Hospital-wide Quality Improvement Initiative Research Articles

Reducing use of triple therapy after percutaneous coronary intervention: Results from a hospital-wide quality improvement initiative.

Trials have shown that for patients on oral anticoagulants (OAC), a short course of dual antiplatelet therapy (DAPT) with OAC reduces post-percutaneous coronary intervention (PCI) bleeding without increasing ischemic events. Adoption of this strategy has been variable. We evaluated the impact of an institutional quality improvement (QI) initiative to reduce the use of triple therapy (TT, OAC + DAPT) and improve discharge communication post-PCI. A hospital-wide QI initiative was developed to minimize time on TT post-PCI. Interventions included institutional guidelines emphasizing discharge on OAC with a P2Y12 inhibitor or reducing TT duration to ≤30 days, changes to the computerized decision-support system, and an educational curriculum for house staff. PCI patients 18 months before and after the initiative (2017-2020) were reviewed along with a faculty survey assessing prescribing practices to evaluate the efficacy of the interventions. Among 2797 PCIs reviewed, 431 were included based on OAC at discharge: 24.9% female, 80.1% White, and the mean age was 74 years. The most common indications for OAC were atrial fibrillation (70.1%) and left ventricular dysfunction (11.4%). Mean duration of TT decreased (58.7-37.8 days, p = 0.02) and patients discharged on TT ≤ 30 days increased (24%-37%, p = 0.019) after intervention. Of surveyed faculty (n = 20), 75.0% reported familiarity with the guidelines and 57.9% reported using them to make therapy decisions. Following the implementation of a QI initiative, fewer patients were discharged on TT and shorter durations of TT were used. Similar initiatives should be considered at institutions with the prevalent use of TT post-PCI.

D-24 | Reducing Use of Triple Therapy after Percutaneous Coronary Intervention: Results from a Hospital-wide Quality Improvement Initiative

Randomized trials have shown that for patients on oral anticoagulants (OAC), a short course of dual antiplatelet therapy (DAPT) with OAC reduces post-percutaneous coronary intervention (PCI) bleeding without increasing ischemic events. However, adoption of this strategy has been variable. Here we evaluate the impact of an institutional initiative to reduce the use of triple therapy (TT, OAC + DAPT) post-PCI.

Confidence-weighted Testing as an Impactful Education Intervention within a Pediatric Sepsis Quality Improvement Initiative.

Confidence-weighted testing assesses learners' beliefs about their knowledge and skills. As part of a hospital-wide quality improvement initiative to enhance care for pediatric patients with suspected sepsis, we developed a novel intervention using confidence-weighted testing to identify institutional areas of misinformation and knowledge gaps while also providing real-time feedback to individual learners. We developed pediatric sepsis eLearning modules incorporating confidence-weighted testing. We distributed them to nurses, advanced practitioners, and physicians in emergency departments and acute care/non-intensive care unit inpatient settings in our hospital system. We analyzed completion and response data over 2 years following module distribution. Our outcomes included completion, confidently held misinformation (CHM; when a learner answers a question confidently but incorrectly), struggle (when a learner repeatedly answers a question incorrectly or with low confidence), and mastery (when a learner initially answers a question correctly and confidently). Eighty-three percent of assigned learners completed the modules (1,463/1,754). Although nurses had significantly more misinformation and struggled more than physicians and advanced practitioners, learners of all roles achieved 100% mastery as part of module completion. The greatest CHM and struggle were found in serum lactate interpretation's nuances and the hemodynamic shock states commonly seen in sepsis. Our novel application of confidence-weighted testing enhanced learning by correcting learners' misinformation. It also identified systems issues and institutional knowledge gaps as targets for future improvement.

Danger in the jungle: sensible care to reduce avoidable acute kidney injury in hospitalized children

When children require hospital admission, many receive medications with nephrotoxic potential. As such, this can translate into an increased risk of acute kidney injury. In this context, acute kidney injury is hospital acquired, often iatrogenic, and portends risk of adverse outcomes. The Nephrotoxic Injury Negated by Just-in-Time Action study implemented a multicenter hospital-wide quality improvement initiative to detect and reduce nephrotoxin exposure in children aimed at decreasing the rates of potentially avoidable acute kidney injury. This commentary explores the findings and implications of the Nephrotoxic Injury Negated by Just-in-Time Action study.

A Resident-Led Initiative to Increase Documentation of Surrogate Decision Makers for Hospitalized Patients.

Identification of surrogate decision makers (SDMs) is an important part of advance care planning for hospitalized patients. Despite its importance, the best methods for engaging residents to sustainably improve SDM documentation have not been identified. We implemented a hospital-wide quality improvement initiative to increase identification and documentation of SDMs in the electronic health record (EHR) for hospitalized patients, utilizing a Housestaff Quality and Safety Council (HQSC). EHR documentation of SDMs for all adult patients admitted to a tertiary academic hospital, excluding psychiatry, were tracked and grouped by specialty in a weekly run chart during the intervention period (July 2015 through April 2016). This also continued postintervention. Interventions included educational outreach for residents, monthly plan-do-study-act cycles based on performance feedback, and a financial incentive of a one-time payment of 0.75% of a resident's salary put into the retirement account of each resident, contingent on meeting an SDM documentation target. Comparisons were made using statistical process control and chi-square tests. At baseline, SDMs were documented for 11.1% of hospitalized adults. The intervention period included 9146 eligible admissions. Hospital-wide SDM documentation increased significantly and peaked near the financial incentive deadline at 48% (196 of 407 admissions, P < 001). Postintervention, hospital-wide SDM documentation declined to 30% (134 of 446 admissions, P < .001), but remained stable. This resident-led intervention sustainably increased documentation of SDMs, despite a decline from peak rates after the financial incentive period and notable differences in performance patterns by specialty admitting service.

Pain Experience in a US Children's Hospital: A Point Prevalence Survey Undertaken After the Implementation of a System-Wide Protocol to Eliminate or Decrease Pain Caused by Needles.

Pain in hospitalized children remains under-assessed and undertreated. With this study, we aim to describe results from a repeat single-day, hospital-wide survey of children's pain and its treatment after the initiation of a hospital-wide quality improvement initiative used to reduce or eliminate pain caused by needle procedures. All patients and parents listed on the inpatient morning census, in emergency department and outpatient surgery registration lists, were invited to participate in a brief single-day point prevalence survey of their experience with pain and its management in the hospital setting. Results were compared with a survey conducted 2 years earlier, before implementation of a system-wide Children's Comfort Promise needle pain treatment and prevention protocol. A total of 194 children and their parents participated in the current survey. A higher percentage of children reported having no pain compared with the previous survey (33% vs 24%; P = .07; not significant) and fewer experienced severe pain (score ≥7 out of 10). Fewer children identified pain caused by needles as the cause of the worst pain (21% vs 30%), although it remained the highest reported cause of the most painful experience overall. The number of pain management strategies administered and offered to children with needle pain (distraction, positioning, numbing cream, and sucrose and/or breastfeeding for infants) increased. The implementation of a mandatory Comfort Promise protocol used to minimize or prevent pain caused by elective needle procedures was associated with a significant reduction in overall pain prevalence and improved use of evidence-based practices for needle pain management.

Effect of a Hospitalwide Quality Improvement Initiative to Promote High-Value Care

In the United States, regulatory bodies, state licensing boards, hospital accreditation organizations, and medical specialty boards have increased their demands for data, public reporting, and improvement. Survey research suggests that as much as $15 billion is spent on reporting quality measures, but those costs, as well as those associated with improvement, have not been sufficiently characterized. A study was conducted to examine, in detail, the costs incurred by one health care organization—an academic health center (AHC) with employed physicians—in responding to quality and safety requirements.To identify annual costs associated with an AHC's quality and safety infrastructure, a conceptual model was developed for organizing costs into four domains—Measurement and Reporting, Safety, Quality Improvement, and Training and Communication. In an inventory approach, a purpose-specific instrument was used to aggregate and sort costs; clinicians and administrators were asked to identify all domain activities and the associated full-time equivalents and other direct costs (labor and nonlabor) allocated to each activity.For this AHC, nearly $30 million of direct costs—more than 1.1% of net patient service revenue—were incurred to maintain the quality infrastructure. Approximately 81.6% of the costs were associated with mandates by regulators, accreditors, and payers—49.8% of which supported required public reporting.Indisputable good for patients and providers has resulted from organizational investments in quality and safety. But policy makers must be cognizant of potential trade-offs and explicitly recognize the incremental costs of additional measurement, improvement, and mandated reporting in their decision making.

Abstract WP321: Strokes in Your Own Backyard: A Hospital Wide Quality Improvement Initiative to Create and Improve Inpatient Code Stroke Metrics Which Lead to Quicker Interventions

Introduction: TARGET:STROKE (TS) has established metrics for hospitals to measure the timely administration of thrombolytics. However, these time metrics may not apply to patients who suffer a stroke while admitted to the hospital, since the initial time is the emergency department (ED) door time. The aim of this project was to create metrics and an algorithm applicable to an Inpatient Code Stroke (ICS), and assess a hospital wide education series to improve times to intervention. Methods: ICS metrics defined by TS were established with the Symptom Recognition Time (SRT) to equate to the ED door time, and assessed pre and post intervention. The intervention was a hospital wide education of stroke symptoms, as well the ICS process. A badge reference card with this information was given to nurses. Data were recorded for 6 months pre and post implementation. Outcomes included SRT to stroke team notification, CT scan initiation and interpretation, thrombolytic administration and groin puncture. Fisher’s Exact and Wilcoxon Rank Sum Tests were used for data analysis. Results: There were 86 ICS activations (34 pre and 51 post intervention). There was no difference in baseline demographics, and ICS activation based on unit type. Surgical patients were the most common to have an ICS activation (25.8%). There was a strong trend of SRT to stroke team notification being faster post intervention (median: 22 [0-435] mins pre vs. 12 [0-187] mins post, p=0.059). SRT to groin puncture was faster post intervention (median: 131 [0-286] mins pre vs. 67 [38-91] post, p=0.006). There were more patients who had SRT to thrombolytic ≤ 60 mins or SRT to groin puncture ≤ 90 mins post-intervention (4 [33.3%] pre vs. 10 [71.4%] post, p=0.036). Conclusion: This is the first study to demonstrate that implementation of an ICS algorithm and its accompanying education can increase the percentage of patients who receive thrombolytics and groin puncture for thrombectomy ≤ 60 mins and ≤ 90 mins from SRT, respectively.

Improving Response to Suspected Sepsis: Results of a Hospital-wide Quality Improvement Initiative

Improving Response to Suspected Sepsis: Results of a Hospital-wide Quality Improvement Initiative

Impact of a Successful Speaking Up Program on Health-Care Worker Hand Hygiene Behavior.

Background:Health-care worker (HCW) hand hygiene (HH) is the cornerstone of efforts to reduce hospital infections but remains low. Real-time mitigation of failures can increase process reliability to > 95% but has been challenging to implement for HH.Objective:To sustainably improve HCW HH to > 95%.Methods:A hospital-wide quality improvement initiative to improve HH was initiated in February 2012. HCW HH behavior was measured by covert direct observation utilizing multiple-trained HCW volunteers. HH compliance was defined as correct HH performed before and after contact with the patient or the patient’s care area. Interventions focusing on leadership support, HCW knowledge, supply availability, and culture change were implemented using quality improvement science methodology. In February 2014, the hospital began the Speaking Up for Safety Program, which trained all HCWs to identify and mitigate HH failures at the moment of occurrence and addressed known barriers to speaking up.Results:Between January 1, 2012, and January 31, 2016, there were 30,514 HH observations, averaging 627 observations per month (9% attending physicians, 12% resident physicians, 46% nurses, 33% other HCW types). HCW HH gradually increased from 75% to > 90% by December 2014. After the Speaking Up for Safety Program, HCW HH has been > 95% for 20 months. Physician HH compliance has been above 90% for over a year.Conclusion:Creating a specific process for staff to speak up and prevent HH failures, as part of a multimodal improvement effort, can sustainably increase HCW HH above 95%.

Impact of a Hospitalwide Quality Improvement Initiative on Emergency Department Throughput and Crowding Measures

This pre- and postintervention analysis evaluates the impact of a systemwide, comprehensive, executively supported quality improvement (QI) project on emergency department (ED) throughput measures and crowding in a large nonacademic community hospital. The two primary endpoints used to assess the impact of the project were (1) the percentage of all patients who were door-in to door-out in less than three hours and (2) the percentage of patients who left without being seen (LWBS). Secondary endpoints for throughput were mean door-in to door-out, door-in to physician, physician to disposition, and disposition to door-out times for all patients. Secondary endpoints for crowding were median disposition to door-out time of admitted patients and the percentage of admitted patients with a disposition to door-out time of ≥ one, two, and six hours. A total of 666,640 patient visits were included in the primary endpoint analyses, with no patients excluded. The percentage of patients meeting the three-hour door-in to door-out goal after the QI project was 81.4%, versus 46.5% in the pre-QI group (difference, 34.9 percentage points; 95% confidence interval [CI] = 34.7-35.1; p < 0.0001). The postintervention LWBS rate was 0.49%, versus 4.00% in the pre-QI group (difference, 3.51 percentage points; 95% CI = 3.43-3.58; p < 0.0001). A total of 417,673 patient visits were screened for inclusion for the secondary endpoint analyses. The pre-QI and post-QI groups were also compared for secondary endpoints, and significant improvement was noted in all analyses. This study suggests that a comprehensive systemwide and executively supported QI project can make sustained multiyear improvements in ED throughput and LWBS. Further research is needed to determine if this standardized set of changes can be generalized to other hospital systems.

Abstract 125: Improving ECG Services at a Children’s Hospital: Implementation of a Digital ECG System

Background: Pediatric ECGs and ECG interpretation were all paper-based until 2012 at our Children’s Hospital. There were significant delay between the time when the ECGs were performed and when they were officially interpreted by a cardiologist for the formal the medical records. To better understand the factors contributing to the delay or failure to complete an ECG report, we created a Fishbone (Ishikawa) Diagram to help facilitate a solution. (See Diagram 1 below). We hypothesized that the introduction of a completely digital ECG system would increase the volume of ECGs interpreted and improve the capture and billing of ECG services. Diagram 1-Fishbone diagram of factors affecting ECG flow Methods: As part of a hospital wide quality improvement initiative, a digital ECG service (Muse®, GE) was implemented at the Children’s Hospital at Montefiore in June 2012. The total volume of ECGs performed in the first 6 months of the digital ECG era (Post-Digital, June 2012 - Dec 2012) was compared to 18 months of the pre-digital era (Pre-Digital, Jan 2011 - May 2012). In addition, billing times were compared in the Pre-Digital and Post-Digital eras and an assessment of workflow were performed. Pre-Digital and Post-Digital data were compared via t-tests. (Diagram 2 illustrates the ECG workflow in both eras) Diagram 2-ECG workflow in the Pre Digital vrs Digital Eras Results: Table 1 Conclusion: Implementation of a digital ECG system increased the volume of ECGs interpreted and reported at a children’s Hospital.

Improving ECG Services at a Children's Hospital: Implementation of a Digital ECG System.

Background. The use of digital ECG software and services is becoming common. We hypothesized that the introduction of a completely digital ECG system would increase the volume of ECGs interpreted at our children's hospital. Methods. As part of a hospital wide quality improvement initiative, a digital ECG service (MUSE, GE) was implemented at the Children's Hospital at Montefiore in June 2012. The total volume of ECGs performed in the first 6 months of the digital ECG era was compared to 18 months of the predigital era. Predigital and postdigital data were compared via t-tests. Results. The mean ECGs interpreted per month were 53 ± 16 in the predigital era and 216 ± 37 in the postdigital era (p < 0.001), a fourfold increase in ECG volume after introduction of the digital system. There was no significant change in inpatient or outpatient service volume during that time. The mean billing time decreased from 21 ± 27 days in the postdigital era to 12 ± 5 days in the postdigital era (p < 0.001). Conclusion. Implementation of a digital ECG system increased the volume of ECGs officially interpreted and reported.

Nonpunitive Medication Error Reporting

To identify underlying practices and attitudes on medication error occurrences and reporting practices. In response to a hospital-wide quality improvement initiative, a task force was formed to facilitate a nonpunitive culture toward reporting medication errors. To identify underlying practices and attitudes on medication errors and medication error reporting, a baseline survey was conducted. Based on findings, an initiative that included modifications to clinical and administrative processes was developed and implemented. A pre/post initiative questionnaire to measure staff practices and attitudes on medication error reporting was developed and administered. Findings from the presurvey were used to craft the Nonpunitive Patient Safety Policy and its implementation plan. Pre-post comparative analysis was performed following a baseline-postimplementation design. Conceptually, a medication error is qualified by its outcome severity. Medication errors with more serious outcomes are more likely to be reported than those with less serious ones. Staff perception that medication error reporting carries the risks of disciplinary action was identified as a primary barrier to the likelihood of reporting. Evaluation of the initiative suggests that a multicomponent approach facilitates positive movement in the direction of a nonpunitive culture toward reporting medication errors.