Handover Of Care Research Articles

Effectiveness of the Practice of Standardized Handover Process Using a Checklist in the Postanesthesia Care Unit: An Observational Study.

Patient handovers without any structured checklist may omit essential information that might have undesirable consequences for patients. We sought to determine the effectiveness of a structured postanesthesia care handover (PACH) checklist in the postanesthesia care unit (PACU) to reduce adverse clinical outcomes. A single-center, prospective, pre-postimplementation study was conducted. Moreover, post-PACH checklist implementation data were collected from 130 participants ( n = 65 in each group) by an independent observer. Data analysis was performed using the SPSS (25.0) version (IBM SPSS statistics). The Chi-square test was used to compare the dichotomous response. A statistically significant reduction in hypoxemia (21.5% vs. 0; P < 0.001) was observed in the postimplementation group. There were significant improvements in patient information ( P < 0.01), reduction in variations in hemodynamic parameters ( P < 0.01), and improvement in the quality of information transferred concerning surgical procedures ( P < 0.01). The number of phone calls to consultants was significantly lower in the PACH group. Implementation of the PACH checklist was associated with no hypoxemic events in PACU by improving the quality of communication. The implementation of a structured checklist in PACU should be mandatory in the postoperative intensive care unit.

Coordination of oral anticoagulant care at hospital discharge (COACHeD): pilot randomised controlled trial

ObjectivesTo evaluate whether a focused, expert medication management intervention is feasible and potentially effective in preventing anticoagulation-related adverse events for patients transitioning from hospital to home.DesignRandomised, parallel design.SettingMedical wards at...

Impact of anesthesia handover on postoperative pain, nausea, and vomiting among adults undergoing general anesthesia

Objective: This study aimed to investigate the impact of intraoperative anesthesia care handovers on mortality, hospital readmission, and intraoperative/postoperative complications in patients undergoing major surgery in Saudi Arabia. Methods: It was a retrospective cohort study conducted in Riyadh, Saudi Arabia. An Excel sheet was used for data entry. A convenient sampling method was used in the study. Results: The majority of the patients were female (53.7%) and aged between 21 and 60 years (71.5%). Overweight and obese individuals accounted for a significant proportion of the sample. Anesthesia handover was performed for a small percentage of patients (11.3%). Postoperative pain was reported by 37.5% of patients, while nausea and vomiting were experienced by a smaller percentage. The use of pain medications was relatively low (22.2%), with morphine being the most common choice. Vital parameters such as heart rate and blood pressure showed significant changes after the procedure. Anesthesia handover was associated with higher rates of postoperative pain and had a significant correlation with postoperative nausea and vomiting. Conclusion: The findings of this study contributed to improving perioperative care and optimizing patient outcomes in the field of anesthesia. The study highlighted the importance of tailored pain management strategies and standardized protocols for anesthesia handover. Further research is needed to refine perioperative practices and enhance overall patient care.

A Quality Improvement Initiative to Reduce Adverse Effects of Transitions of Anesthesia Care on Postoperative Outcomes: A Retrospective Cohort Study.

An intraoperative transfer of care from one anesthesia provider to another, or handover, may result in information loss and contribute to adverse patient outcomes. In 2019 the authors undertook a quality improvement effort to increase the use of a structured intraoperative handover tool incorporated in the electronic medical record. The authors hypothesized that intraoperative handovers of anesthesia care would be associated with adverse patient outcomes, and that increased use of a structured tool would attenuate this effect. This study included adult patients undergoing noncardiac surgery of at least 1 h duration performed during the period 2016 to 2021. Cases with a handover were identified if either there was a change of attending anesthesiologist or change of nurse anesthetist or resident for more than 35 min. The primary outcome was the occurrence of a composite of postoperative mortality and major postoperative morbidity. The effect of the intervention was analyzed by examining the quarterly change in odds ratio for the primary outcome for cases with and without a handover. A total of 121,077 cases, 40.4% of which had a handover, were included. After weighting, the composite outcome was statistically associated with handovers (3,517 of 48,986 [7.2%] in handover cases vs. 4,470 of 72,091 [6.2%] in nonhandover cases; odds ratio, 1.08; 95% CI, 1.04 to 1.12). Time series analysis showed a marked increase in usage of the structured tool after the initial intervention. The odds ratio for the composite outcome showed a significant decrease over time after the initial intervention (t = -3.97; P < 0.001), with the slope of the odds ratio versus time curve decreasing from 0.002 (95% CI, 0.001 to 0.004; P = 0.018) to -0.011 (95% CI, -0.01 to -0.018; P < 0.001). Intraoperative handovers are significantly associated with adverse outcomes even after controlling for multiple confounding variables. Use of a structured handover tool during anesthesia care may attenuate the adverse effect.

An electronic operation note proforma improves the quality of operation notes in burns surgery.

An Operation Note should provide a comprehensive account of the details of a surgical procedure performed and document clinically relevant events which occur throughout the procedure. The Royal College of Surgeons of England, in 2014, updated guidelines on specific criteria to be included in operation notes. Standardisation using procedure-specific operation notes has been shown to significantly improve adherence to these guidelines. The aim of this study was to evaluate the quality of operation notes in the Irish National Burns Unit before and after the design and implementation of an electronic patient record and the subsequent introduction of an operation template and a burns surgery specific checklist, within the electronic system. A 30-point checklist was designed based on existing sources. Operation notes prior to and following the adoption of a electronic-based operation note were analysed, and then reanalysed following the introduction of a procedure-specific operation note. Ninety-three operation notes were included for analysis. An electronic operation record significantly improved the quality of documentation within our unit. The subsequent procedure specific operation note had a significant improvement across all areas and achieved 100% compliance in many categories. The use of an electronic patient record to document a patient's procedure has been shown to significantly improve the quality of documentation. One could expect this to result in an improved patient hand-over and subsequent episode of care. We highlight a number of initial pit-falls that others may avoid in their implementation of a digital record.

Outlier or handover: outcomes for General Medicine inpatients.

Objective Patients admitted from the emergency department may be co-located on the treating team's 'home ward'. If no bed is available, patients may be sent to another ward, where they may remain under the admitting team as an 'outlier'. Conversely, care may be handed over to the team on whose home ward they are located. We conducted a retrospective analysis to understand the impact of outlier status and handovers of care on outcomes for General Medicine inpatients. Methods General Medicine admissions at the Royal Adelaide Hospital between September 2020 and November 2021 were analysed. We examined the rate of hospital-acquired complications, inpatient mortality rate, mortality within 48 h of admission, Relative Stay Index, time of discharge from hospital and rate of adverse events within 28 days of discharge. Results A total of 3109 admissions were analysed. Handovers within 24 h of admission were associated with a longer length of stay. There was a trend towards higher rates of adverse events within 28 days of discharge with handovers of care. Outlier status did not affect any outcome measures. Conclusions Handovers within the first 24 h of admission are associated with longer than expected length of stay.

Experiences of service transitions in Australian early intervention psychosis services: a qualitative study with young people and their supporters

BackgroundDifferent Early Intervention Psychosis Service (EIPS) models of care exist, but many rely upon community-based specialist clinical teams, often with other services providing psychosocial care. Time-limited EIPS care creates numerous service transitions that have potential to interrupt continuity of care. We explored with young people (YP) and their support people (SP) their experiences of these transitions, how they affected care and how they could be better managed.MethodsUsing purposive sampling, we recruited twenty-seven YP, all of whom had been hospitalised at some stage, and twelve SP (parents and partners of YP) from state and federally funded EIPS in Australia with different models of care and integration into secondary mental health care. Audio-recorded interviews were conducted face-to-face or via phone. A diverse research team (including lived experience, clinician and academic researchers) used an inductive thematic analysis process. Two researchers undertook iterative coding using NVivo12 software, themes were developed and refined in ongoing team discussion.ResultsThe analysis identified four major service-related transitions in a YP’s journey with the EIPS that were described as reflecting critical moments of care, including: transitioning into EIPS; within service changes; transitioning in and out of hospital whilst in EIPS care; and, EIPS discharge. These service-related transition affected continuity of care, whilst within service changes, such as staff turnover, affected the consistency of care and could result in information asymmetry. At these transition points, continuity of care, ensuring service accessibility and flexibility, person centredness and undertake bio-psychosocial support and planning were recommended. State and federally funded services both had high levels of service satisfaction, however, there was evidence of higher staff turnover in federally funded services.ConclusionService transitions were identified as vulnerable times in YP and SP continuity of care. Although these were often well supported by the EIPS, participants provided illustrative examples for service improvement. These included enhancing continuity and consistency of care, through informed and supportive handovers when staff changes occur, and collaborative planning with other services and the YP, particularly during critical change periods such as hospitalisation.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Facilitating high quality acute care in resource-constrained environments: Perspectives of patients recovering from sepsis, their caregivers and healthcare workers in Uganda and Malawi.

Sepsis is a major global health problem, especially in sub-Saharan Africa. Improving patient care requires that healthcare providers understand patients' priorities and provide quality care within the confines of the context they work. We report the perspectives of patients, caregivers and healthcare workers regarding care quality for patients admitted for sepsis to public hospitals in Uganda and Malawi. This qualitative descriptive study in two hospitals included face-to face semi-structured interviews with purposively selected patients recovering from sepsis, their caregivers and healthcare workers. In both Malawi and Uganda, sepsis care often occurred in resource-constrained environments which undermined healthcare workers' capacity to deliver safe, consistent and accessible care. Constraints included limited space, strained; water, sanitation and hygiene (WASH) amenities and practices, inadequate human and material resources and inadequate provision for basic needs including nutrition. Heavy workloads for healthcare workers strained relationships, led to poor communication and reduced engagement with patients and caregivers. These consequences were exacerbated by understaffing which affected handover and continuity of care. All groups (healthcare workers, patients and caregivers) reported delays in care due to long queues and lack of compliance with procedures for triage, treatment, stabilization and monitoring due to a lack of expertise, supervision and context-specific sepsis management guidelines. Quality sepsis care relies on effective severity-based triaging, rapid treatment of emergencies and individualised testing to confirm diagnosis and monitoring. Hospitals in resource-constrained systems contend with limitations in key resources, including for space, staff, expertise, equipment and medicines, in turn contributing to gaps in areas such as WASH and effective care delivery, as well as communication and other relational aspects of care. These limitations are the predominant challenges to achieving high quality care.

Coordination of Oral Anticoagulant Care at Hospital Discharge (COACHeD): protocol for a pilot randomised controlled trial

BackgroundOral anticoagulants (OACs) are commonly prescribed, have well-documented benefits for important clinical outcomes but have serious harms as well. Rates of OAC-related adverse events including thromboembolic and hemorrhagic events are especially high shortly after hospital discharge. Expert OAC management involving virtual care is a research priority given its potential to reach remote communities in a more feasible, timely, and less costly way than in-person care. Our objective is to test whether a focused, expert medication management intervention using a mix of in-person consultation and virtual care follow-up, is feasible and effective in preventing anticoagulation-related adverse events, for patients transitioning from hospital to home.Methods and analysisA randomized, parallel, multicenter design enrolling consenting adult patients or the caregivers of cognitively impaired patients about to be discharged from medical wards with a discharge prescription for an OAC. The interdisciplinary multimodal intervention is led by a clinical pharmacologist and includes a detailed discharge medication reconciliation and management plan focused on oral anticoagulants at hospital discharge; a circle of care handover and coordination with patient, hospital team and community providers; and early post-discharge follow-up virtual medication check-up visits at 24 h, 1 week, and 1 month. The control group will receive usual care plus encouragement to use the Thrombosis Canada website.The primary feasibility outcomes include recruitment rate, participant retention rates, trial resources management, and the secondary clinical outcomes include adverse anticoagulant safety events composite (AASE), coordination and continuity of care, medication-related problems, quality of life, and healthcare resource utilization. Follow-up is 3 months.DiscussionThis pilot RCT tests whether there is sufficient feasibility and merit in coordinating oral anticoagulant care early post-hospital discharge to warrant a full sized RCT.Trial registrationNCT02777047.

Seeking Clarity About Intraoperative Anesthesia Patient Handovers

Patient care handovers (sometimes called handoffs) are organized transfers of pertinent patient information and responsibility between health care professionals. These handoffs are becoming more common as they represent an obligatory component of modern hospital care.

Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications Among Adults

Intraoperative handovers of anesthesia care are common. Handovers might improve care by reducing physician fatigue, but there is also an inherent risk of losing critical information. Large observational analyses report associations between handover of anesthesia care and adverse events, including higher mortality. To determine the effect of handovers of anesthesia care on postoperative morbidity and mortality. This was a parallel-group, randomized clinical trial conducted in 12 German centers with patients enrolled between June 2019 and June 2021 (final follow-up, July 31, 2021). Eligible participants had an American Society of Anesthesiologists physical status 3 or 4 and were scheduled for major inpatient surgery expected to last at least 2 hours. A total of 1817 participants were randomized to receive either a complete handover to receive anesthesia care by another clinician (n = 908) or no handover of anesthesia care (n = 909). None of the participating institutions used a standardized handover protocol. The primary outcome was a 30-day composite of all-cause mortality, hospital readmission, or serious postoperative complications. There were 19 secondary outcomes, including the components of the primary composite, along with intensive care unit and hospital lengths of stay. Among 1817 randomized patients, 1772 (98%; mean age, 66 [SD, 12] years; 997 men [56%]; and 1717 [97%] with an American Society of Anesthesiologists physical status of 3) completed the trial. The median total duration of anesthesia was 267 minutes (IQR, 206-351 minutes), and the median time from start of anesthesia to first handover was 144 minutes in the handover group (IQR, 105-213 minutes). The composite primary outcome occurred in 268 of 891 patients (30%) in the handover group and in 284 of 881 (33%) in the no handover group (absolute risk difference [RD], -2.5%; 95% CI, -6.8% to 1.9%; odds ratio [OR], 0.89; 95% CI, 0.72 to 1.10; P = .27). Nineteen of 889 patients (2.1%) in the handover group and 30 of 873 (3.4%) in the no handover group experienced all-cause 30-day mortality (absolute RD, -1.3%; 95% CI, -2.8% to 0.2%; OR, 0.61; 95% CI, 0.34 to 1.10; P = .11); 115 of 888 (13%) vs 136 of 872 (16%) were readmitted to the hospital (absolute RD, -2.7%; 95% CI, -5.9% to 0.6%; OR, 0.80; 95% CI, 0.61 to 1.05; P = .12); and 195 of 890 (22%) vs 189 of 874 (22%) experienced serious postoperative complications (absolute RD, 0.3%; 95% CI, -3.6% to 4.1%; odds ratio, 1.02; 95% CI, 0.81 to 1.28; P = .91). None of the 19 prespecified secondary end points differed significantly. Among adults undergoing extended surgical procedures, there was no significant difference between the patients randomized to receive handover of anesthesia care from one clinician to another, compared with the no handover group, in the composite primary outcome of mortality, readmission, or serious postoperative complications within 30 days. ClinicalTrials.gov Identifier: NCT04016454.

Young people who have fallen through the mental health transition gap: a qualitative study on primary care support.

BackgroundOwing to poor continuity of care between child and adult mental health services, young people are often discharged to their GP when they reach the upper boundary of child and adolescent mental health services (CAMHS). This handover is poorly managed, and GPs can struggle to support young people without input from specialist services. Little is known about young people’s experiences of accessing mental health support from their GP after leaving CAMHS.AimTo explore the experiences and perspectives of young people and the parents/carers of young people receiving primary care support after CAMHS and to identify barriers and facilitators to accessing primary care.Design and settingQualitative study with young people and parents in two English counties: London and West Midlands.MethodNarrative interviews were conducted with 14 young people and 13 parents who had experienced poor continuity of care after reaching CAMHS transition boundary. Data were analysed using reflexive thematic analysis.ResultsThree themes were identified: unmet mental health needs, disjointed care, and taking responsibility for the young person’s mental health care. Barriers included the perception that GPs couldn’t prescribe certain medication, anxiety caused by the general practice environment, and having to move to a new practice at university. Young people’s positive experiences were more likely to include having a long-term relationship with their GP and finding that their GP made time to understand their needs and experiences.ConclusionGPs could help to meet the unmet needs of young people unable to access specialist mental health services after leaving CAMHS. There is a need for comprehensive handover of care from CAMHS to GPs, which could include a joint meeting with the young person and a member of the CAMHS team. Future research should focus on interventions which improve continuity of care for young people after leaving CAMHS, and collaborative working across community mental health services.

Improving the handover process in a psychiatry liaison setting

Efficient handover of patient care is integral to clinical safety. Barriers in communication can lead to adverse outcomes. The Integrated Liaison Assessment Team (ILAT) has a daily handover meeting which...

397 Medical Reconciliation in Acute Surgical Patients – Are We Letting Our Patients Down?

IntroductionNICE guidelines state that medication reconciliation should occur within 24 hours of admission or as soon after as possible. Accurate and timely prescription of these medications is crucial to ensure optimal care. Due to the COVID-19 pandemic, primary care is busier and thus difficult to contact and with neck of kin not present, the challenges of accurate medicine reconciliation may be exacerbated.MethodA retrospective audit was performed over a fortnight of all acute surgical admissions to a district general hospital. Data was collected as to the time regular medications were prescribed, the source of medical reconciliation and the access to GP network systems for patients.ResultsA total of 66 patients were admitted during the time period. 44 patients had regular prescriptions. Of those 68% had regular medications prescribed within 24 hours. 22% did not have regular prescriptions prescribed throughout their inpatient stay. 91% of the patients prescribed medications within 24hours had a working link to the GP network whereas only 58% of those who were never prescribed had a working system.ConclusionsAlthough a good proportion of acute surgical admissions are prescribed their medications within 24 hours, the proportion who are prescribed past this point is low and a sizeable proportion are never prescribed. A significant contributing factor to this could be poor infrastructure relating to the connection between secondary and primary care and poor handover between on-call and post-take teams. Accurate drugs history during the initial clerking is crucial to mitigate these errors long term.

Association Between Handover of Anesthesiology Care and 1-Year Mortality Among Adults Undergoing Cardiac Surgery

Handovers of anesthesia care from one anesthesiologist to another is an important intraoperative event. Despite its association with adverse events after noncardiac surgery, its impact in the context of cardiac surgery remains unclear. To compare the outcomes of patients who were exposed to anesthesia handover vs those who were unexposed to anesthesia handover during cardiac surgery. This retrospective cohort study in Ontario, Canada, included Ontario residents who were 18 years or older and had undergone coronary artery bypass grafting or aortic, mitral, tricuspid valve, or thoracic aorta surgical procedures between 2008 and 2019. Exclusion criteria were non-Ontario residency status and other concomitant procedures. Statistical analysis was conducted from April 2021 to June 2021, and data collection occurred between November 2020 to January 2021. Complete handover of anesthesia care, where the case is completed by the replacement anesthesiologist. The coprimary outcomes were mortality within 30 days and 1 year after surgery. Secondary outcomes were patient-defined adverse cardiac and noncardiac events (PACE), intensive care unit (ICU), and hospital lengths of stay (LOS). Inverse probability of treatment weighting based on the propensity score was used to estimate adjusted effect measures. Mortality was assessed using a Cox proportional hazard model, PACE using a cause-specific hazard model with death as a competing risk, and LOS using Poisson regression. Of the 102 156 patients in the cohort, 25 207 (24.7%) were women; the mean (SD) age was 66.4 (10.8) years; and 72 843 of surgical procedures (71.3%) were performed in teaching hospitals. Handover occurred in 1926 patients (1.9%) and was associated with higher risks of 30-day mortality (hazard ratio [HR], 1.89; 95% CI, 1.41-2.54) and 1-year mortality (HR, 1.66; 95% CI, 1.31-2.12), as well as longer ICU (risk ratio [RR], 1.43; 95% CI, 1.22-1.68) and hospital (RR, 1.17; 95% CI, 1.06-1.28) LOS. There was no statistically significant association between handover and PACE (30 days: HR 1.09; 95% CI, 0.79-1.49; 1 year: HR 0.89; 95% CI, 0.70-1.13). Handover of anesthesia care during cardiac surgical procedures was associated with higher 30-day and 1-year mortality rates and increased health care resource use. Further research is needed to evaluate and systematically improve the handover process qualitatively.

Handover of Critical Patients in Urgent Care and Emergency Settings: A Systematic Review of Validated Assessment Tools.

The emergency handover of critical patients is used to describe the moment when responsibility for the care of a patient is transferred from one critical patient care healthcare team to another, requiring the accurate delivery of information. However, the literature provides few validated assessment tools for the transfer of critical patients in urgent care and emergency settings. To identify the available evaluation tools that assess the handover of critical patients in urgent and emergency care settings in addition to evaluations of their psychometric properties, a systematic review was carried out using PubMed, Scopus, Cinahl, Web of Science (WoS), and PsycINFO, in accordance with PRISMA guidelines. The quality of the studies was assessed using the COSMIN checklist. Finally, eight articles were identified, of which only three included validated tools for evaluating the handover of critical patients in emergency care. Content validity, construct validity, and internal consistency were the most studied psychometric properties. Three studies evaluated error and reliability, criterion validity, hypothesis testing, and sensitivity. None of them considered cross-cultural adaptation or the translation process. This systematic psychometric review shows the existing ambiguities in the handover of critically ill patients and the scarcity of validated evaluation tools. For all of these reasons, we consider it necessary to further investigate urgent care and emergency handover settings through the design and validation of an assessment tool.

Improving handover competency in preclinical medical and health professions students: establishing the reliability and construct validity of an assessment instrument

BackgroundAs part of the worldwide call to enhance the safety of patient handovers of care, the Association of American Medical Colleges (AAMC) requires that all graduating students “give or receive a patient handover to transition care responsibly” as one of its Core Entrustable Professional Activities (EPAs) for Entering Residency. Students therefore require educational activities that build the necessary teamwork skills to perform structured handovers. To date, a reliable instrument designed to assess teamwork competencies, like structured communication, throughout their preclinical and clinical years does not exist.MethodOur team developed an assessment instrument that evaluates both the use of structured communication and two additional teamwork competencies necessary to perform safe patient handovers. This instrument was utilized to assess 192 handovers that were recorded from a sample of 229 preclinical medical students and 25 health professions students who participated in a virtual course on safe patient handovers. Five raters were trained on utilization of the assessment instrument, and consensus was established. Each handover was reviewed independently by two separate raters.ResultsThe raters achieved 72.22 % agreement across items in the reviewed handovers. Krippendorff’s alpha coefficient to assess inter-rater reliability was 0.6245, indicating substantial agreement among the raters. A confirmatory factor analysis (CFA) demonstrated the orthogonal characteristics of items in this instrument with rotated item loadings onto three distinct factors providing preliminary evidence of construct validity.ConclusionsWe present an assessment instrument with substantial reliability and preliminary evidence of construct validity designed to evaluate both use of structured handover format as well as two team competencies necessary for safe patient handovers. Our assessment instrument can be used by educators to evaluate learners’ handoff performance as early as their preclinical years and is broadly applicable in the clinical context in which it is utilized. In the journey to optimize safe patient care through improved teamwork during handovers, our instrument achieves a critical step in the process of developing a validated assessment instrument to evaluate learners as they seek to accomplish this goal.

Experiences of primary care physicians managing postpartum care: a qualitative research study

BackgroundThe postpartum period is redefined as 12 weeks following childbirth. Primary care physicians (PCP) often manage postpartum women in the community after uneventful childbirths. Postpartum care significantly impacts on the maternal and neonatal physical and mental health. However, evidence has revealed unmet needs in postpartum maternal care.AimThe study aimed to explore the experiences of PCPs in managing postpartum mothers.MethodsFour focus group discussions and eleven in-depth interviews with twenty-nine PCPs were conducted in this qualitative research study in urban Singapore. PCPs of both gender and variable postgraduate training background were purposively enrolled. Audited transcripts were independently coded by two investigators. Thematic content analysis was performed using the codes to identify issues in the “clinician”, “mother”, “postpartum care” and “healthcare system & policy” domains stipulated in “The Generalists’ Wheel of Knowledge, Understanding and Inquiry” framework.FindingsPCPs’ personal attributes such as gender and knowledge influenced their postpartum care delivery. Prior training, child caring experience and access to resource materials contributed to their information mastery of postpartum care. Their professional relationship with local multi-ethic and multi-lingual Asian mothers was impacted by their mutual communication, language compatibility and understanding of local confinement practices. Consultation time constraint, awareness of community postnatal services and inadequate handover of care from the specialists hindered PCPs in the healthcare system.DiscussionPersonal, maternal and healthcare system barriers currently prevent PCPs from delivering optimal postpartum care.ConclusionInterventions to overcome the barriers to improve postpartum care will likely be multi-faceted across domains discussed.

ICRE Abstracts: Quality Improvement

ICRE Abstracts: Quality Improvement