Evidence-based Care Processes Research Articles

Association of National Accreditation Program for Rectal Cancer Accreditation with Outcomes after Rectal Cancer Surgery.

The National Accreditation Program for Rectal Cancer (NAPRC) defined a set of standards in 2017 centered on multidisciplinary program structure, evidence-based care processes, and internal audit to address widely variable rectal cancer practices and outcomes across U.S. hospitals. There have been no studies to-date testing the association between NAPRC accreditation and rectal cancer outcomes. This was a retrospective, observational study of Medicare beneficiaries aged 65-99 years with rectal cancer who underwent proctectomy from 2017-2020. The primary exposure was NAPRC accreditation and the primary outcomes included mortality (in-hospital, 30-day, 1-year) and 30-day complications, readmissions, and reoperations. Associations between NAPRC accreditation and each outcome were tested using multivariable logistic regression with risk-adjustment for patient and hospital characteristics. Among 1,985 hospitals, 65 were NAPRC accredited (3.3%). Accredited hospitals were more likely to be nonprofit and teaching with ≥ 250 beds. Among 20,202 patients, 2,078 patients (10%) underwent proctectomy at an accredited hospital. Patients at accredited hospitals were more likely to have an elective procedure with a minimally invasive approach and sphincter preservation. Risk-adjusted in-hospital mortality (1.1% vs. 1.3%; p=0.002), 30-day mortality (2.1% vs. 2.9%; p<0.001), 30-day complication (18.3% vs. 19.4%; p=0.01), and 1-year mortality rates (11.0% vs. 12.1%; p<0.001) were significantly lower at accredited compared to non-accredited hospitals. NAPRC accredited hospitals have lower risk-adjusted morbidity and mortality for major rectal cancer surgery. Although NAPRC standards address variability in practice, without directly addressing surgical safety, our findings suggest that NAPRC accredited hospitals may provide higher quality surgical care.

A quasi-experimental evaluation of the association between implementation of Quality-Based Procedures funding for hip fractures and improvements in processes and outcomes for hip fracture patients in Ontario: an interrupted time series analysis.

In 2013, Ontario introduced a patient-based funding model for hip fracture care (Quality-Based Procedures [QBP]). The association of QBP implementation with changes in processes and outcomes has not been evaluated. We conducted a quasi-experimental study using linked health data for adult hip fractures as an interrupted time series. The pre-QBP period was from 2008 to 2012 and the post-QBP period was from 2014 to 2018; 2013 was excluded as a wash-in period. We used segmented regression analyses to estimate the association of QBP implementation with changes in processes (surgery in less than two days from admission, use of echocardiography, use of nerve blocks, and provision of geriatric care) and clinical outcomes (90-day mortality, 90-day readmissions, length of stay, and days alive at home). We estimated the immediate (level) change, trend (slope) postimplementation, and total counterfactual differences. Sensitivity analyses included case-mix adjustment and stratification by hospital type and procedure. We identified 45,500 patients in the pre-QBP period and 41,256 patients in the post-QBP period. There was a significant total counterfactual increase in the use of nerve blocks (11.1%; 95% confidence interval [CI], 6.2 to 16.0) and a decrease in the use of echocardiography (-2.5%; 95% CI, -3.7 to -1.3) after QBP implementation. The implementation of QBP was not associated with a clinically or statistically meaningful change in 90-day mortality, 90-day readmission, length of stay, or number of days alive at home. Evaluation of the QBP program is crucial to inform ongoing and future changes to policy and funding for hip fracture care. The introduction of the QBP Hip Fracture program, supported by evidence-based recommendations, was associated with improved application of some evidence-based processes of care but no changes in clinical outcomes. There is a need for ongoing development and evaluation of funding models to identify optimal strategies to improve the value and outcomes of hip fracture care. Open Science Framework ( https://osf.io/2938h/ ); first posted 13 June 2022.

Engaging Older Adults and Families Using the IDEAL Discharge Protocol: A Quality Improvement Initiative to Improve Outcomes and Reduce Readmissions.

Older adults have challenges understanding newly prescribed medications after discharge and must be more adherent with medications and follow up with their primary care provider. A collaborative discharge process is critical to improving patient outcomes and reducing avoidable readmission rates. This quality improvement (QI) initiative engaged 44 patients and families in the IDEAL Discharge Protocol-an evidence-based collaborative care process focused on discussion, education, and post-discharge follow up. Post-discharge follow up resulted in the completion of 52.2% of follow-up calls and 45.5% of follow-up appointments scheduled, and a 4% reduction in readmission rates. Medication adherence was assessed and found to be 93.3%, and 100% of participants received education while engaged in the study. The IDEAL Discharge Protocol aided in improving the discharge process to better equip patients with the tools to transition home successfully after discharge. [Journal of Gerontological Nursing, 49(10), 13-19.].

Implementation of geriatric screening in the emergency department using the Consolidated Framework for Implementation Research.

Implementation of evidence-based care processes (EBP) into the emergency department (ED) is challenging and there are only a few studies of real-world use of theory-based implementation frameworks. We report final implementation results and sustainability of an EBP geriatric screening program in the ED using the Consolidated Framework for Implementation Research (CFIR). The EBP involved nurses screening older patients for delirium (Delirium Triage Screen), fall risk (4-Stage Balance Test), and vulnerability (Identification of Seniors at Risk score) with subsequent appropriate referrals to physicians, therapy specialists, or social workers. The proportions of screened adults ≥65 years old were tracked monthly. Outcomes are reported January 2021-December 2022. Barriers encountered were classified according to CFIR. Implementation strategies were classified according to the CFIR-Expert Recommendations for Implementing Change (ERIC). Implementation strategies increased geriatric screening from 5% to 68%. This did not meet our prespecified goal of 80%. Change was sustained through several COVID-19 waves. Inner setting barriers included culture and implementation climate. Initially, the ED was treated as a single inner setting, but we found different cultures and uptake between ED units, including night versus day shifts. Characteristics of individuals barriers included high levels of staff turnover in both clinical and administrative roles and very low self-efficacy from stress and staff turnover. Initial attempts with individualized audit and feedback were not successful in improving self-efficacy and may have caused moral injury. Adjusting feedback to a team/unit level approach with unitwide stretch goals worked better. Identifying early adopters and conducting on-shift education increased uptake. Lessons learned regarding ED culture, implementation in interconnected health systems, and rapid cycle process improvement are reported. The pandemic exacerbated barriers to implementation in the ED. Cognizance of a large ED as a sum of smaller units and using the CFIR model resulted in improvements.

Evidence-Based Practice (EBP) evaluation rubric for MSN students

A rubric is a measurement tool used in assessment that recognizes the criteria for completing the tasks and provides standards for each level of performance. The use of rubrics enables educators to formulate standards and explicit grading for the students. Moreover, it provides clear guidelines to the learners regarding task expectations. Improvement in nursing research has made implementing evidence-based practice feasible for nursing students. The adoption of evidence-based care process is relatively slow in the context of nursing and there is a gap in implementing evidencebased practice in a clinical setting. The culture of evidence-based care can be adopted by enhancing the student nurses' knowledge, skills, and attitude (DiCenso et al., 1998). Educators need to formulate their teaching and assessment methodologies in a way to compel their students for achieving cognitive thinking. The higher level of competencies may be inculcated in students through involving and assessing them in evidence-based, rationalized methodologies to enhance their level of critical thinking, skills, independence, and decision-making in the provision of care. The guidelines developed for the assessment of nursing students' Evidence-Based Practice need further modification with clear measurement and level of quality for reaching each level of performance. A composite analytic rubric is suggested to use when educators assess complex skills and clinical performance of nursing students. It provides complete feedback and reduces subjectivity to a great extent due to its comprehensive dimensions. It provides a common basis of judgment, and justification in feedback and enables the teacher to make a fair, valid, and reliable judgment. Moreover, it helps students identify their strengths and weaknesses and formulate their efforts for improvement.

Processes of Care and Associated Factors in Patients With Stroke by Immigration Status.

Receiving evidence-based stroke care processes is associated with good clinical outcome. However, data on early stroke care among immigrants are scarce. We investigated whether guideline-recommended acute stroke care and associated factors differ between immigrants and Danish-born residents. Patients admitted with ischemic and hemorrhagic stroke diagnoses (n=129,724) between 2005 and 2018 were identified from the Danish Stroke Registry. We included 123,928 Danish-born residents and 5796 immigrants with stroke. Compared with Danish-born residents, immigrants were less likely to be admitted to a stroke unit within 24 hours after stroke onset (81.5% vs. 83.9%, P <0.001) and had lower odds of early stroke care including dysphagia screening, physiotherapy, occupational therapy, and nutritional assessment. After adjustment for age, sex, clinical, and sociodemographic factors, immigrants had lower odds of early stroke unit admission (odds ratio [OR]: 0.97; 95% CI, 0.94-0.99), early dysphagia screening (OR: 0.96; 95% CI, 0.93-0.98), early physiotherapy (OR: 0.96; 95% CI, 0.94-0.99), and early occupational therapy (OR: 0.96; 95% CI, 0.93-0.98) than Danish-born residents. Small absolute differences in overall quality of stroke care were found when comparing immigrants and Danish-born residents. Significant factors associated with greater likelihood of stroke care included high income, high education, and cohabitation. Immigrants had lower chances of early stroke unit admission and received fewer individual early stroke care processes such as dysphagia screening, physiotherapy and occupational therapy than Danish-born residents. However, the absolute disparities were in general minor and largely influenced by socioeconomic status and cohabitation.

Assessment of Hospital Performance Using Quality of Care Indicators in Patients with Acute Coronary Syndrome

BACKGROUND: Global researchers have found a wide practice gap between the optimal care and actual care of patients with acute coronary syndrome (ACS). AIM: The main objective of the present study was to evaluate the quality of care provided to patients with ACS and compare our results to that of other similar studies and international standards. METHODS: A descriptive study was conducted using review of medical records and medical charts of new patients admitted and treated as ACS at the Department of Critical Care Medicine, Cairo University, from January 1, 2015, to December 31, 2020. For the purpose of the analysis, a set of highly predictive quality indicators was used. RESULTS: 967 patients were divided into two groups: 621 patients with acute ST-segment elevation myocardial infarction (STEMI) (mean age: 58.49 ± 11.45 years, 81.8% of males) and 34.9% presented to hospital in &lt;4 h of symptom onset. Primary percutaneous coronary interventions (PCIs) were applied on 71.3% of cases (N = 443) and the mean “door-to-balloon” time was 78.8 min. In the first 24 h, acetylsalicylic acid (ASA), β-blockers, and angiotensin-converting enzyme inhibitors (ACE-I) or AR-blockers were administered in 100%, 65.9%, and 73.4% of the total eligible cases, respectively. At discharge, ASA, β-blockers, ACE-I/ARBs, and statins were prescribed in 90.8%, 78.3%, 82.8%, and 90.8%, respectively. 346 patients were with UA/NSTEMI (mean age 63±25.7 years, 69.4% male), while 21.7% of patients were presented to hospital after less than 4 hours of symptoms onset. Early PCIs were applied on 28.1% of cases (N = 97). In the first 24 h, ASA, β-blockers, and ACE-I or AR-blockers were administered in 100%, 78.3%, and 78.6% of the total eligible cases, respectively. At discharge, ASA, β-blockers, ACE-I/ARBs, and statins were prescribed in 93.4%, 83.2%, 81.2%, and 92.8%, respectively. In this study, a relation between different quality indicators with inhospital major adverse cardiac event and outcome was observed. CONCLUSION: There is still substantial work that lies ahead on the way to improve the uptake to evidence-based processes of care. We found some disparities between guidelines and clinical practice for ACS patients and a significant association between process indicators and inhospital outcomes. Our findings are potentially helpful for assessing and improving the quality of care for ACS patients in Egypt.

Six years’ experience of participation of the Institute of Emergency Medicine from Chisinau, Republic of Moldova in the Registry of Stroke Care Quality

Background. The Institute of Emergency Medicine from Chisinau has joined the Registry of Stroke Care Quality (RES-Q) in 2017. Material and Methods. We have analyzed the stroke patients’ data introduced in RES-Q between 20172022. Baseline characteristics, stroke-related factors, processes of care, and discharge destination were examined. Results. Data were available for 489 stroke patients. The proportion of patients with ischemic strokes receiving thrombolysis therapy has substantially increased from 2.78% in 2017 to 20% in 2022, and the median door-toneedle time decreased from 85 minutes (2017) to 48 minutes (2021). Thrombectomy began to be performed in 2018 at the Institute of Emergency Medicine, the rate of stroke patients receiving thrombectomy increased from 3.23% in 2019 to 10% in 2022, median door-to-groin time decreased from 228.5 minutes in 2019 to 102 minutes in 2021. More than 80% of patients received secondary prevention therapies that were level-1 evidence-based processes of care: antihypertensive agents (89.47% – 98.44%), antiplatelet drugs (81.63% – 100%), anticoagulants for patients with atrial fibrillation (25% in 2018 vs 100% in 2021), but cholesterol-lowering medication was prescribed to approximately a half of the participants (44.23% – 60.0%). There were more deaths in the pandemic years (36.67% in 2021 vs 18.99% in 2017). Conclusion. Most hospitalized stroke patients admitted to the Institute of Emergency Medicine received evidence-based care. The COVID-19 pandemic has left its mark on the number of stroke hospitalizations, but the quality of in-hospital stroke care was not dramatically affected.

Evidence-Based Surgery

Evidence-based surgery describes the consistent and judicious use of the best available scientific evidence in making decisions about the care of surgical patients. In this chapter, guidelines and secondary sources of scientific evidence are provided. Examples include Clinical Evidence, the Cochrane Database of Systematic Reviews, and the Institute for Healthcare Improvement. Levels of evidence are defined. Appraising scientific evidence via specific study designs is described, including studies’ internal and external validity (generalizability). In evaluating the quality of a study, the properties of chance (Type I and Type II errors); bias (selection bias and measurement bias); and confounding (along with randomization, restriction and matching, instrumental variable analysis, stratification, and propensity score risk adjustment) are defined. Interpreting and applying evidence to practice (external validity) are discussed. A discussion of evidence-based surgery and quality of care is provided and focuses on how efforts to assess quality on evidence-based processes of care or clinical outcomes are as much practical as philosophical. A figure shows processes that affect the internal and external validity of a clinical study. Tables show levels of evidence, as stratified by the U.S. Preventive Services Task Force, and methods observed in published clinical studies that demonstrate efforts to minimize the effects of chance, bias, and confounding. This review contains 1 figure, 3 tables, and 42 references.

Adherence to evidence-based processes of care reduces one-year mortality after aneurysmal subarachnoid hemorrhage (aSAH)

BackgroundThere is limited research on the provision of evidence-based care and its association with outcomes after aneurysmal subarachnoid hemorrhage (aSAH). AimsWe examined adherence to evidence-based care after aSAH and associations with survival and discharge destination. Also, factors associated with evidence-based care including age, sex, Charlson comorbidity index, severity scores, and delayed cerebral ischemia and infarction were examined for association with survival and discharge destination. MethodsIn a retrospective cohort (2010–2016) of all aSAH cases across two comprehensive cerebrovascular centres, we extracted 3 indicators of evidence-based aSAH care from medical records: (1) antihypertensives prior to aneurysm treatment, (2) nimodipine, and (3) aneurysm treatment (coiling/clipping). We defined ‘optimal care’ as receiving all eligible processes of care. Survival at 1 year was obtained by data linkage. We estimated (1) proportion of patients and characteristics associated with receiving processes of care, (2) associations between processes of care with 1-year mortality using cox-proportional hazard model and discharge destination with log binomial regression adjusting for age, sex, severity of aSAH, delayed cerebral ischemia and/or cerebral infarction and comorbidities. Sensitivity analyses explored effect modification of the association between processes of care and outcome by management type (active versus comfort measures). ResultsAmong 549 patients (69% women), 59% were managed according to the guidelines. Individual indicators were associated with lower 1-year mortality but not discharge destination. Optimal care reduced mortality at 1 year in univariable (HR 0.24 95% CI 0.17–0.35) and multivariable analyses (HR 0.51 95% CI 0.34–0.77) independent of age, sex, severity, comorbidities, and hospital network. ConclusionAdherence to processes of care reduced 1-year mortality after aSAH. Many patients with aSAH do not receive evidence-based care and this must be addressed to improve outcomes.

Evidence based processes to prevent readmissions: more is better, a ten-site observational study

Background30-day hospital readmissions are an indicator of quality of care; hospitals are financially penalized by Medicare for high rates. Numerous care transition processes reduce readmissions in clinical trials. The objective of this study was to examine the relationship between the number of evidence-based transitional care processes used and the risk standardized readmission rate (RSRR).MethodsDesign: Mixed method, multi-stepped observational study. Data collection occurred 2014–2018 with data analyses completed in 2021. Setting: Ten VA hospitals, chosen for 5-year trend of improving or worsening RSRR prior to study start plus documented efforts to reduce readmissions. Participants: During five-day site visits, three observers conducted semi-structured interviews (n = 314) with staff responsible for care transition processes and observations of care transitions work (n = 105) in inpatient medicine, geriatrics, and primary care. Exposure: Frequency of use of twenty recommended care transition processes, scored 0–3. Sites’ individual process scores and cumulative total scores were tested for correlation with RSRR. Outcome: best fit predicted RSRR for quarter of site visit based on the 21 months surrounding the site visits.ResultsTotal scores: Mean 38.3 (range 24–47). No site performed all 20 processes. Two processes (pre-discharge patient education, medication reconciliation prior to discharge) were performed at all facilities. Five processes were performed at most facilities but inconsistently and the other 13 processes were more varied across facilities. Total care transition process score was correlated with RSRR (R2 = 0..61, p < 0.007).ConclusionsSites making use of more recommended care transition processes had lower RSRR. Given the variability in implementation and barriers noted by clinicians to consistently perform processes, further reduction of readmissions will likely require new strategies to facilitate implementation of these evidence-based processes, should include consideration of how to better incorporate activities into workflow, and may benefit from more consistent use of some of the more underutilized processes including patient inclusion in discharge planning and increased utilization of community supports. Although all facilities had inpatient social workers and/or dedicated case managers working on transitions, many had none or limited true bridging personnel (following the patient from inpatient to home and even providing home visits). More investment in these roles may also be needed.

The Importance of Quality Assurance and Quality Improvement in Low- and Middle-Income Settings

Purpose of ReviewThis review will discuss the importance of quality improvement in low- and middle-income settings as well as several potential barriers to these measures.Recent FindingsThere is substantial potential for growth in the field of quality improvement in low-resource settings. The extent of quality improvement (QI) research in low-resource settings is limited but expanding.SummaryPatient harm that is attributable to the costs of poor quality is a significant factor in all practice settings but is arguably of greater impact in limited-resource settings. Due to the recognized human, physical, and technological resource limitations in low- and middle-income countries, the delivery of quality healthcare can be variable in many settings, with discrepancies in evidence-based, evidence-informed, and customary care processes. Disparities in training and development of workforce providers exist in addition to limited availability of funding for QI research. Governmental, health ministry, and health system support is also variable. Attention to all of these areas is ultimately necessary to implement affordable and realistic quality improvement initiatives, education, training, and patient safety strategies that can mitigate harms, improve and establish more reliable outcomes, and develop a culture of safety to grow more sustainable and effective workforces and systems.

Checklist for Early Recognition and Treatment of Acute Illness and Injury: An Exploratory Multicenter International Quality-Improvement Study in the ICUs With Variable Resources.

To determine whether the "Checklist for Early Recognition and Treatment of Acute Illness and Injury" decision support tool during ICU admission and rounding is associated with improvements in nonadherence to evidence-based daily care processes and outcomes in variably resourced ICUs. This before-after study was performed in 34 ICUs (15 countries) from 2013 to 2017. Data were collected for 3 months before and 6 months after Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation. Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation using remote simulation training. The coprimary outcomes, modified from the original protocol before data analysis, were nonadherence to 10 basic care processes and ICU and hospital length of stay. There were 1,447 patients in the preimplementation phase and 2,809 patients in the postimplementation phase. After adjusting for center effect, Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation was associated with reduced nonadherence to care processes (adjusted incidence rate ratio [95% CI]): deep vein thrombosis prophylaxis (0.74 [0.68-0.81), peptic ulcer prophylaxis (0.46 [0.38-0.57]), spontaneous breathing trial (0.81 [0.76-0.86]), family conferences (0.86 [0.81-0.92]), and daily assessment for the need of central venous catheters (0.85 [0.81-0.90]), urinary catheters (0.84 [0.80-0.88]), antimicrobials (0.66 [0.62-0.71]), and sedation (0.62 [0.57-0.67]). Analyses adjusted for baseline characteristics showed associations of Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation with decreased ICU length of stay (adjusted ratio of geometric means [95% CI]) 0.86 [0.80-0.92]), hospital length of stay (0.92 [0.85-0.97]), and hospital mortality (adjusted odds ratio [95% CI], 0.81 (0.69-0.95). A quality-improvement intervention with remote simulation training to implement a decision support tool was associated with decreased nonadherence to daily care processes, shorter length of stay, and decreased mortality.

Assessment of a Pharmacist-Led Direct Oral Anticoagulant Monitoring Clinic

Direct oral anticoagulants (DOACs) are recommended as first-line therapy for treatment and prevention of venous thromboembolism (VTE) and prevention of stroke related to nonvalvular atrial fibrillation. Recent publications have suggested incorporating DOAC monitoring into anticoagulant management clinics. The Eastern Health Adult Outpatient Thrombosis Service (Newfoundland and Labrador) includes a pharmacist-led DOAC monitoring clinic that uses standardized evidence-based care processes. To describe a new pharmacist-led DOAC monitoring clinic and to assess patients' adherence to medication therapy, adherence to guideline-recommended frequencies for blood work, and adverse and non-adverse events. This retrospective chart review involved patients who attended their first visit to the DOAC clinic between October 10, 2017, and May 31, 2018. Patients were followed until November 30, 2018. Data were abstracted from electronic hospital records and the provincial pharmacy network. Descriptive statistics were used to analyze the data: categorical variables were presented as frequencies and percentages; continuous variables were analyzed and presented as means with standard deviations and, where applicable, as medians with interquartile ranges. Forty-seven patients, who attended a total of 74 clinic visits, were included. Twenty-eight patients (60%) were adherent to their DOAC therapy. All patients had blood work completed before each clinic appointment. The mean time between the first and second sets of blood tests was 6.2 (standard deviation [SD] 1.4) months and between the second and third sets of blood tests was 5.1 (SD 1.0) months. There were no episodes of VTE or major bleeding. There was 1 cerebrovascular accident (3.2 events per 100 person-years, 95% confidence interval [CI] 0.2-15.7) and 5 episodes of clinically relevant non-major bleeding (12.8 events per 100 person-years, 95% CI 4.1-30.1). Pharmacists identified 51 issues at the clinic appointments, of which 48 were medication-related. Referral to the Thrombosis Service physician was required to resolve 8 (16%) of the issues identified. A brief discussion between the Thrombosis Service physician and pharmacist was required to resolve 30 (59%) of the issues, with 13 (25%) resolved by the pharmacist alone. This study described the implementation and outcomes of a novel pharmacist-led DOAC clinic. Clinic patients underwent blood work at recommended intervals and received guidance on adherence and adverse events; as such, patients had follow-up that aligned with guideline recommendations.

Defect-free care trends in the Paul Coverdell National Acute Stroke Program, 2008-2018

In an effort to improve stroke quality of care and patient outcomes, quality of care metrics are monitored to assess utilization of evidence-based stroke care processes as part of the Paul Coverdell National Acute Stroke Program (PCNASP). We aimed to assess temporal trends in defect-free care (DFC) received by stroke patients in the PCNASP between 2008 and 2018. Quality of care data for 10 performance measures were available for 849,793 patients aged ≥18 years who were admitted to a participating hospital with a clinical diagnosis of stroke between 2008 and 2018. A patient who receives care according to all performance measures for which they are eligible, receives "defect-free care" (DFC) (eg, appropriate medications, assessments, and education). Generalized estimating equations were used to examine the factors associated with receipt of DFC. DFC among ischemic stroke patients increased from 38.0% in 2008 to 80.8% in 2018 (P < .0001), with the largest improvement seen in receipt of stroke education (relative percent change, RPC = 64%). Similarly, DFC for hemorrhagic stroke and transient ischemic attack patients increased from 46.7% to 82.6% (RPC = 76.9%) and 39.9% to 85.0% (RPC = 113.0%) (P < .001), respectively. Among ischemic stroke patients, the adjusted odds for receiving DFC were lower for women, patients aged 18 to 54 years, Medicaid or Medicare participants, and patients with atrial fibrillation (P < .05). From 2008 to 2018, receipt of DFC by ischemic stroke patients significantly increased in the PCNASP; however certain subgroups were less likely to receive this level of care. Targeted quality improvement initiatives could result in even further improvements among all stroke patients and help reduce disparities in care.

Abstract 331: Area Specific Differences for Quality of Care and Outcomes in Ischemic Stroke in China

Background: Former studies suggest differences in stroke care associated with race, age or gender. We sought to find whether such disparities existed in different areas in patients hospitalized with stroke among hospitals participating in the China Stroke Center Association. Methods: In-hospital mortality and 4 stroke performance measures among 660,225 patients admitted with ischemic stroke in the Eastern, Central and Western regions of China in the China Stroke Center Association between 2015 and 2019. Results: After adjustment for both demographics and diseases history variables, western patients had lower odds relative of receiving intravenous thrombolysis (Eastern: OR, 1.78; 95%CI, 1.72 to 1.84; Central: OR, 1.55; 95%CI, 1.50 to 1.60), early antithrombotics (Eastern: OR, 1.95; 95%CI, 1.90 to 1.99; Central: OR, 1.86; 95%CI, 1.81 to 1.90), dysphagia screening (Eastern: OR, 1.03; 95%CI, 1.01 to 1.04; Central: OR, 0.83; 95%CI, 0.81 to 0.84) and NIHSS (Eastern: OR, 1.18; 95%CI, 1.16 to 1.20; Central: OR, 1.50; 95%CI, 1.48 to 1.53). However, the in-hospital death was higher in eastern and central regions (Eastern: OR, 0.48; 95%CI, 0.43 to 0.54; Central: OR, 0.51; 95%CI, 0.45 to 0.57). Conclusions: Western patients with stroke received fewer evidence-based care processes than central or eastern patients. Quality of care improvement in stroke should be focused on the west. The high mortality of the east and central probably resulted in that better hospitals in these areas received more severe patients substantially.

The Association of ICU Acuity With Adherence to ICU Evidence-Based Processes of Care

Admission to high-acuity ICUs has been associated with improved outcomes compared with outcomes in low-acuity ICUs, although the mechanism for these findings is unclear. The goal of this study was to determine if high-acuity ICUs more effectively implement evidence-based processes of care that have been associated with improved clinical outcomes. This retrospective cohort study was performed in adult ICU patients admitted to 322 ICUs in 199 hospitals in the Philips ICU telemedicine database between 2010 and 2015. The primary exposure was ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles. Multivariable logistic regression was used to examine relations of ICU acuity with adherence to evidence-based VTE and stress ulcer prophylaxis, and with the avoidance of potentially harmful events. These events included hypoglycemia, sustained hyperglycemia, and liberal transfusion practices (defined as RBC transfusions prescribed for nonbleeding patients with preceding hemoglobin levels≥ 7 g/dL). Among 1,058,510 ICU admissions, adherence to VTE and stress ulcer prophylaxis was high across acuity levels. In adjusted analyses, those admitted to low-acuity ICUs compared with the highest acuity ICUs were more likely to experience hypoglycemic events (adjusted OR [aOR], 1.12; 95%CI, 1.04-1.19), sustained hyperglycemia (aOR, 1.07; 95%CI, 1.04-1.10), and liberal transfusion practices (aOR, 1.55; 95%CI, 1.33-1.82). High-acuity ICUs were associated with better adherence to several evidence-based practices, which may be a marker of high-quality care. Future research should investigate how high-acuity ICUs approach ICU organization to identify targets for improving the quality of critical care across all ICU acuity levels.

Towards standardisation of evidence-based clinical care process specifications.

There is a strong push towards standardisation of treatment approaches, care processes and documentation of clinical practice. However, confusion persists regarding terminology and description of many clinical care process specifications which this research seeks to resolve by developing a taxonomic characterisation of clinical care process specifications. Literature on clinical care process specifications was analysed, creating the starting point for identifying common characteristics and how each is constructed and used in the clinical setting. A taxonomy for clinical care process specifications is presented. The De Bleser approach to limited clinical care process specifications characterisation was extended and each clinical care process specification is successfully characterised in terms of purpose, core elements and relationship to the other clinical care process specification types. A case study on the diagnosis and treatment of Type 2 Diabetes in the United Kingdom was used to evaluate the taxonomy and demonstrate how the characterisation framework applies. Standardising clinical care process specifications ensures that the format and content are consistent with expectations, can be read more quickly and high-quality information can be recorded about the patient. Standardisation also enables computer interpretability, which is important in integrating Learning Health Systems into the modern clinical environment. The approach presented allows terminologies for clinical care process specifications that were widely used interchangeably to be easily distinguished, thus, eliminating the existing confusion.

807 Implementation of an Evidence-based Wound Care Process at a Regional Burn Center Reduces Hospital Acquired Infections

Abstract Introduction Central line associated blood stream infection (CLABSI) rates in burn patients exceeds the national average. The purpose of this study was to determine if implementation of an evidence-based process for wound care and central line management reduce infections. Methods A protocol for central line and wound care was developed in conjunction with another burn center with lower CLABSI rates and a care bundle, based on colorectal surgical literature. The new protocol required hand to elbow washing prior to wound care, separating the dirty and clean steps of the wound care process, changing protective gear when going from dirty to clean and performing the Hospital Acquired Infection (HAI) bundle elements separate from wound care. CLABSI and Ventilator Associated Pneumonia (VAP) rates were then compared with the previous year. Results Following implementation of the new wound care guidelines, the number of CLABSIs declined from 10 in 2017 to 2 in 2018 and 1 so far in 2019 (through August 2019). The median number of CLABSIs per 1000 days was 0 (range of 0 to 11) before the bundle and 0 (range of 0 to 4.2) after implementation of the bundle. Using the Wilcox rank sum test, there was no significant difference (p=0.09) between the CLABSI rate per 1000 device days between the time period before the bundle implementation and after the bundle implementation, however this may be due to the small sample size. Although the CLABSI rate did not show a statistically significant decrease, the proportion of positive blood cultures decreased by 50% after implementation of the bundle. The number of VAPs declined from 8 in 2017 to 6 in 2018 and so far in 2019 no VAPs have been reported (through August 2019). There was no difference in device days between groups. Conclusions Creating a wound care process that clearly defines and separates clean and dirty steps, similar to colorectal surgical bundles in the reduction of Surgical Site Infection, reduced CLABSI and HAI rates in a clinically significant, if not statistically significant way in the Burn Intensive Care Unit. Further study is needed to increase the power of this study to possibly detect statistically significant differences. Applicability of Research to Practice Implementation of an evidence-based, standardized practice for wound care improved infection rates at one regional burn center. It would be beneficial for this process to be replicated at other centers to further test correlation with infection reduction.

Compliance With Evidence-Based Processes of Care After Transitions Between Staff Intensivists.

We sought to evaluate the impact of transitions of care among staff intensivists on the compliance with evidence-based processes of care. Cohort study using data from the Toronto Intensive Care Observational Registry. Seven academic ICUs in Toronto, Ontario. Critically ill mechanically ventilated adult patients. We explored the effects of the weekly transition of care among staff intensivists on compliance with three evidence-based processes of care (spontaneous breathing trials, lung-protective ventilation, and neuromuscular blocking agents). Two practices that are less guided by evidence (early discontinuation of antibiotics and extubation attempts) served as positive controls. We conducted the analysis using generalized estimating equations to account for clustering at the patient level. The cohort consisted of 10,570 patients admitted between June 2014 and August 2018. Compliance varied for each practice (63.6%, 42.5%, and 21.1% for lung-protective ventilation, spontaneous breathing trials, and neuromuscular blockade, respectively). There was no effect of transitions of care on compliance with spontaneous breathing trials (odds ratio, 1.00; 95% CI, 0.95-1.07), lung-protective ventilation (odds ratio, 1.07, 95% CI, 0.90-1.26), or neuromuscular blockade use (odds ratio, 0.95; 95% CI, 0.75-1.20). However, early antibiotic discontinuation was more likely (odds ratio, 1.23; 95% CI, 1.06-1.42) and extubation attempts were less frequent (odds ratio, 0.77; 95% CI, 0.65-0.93) after a transition of care. We observed no significant impact of transitions of care between individual staff physicians on evidence-based processes of care for mechanically ventilated adult patients. However, transitions were associated with a lower likelihood of extubation and higher odds of earlier discontinuation of antibiotics.