long term care) Process measures-time to diet and ambulation-tracking of number of days of urinary catheter in situ-compliance with GOC discussions-use of assessment screening tools-spinal clearance &lt;24 hours Results: Enrollment of patients into GREAT based on study criteria lowered the threshold for triggering a trauma team consult, improving the recognition rate of geriatric trauma. This was reflected in the decreased average ISS scores and higher rate of trauma consults. Ground level falls, which previously did not typically activate a trauma consult, are now be recognized as major trauma. With the GTN, we determined that gaps exist in the current monitoring of key performance measures. Through the GREAT data collection process, we were able to establish baseline data and target PDSA changes to address these gaps. Advice and Lessons Learned: This quality initiative was designed as a proof of concept model for early identification of the geriatric trauma patient and a collaborative team approach to optimize care processes, and in turn minimize complications. The GTN role was vital to identify patients, implement screening tools, and coordinate care. With limited resources and increasing work loads for all programs, the additional GTN role required site leadership and stakeholder support. Ideally, a protocolized geriatric trauma team activation and admission process would ensure all patients receive screening tools as part of their in-patient orders for early assessments and interventions. Further educational campaigns will need to be developed to increase awareness of the importance of geriatric trauma. Additionally, processes need to be streamlined for data gathering and monitoring of performance measures. Access to screening tools and order sets need to be user friendly, built into currently existing workflows, and evaluated for optimization.

Although kidney transplant recipients at the authors' institution had a short length of stay (LOS), delayed discharges and early readmissions were common; medication use and safety were at the core of these issues. A multidisciplinary quality improvement initiative was developed that targeted eliminating these issues. The team developed key initiatives including improved medication reconciliation, development of a diabetes management service, and improved discharge medication dispensing, delivery, education, and scrutiny. Follow-up analysis demonstrated reduced medication discrepancies by >2 per patient and obtaining 100% adherence with reconciliation. Pharmacists reviewed discharge medications, reaching 100% by study end, leading to a 40% reduction in medication safety issues. LOS remained short, and delayed discharges were reduced by 14%; 7-day readmission rates decreased by 50%. Acute rejection and infection rates also significantly decreased. In conclusion, a multidisciplinary quality improvement initiative can improve medication safety in kidney transplant patients, which can lead to improved clinical outcomes.

The majority of opioid analgesics prescribed for pain after ambulatory pediatric surgery remain unused. Most parents do not dispose of these leftover opioids or dispose of them in an unsafe manner. We aimed to evaluate the association of optimal opioid disposal with a multidisciplinary quality improvement (QI) initiative that proactively educated parents about the importance of optimal opioid disposal practices and provided a home opioid disposal kit before discharge after pediatric ambulatory surgery. Opioid disposal behaviors were assessed during a brief telephone interview pre- (Phase I) and post-implementation (Phase II) after surgery. For each phase, we aimed to contact the parents of 300 pediatric patients ages 0 to 17 years who were prescribed an opioid after an ambulatory surgery. The QI initiative included enhanced education and a home opioid disposal kit including DisposeRX ® , a medication disposal packet that renders medications inert within a polymeric gel when mixed with water. Weighted segmented regression models evaluated the association between the QI initiative and outcomes. We considered the association between the QI initiative and outcome significant if the beta coefficient for the change in intercept between the end of Phase I and the beginning of Phase II was significant. Safe opioid disposal and any opioid disposal were evaluated as secondary outcomes. The analyzed sample contained 161 pediatric patients in Phase I and 190 pediatric patients in Phase II. Phase II (post-QI initiative) cohort compared to Phase I cohort reported higher rates of optimal (58%, n = 111/190 vs 11%, n = 18/161) and safe (66%, n = 125/190 vs 34%, n = 55/161) opioid disposal. Weighted segmented regression analyses demonstrated significant increases in the odds of optimal (odds ratio [OR], 26.5, 95% confidence interval [CI], 4.0-177.0) and safe (OR, 4.4, 95% CI, 1.1-18.4) opioid disposal at the beginning of Phase II compared to the end of Phase I. The trends over time (slopes) within phases were nonsignificant and close to 0. The numbers needed to be exposed to achieve one new disposal event were 2.2 (95% CI, 1.4-3.7]), 3.1 (95% CI, 1.6-7.4), and 4.3 (95% CI, 1.7-13.6) for optimal, safe, and any disposal, respectively. A multidisciplinary approach to educating parents on the importance of safe disposal of leftover opioids paired with dispensing a convenient opioid disposal kit was associated with increased odds of optimal opioid disposal.

Pseudomonas aeruginosa infection causes high morbidity and mortality, especially in immunocompromised patients. Pseudomonas can develop multidrug resistance. As a result, it can cause serious outbreaks in hospital and intensive care unit (ICU) settings, increasing both length of stay and costs. In the second quarter of 2020, in a community hospital's 15-bed ICU, the P. aeruginosa-positive sputum culture rate was unacceptably high, with a trend of increasing prevalence over the previous 3 quarters. We performed a multidisciplinary quality improvement (QI) initiative to decrease the P. aeruginosa-positive rate in our ICU. We used the Define, Measure, Analyze, Improve, and Control model of Lean Six Sigma for our QI initiative to decrease the P. aeruginosa-positive sputum culture rate by 50% over the following year without affecting the baseline environmental services cleaning time. A Plan-Do-Study-Act approach was used for key interventions, which included use of sterile water for nasogastric and orogastric tubes, adherence to procedure for inline tubing and canister exchanges, replacement of faucet aerators, addition of hopper covers, and periodic water testing. We analyzed and compared positive sputum culture rates quarterly from pre-intervention to post-intervention. The initial P. aeruginosa-positive culture rate of 10.98 infections per 1,000 patient-days in a baseline sample of 820 patients decreased to 3.44 and 2.72 per 1,000 patient-days in the following 2 post-intervention measurements. Environmental services cleaning time remained stable at 34 minutes. Multiple steps involving all stakeholders were implemented to maintain this progress. A combination of multidisciplinary efforts and QI methods was able to prevent a possible ICU P. aeruginosa outbreak.

367 Background: ASCO Guidelines recommend oncologists conduct serious illness conservations (SIC) for all patients with advanced cancer. We describe the spreading of a multidisciplinary and patient-family advisor (PFA) quality improvement (QI) initiative to conduct routine SIC at a NCI-designated comprehensive cancer center. Methods: This single center study describes the second phase of a learning health system initiative to conduct routine SIC for all seriously ill patients with cancer. Prior work completed included defining patient eligibility (e.g. two-year surprise question), and deploying a SIC template in the electronic health record (EHR) to capture SIC in a centralized location. Phase II can be categorized into three steps: a) increasing communication coach and PFA capacity; b) refining EHR tools to automate tracking and reporting of outcomes; and c) adoption of the Model for Improvement as the QI methodology to guide testing and implementation. For the first three months, each team engaged in preparatory work including: process mapping, key driver diagram development, and SIC Guide training. In the last six months, each team met weekly to set their own team goals, conducted iterative PDSAs, and reviewed run charts of their performance. Patient-level data on SIC documentation was collected through automated EHR tools and provided to the teams on a weekly basis. Results: Over nine months (3/1/2021 to 12/31/21), four teams screened 510 patients with cancer, identified 272 (53%) patients as eligible for SIC, and 178 (65%) of those eligible had a documented SIC from a baseline of 0%. The breakdown of this combined SIC patient count by clinician author is as follows: team A 40 (22%); team B 45 (25%); team C 9 (5%); team D 14 (8%) and specialty palliative care 70 (39%). Each team set modest, initial SIC documentation goals (range 5-15%), and attainment of first SIC documentation goal varied (range 2 to 4 months). We retained all clinician team members during the study period, but 2 out of 3 PFAs left by study period end. Noted challenges with PFA recruitment and retention included: lengthy recruitment, integration into clinical teams, and resistance to change by teams. Conclusions: The multidisciplinary approach, inclusive of specialty palliative care, increased SIC documentation. PFA involvement, as implemented, met with challenges and yielded mixed results. Additional follow-up will be required to assess if gains can be sustained and/or increased.

Implementation of a multidisciplinary quality improvement project standardizing an approach to screening and treating iron deficiency in pregnancy

Big Data, Predictive Analytics, and Quality Improvement in Kidney Transplantation: A Proof of Concept.

Where’s my med? Improving patient-specific medication storage for emergency department boarders

Background: Pediatric, adolescent and young adult (PAYA) patients are less active than their healthy counterparts, particularly during inpatient stays. Methods: We conducted a quality improvement initiative to increase activity levels in patients admitted to our pediatric oncology and cellular therapy unit using a Plan-Do-Study-Act (PDSA) model. An interdisciplinary team was assembled to develop an incentive-based inpatient exercise and activity program titled Totally Excited About Moving Mobility and Exercise (TEAM Me). As part of the program, patients were encouraged by their care team to remain active during their inpatient stay. As an additional incentive, patients earned stickers to display on TEAM Me door boards along with tickets that could be exchanged for prizes. Activity was assessed by documentation of physical therapy participation, tests of physical function, and surveys of staff perceptions of patient activity levels, motivations, and barriers. Results: Compared to baseline, patient refusals to participate in physical therapy decreased significantly (24% vs. 2%) (p < 0.02), and staff perceptions of patient motivation to stay active increased from 40% to 70% in the post implementation period. There were no changes in physical function tests. Conclusions: An incentive-based exercise program for young oncology inpatients greatly improved patient activity levels, participation in physical therapy and influenced professional caregivers’ beliefs.

BackgroundAt Stanford, two surgical wards, E3 and F3, were responsible for 1/5 of hospital-acquired Clostridioides difficile infection (HO CDI) cases in the fiscal year 2018 (FY2018). We used a quality improvement framework with a goal to reduce yearly HO CDI episodes by 1/2 on these wards.MethodsA multidisciplinary quality improvement team was created with frontline nursing leaders and representatives from colorectal surgery, gynecology oncology, antimicrobial stewardship (ASP), infection prevention, and pharmacy. Coaching and instruction on quality improvement were provided as part of Stanford’s “Realizing Improvement through Team Empowerment” (RITE) program. Using A3 problem solving, root cause analysis identified key drivers, and interventions were performed. Cumulative HO CDI cases in FY2019 and weekly antibiotic days of therapy (DOT) on E3/F3 were monitored.ResultsReview of FY2018 HO CDI cases (n = 14) revealed the most common key driver as inappropriate antibiotic prescribing (8 cases, 57%). Multiple interventions were instituted (Figure 1). Three ASP interventions began February 2019: nursing questioned antibiotic choice/duration on daily interdisciplinary rounds (Figure 2), automatic infectious disease consultation for > 72 hours of piperacillin/tazobactam on gynecology/oncology patients, and twice-weekly rounds between ASP and a colorectal attending. Data from ASP/colorectal rounds from March 19, 2019 to April 16, 2019 showed means of 18.2 minutes taken for chart review and 4.4 minutes for discussion. 25 charts reviewed led to 16 (64%) ASP recommendations and 14/16 (87.5%) of recommendations accepted. Common interventions included: appropriate duration of antibiotics, clarification of the team’s planned duration, and review of microbiology data to narrow therapy. Mean DOT decreased from 35.28 to 21.61 (39%) since July 2018 (Figure 3). Patient volume and case mix index remained stable throughout, suggesting no impact on DOT. Though CDI cases did not decrease, interventions were in place for only 2 months (Figure 4).ConclusionWhile too early to determine its impact on HO CDI rates, a multi-disciplinary team approach utilizing A3 problem solving was successful in implementing effective ASP measures including nursing-led ASP and structured antibiotic timeouts.DisclosuresAll authors: No reported disclosures.

Background and study aims In this study, we evaluated the performance of community hospitals involved in the Dutch quality in endosonography team regarding yield of endoscopic ultrasound (EUS)-guided tissue acquisition (TA) of solid pancreatic lesions using cumulative sum (CUSUM) learning curves. The aims were to assess trends in quality over time and explore potential benefits of CUSUM as a feedback-tool. Patients and methods All consecutive EUS-guided TA procedures for solid pancreatic lesions were registered in five community hospitals between 2015 and 2018. CUSUM learning curves were plotted for overall performance and for performance per center. The American Society of Gastrointestinal Endoscopy-defined key performance indicators, rate of adequate sample (RAS), and diagnostic yield of malignancy (DYM) were used for this purpose. Feedback regarding performance was provided on multiple occasions at regional interest group meetings during the study period. Results A total of 431 EUS-guided TA procedures in 403 patients were included in this study. The overall and per center CUSUM curves for RAS improved over time. CUSUM curves for DYM revealed gradual improvement, reaching the predefined performance target (70 %) overall, and in three of five contributing centers in 2018. Analysis of a sudden downslope development in the CUSUM curve of DYM in one center revealed temporary absence of a senior cytopathologist to have had a temporary negative impact on performance. Conclusions CUSUM-derived learning curves allow for assessment of best practices by comparison among peers in a multidisciplinary multicenter quality improvement initiative and proved to be a valuable and easy-to-interpret means to evaluate EUS performance over time.

To evaluate and increase adherence to an evidence-based audiologic management protocol for children with cleft palate. Prospective, multidisciplinary quality improvement initiative. Tertiary pediatric hospital. Children with cleft palate (with or without cleft lip) between the ages of 0 and 5 years (n = 205). A multidisciplinary team identified key drivers for nonadherence to recommended audiological follow-up and implemented interventions to improve adherence. Key drivers included provider practices and preferences, clinic logistics and flow, and patient/family awareness and education. Several interventions were implemented between 2016 and 2020, including developing an evidence-based audiologic protocol, maximizing access to audiologic clinic visits across multiple departments, cleft team education, and improved team communication. Completion of recommended audiologic assessment at 5 separate care milestones. After implementation of interventions between 2016 and 2020, adherence to recommended audiologic follow-up increased from 59% to 84%. Analysis of individual care milestones revealed that increased access to audiologic testing during team clinics resulted in the largest increase in adherence to recommended follow-up. Additionally, cause-effect analysis revealed that nonadherence due to provider-related causes decreased over the project period to a greater extent than patient/family-related causes. Implementation of an evidence-based audiologic care protocol and improvements in access to early hearing care are feasible in a high-volume multidisciplinary cleft clinic. Adherence to recommended audiologic management can be improved by establishing strategies to improve access to care, team member and family education, and enhanced team communication.