Structured Quality Improvement Research Articles

Delirium Screening in Critically Ill Children: Secondary Analysis of the Multicenter PICU Up! Pilot Trial Dataset, 2019-2020.

To determine the patient-level factors associated with performing daily delirium screening in PICUs with established delirium screening practices. A secondary analysis of 2019-2020 prospective data from the baseline phase of the PICU Up! pilot stepped-wedge multicenter trial (NCT03860168). Six PICUs in the United States. One thousand sixty-four patients who were admitted to a PICU for 3 or more days. None. Of 1064 patients, 74% (95% CI, 71-76%) underwent delirium screening at least once during their PICU stay. On 57% of the 8965 eligible patient days, screening was conducted. The overall prevalence of delirium was 46% across all screened days, and 64% of screened patients experienced delirium at some point during their PICU stay. Factors associated with greater adjusted odds ratio (aOR) of increased daily delirium screening included PICU stay longer than 15 days compared with 1-3 days (aOR 3.36 [95% CI, 2.62-4.30]), invasive mechanical ventilation as opposed to room air (aOR 1.67 [95% CI, 1.32-2.12]), dexmedetomidine infusions (aOR 1.23 [95% CI, 1.04-1.44]) and propofol infusions (aOR 1.55 [95% CI, 1.08-2.23]). Conversely, decreased aOR of daily delirium screening was associated with female gender (aOR 0.78 [95% CI, 0.63-0.96]), and the administration of continuous infusions of opioids (aOR 0.75 [95% CI, 0.63-0.90]) or ketamine (aOR 0.48 [95% CI, 0.29-0.79]). Neither patient age, the presence of family or physical restraints, or benzodiazepine infusions were associated with daily delirium screening rates. In the 2019-2020 PICU UP! cohort, across six PICUs, delirium screening occurred on only 57% of days, despite the presence of established practices. Female gender, patients in the early stages of their PICU stay, and patients not receiving mechanical ventilation were associated with lower odds of daily delirium screening. Our results highlight the need for structured quality improvement processes to both standardize and increase the frequency of delirium screening.

Challenges and Strategies of Higher Vocational Education in China with the New Demographics-Based on the Data Analysis of China’s Seventh National Census

There is an important connection between the development of higher vocational education and the national demographics. According to the data of the seventh national census, China is facing a population reality with negative growth, an inverted pyramid structure, expanding migration, and stable quality improvement. The change in demographics sets out new requirements for the goal, types, structure and quality of higher vocational education. To develop higher vocational education, we should constantly optimize development planning, expand development types, optimize resource allocation and improve development quality.

Abstract 14430: The Corcare Heart Function Optimization Protocol: A Structured Quality Improvement Intervention to Improve Goal Directed Targets for Patients With Reduced Ejection Fraction

Introduction: Reduced ejection fraction (REF) in patients is prevalent, utilizing substantial health care resources. Goal Directed Therapy (GDT) reduces hospitalization, morbidity, and mortality but use is suboptimal. Care in subspecialty clinics following discharge reduces readmission, but is not scaled for longitudinal care of the larger REF population. Canadian guidelines support integration of primary, specialist, and non-physician care in systems to improve outcomes. Hypothesis: A protocol-guided intervention will achieve high rates of GDT for REF patients in a community health care setting. Goal: To evaluate a pragmatic quality-of-care intervention to achieve GDT for REF patients and assess barriers to GDT. Methods: Patients referred for imaging and cardiology consultation at a community facility (Jan 1/15-Dec 31/22) were screened. Patients with LVEF <41% on echocardiogram were included if their cardiologist consented to study protocol GDT and were enrolled at the next scheduled, usual care cardiologist visit. 2 project nurses confirmed patient status and assisted GDT management using medical directives at 9 protocol-specified visits between usual care visits over 32 weeks. The primary target was achieving GDT or maximally tolerated GDT (>0 mg). A secondary endpoint, clinical inertia, was defined as not achieving GDT due to physician or patient choice. Results: 864 patients (13 cardiologists) participated: median age 71 (28-102) years, diabetes 25%, hypertension 60%, atrial fibrillation 22%. At intake: NYHA class ≥2 (60%), EF <30% (45%), 30-35% (27%), 36-40% (29%), REF etiology ischemic (47%), non-ischemic (43%), mixed (10%). The majority achieved GDT in each class; inertia, not intolerance predominantly accounted for those who did not achieve GDT. Conclusion: This pragmatic community-based intervention achieved high rates of GDT that could improve longitudinal care for REF patients, and is potentially scalable and generalizable.

Evaluating the Influence of Land Use and Landscape Pattern on the Spatial Pattern of Water Quality in the Pearl River Basin

Differences in land use and landscape patterns have become crucial factors affecting regional water quality. In order to investigate the effects of different land use and landscape patterns on water quality, this study used dissolved oxygen (DO), ammonia nitrogen (NH4+-N), and potassium permanganate index (CODMn) from 147 conventional water quality monitoring stations in the Pearl River basin of China from January to December 2021 as representative water quality parameters. The quantitative relationship between land use, landscape pattern, and water quality in the Pearl River basin was investigated using geographic information system technology (GIS) and partial least squares (PLS). The results showed that the overall water quality of the Pearl River basin was relatively positive and mainly threatened by organic pollution. The water quality of the Pearl River basin was affected by the spatial characteristics of land use and landscape pattern, showing a poorer spatial pattern on the eastern and western ends and a better one in the central part of the basin. The developed PLS regression model could better explain the quantitative relationship between water quality, land use, and landscape pattern, concluding that unused urban land has the greatest impact on water quality, with an impact coefficient of more than 0.10. The interspersion juxtaposition index (IJI) for representing landscape patterns had the greatest impact on water quality indicators, with an impact coefficient of −0.15 on DO, 0.13 on NH4+-N, and 0.15 on CODMn, respectively. Meanwhile, land use types such as unused land and water and landscape patterns indicated by the Shannon diversity index (SHDI) and the contagion index (CONTAG) had significant effects on watershed water quality. The results of the study provide a reference value for the optimal adjustment of land use structure and water quality improvement in the basin.

Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department

The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.

Improving Geometric Validation Metrics and Ensuring Consistency with Experimental Data through TrioSA: An NMR Refinement Protocol.

Protein model refinement a the crucial step in improving the quality of a predicted protein model. This study presents an NMR refinement protocol called TrioSA (torsion-angle and implicit-solvation-optimized simulated annealing) that improves the accuracy of backbone/side-chain conformations and the overall structural quality of proteins. TrioSA was applied to a subset of 3752 solution NMR protein structures accompanied by experimental NMR data: distance and dihedral angle restraints. We compared the initial NMR structures with the TrioSA-refined structures and found significant improvements in structural quality. In particular, we observed a reduction in both the maximum and number of NOE (nuclear Overhauser effect) violations, indicating better agreement with experimental NMR data. TrioSA improved geometric validation metrics of NMR protein structure, including backbone accuracy and the secondary structure ratio. We evaluated the contribution of each refinement element and found that the torsional angle potential played a significant role in improving the geometric validation metrics. In addition, we investigated protein-ligand docking to determine if TrioSA can improve biological outcomes. TrioSA structures exhibited better binding prediction compared to the initial NMR structures. This study suggests that further development and research in computational refinement methods could improve biomolecular NMR structural determination.

Establishment of a national quality improvement process on oxygen delivery index during cardiopulmonary bypass.

Targeted oxygen delivery during cardiopulmonary bypass (CPB) has received significant attention due to its influence on patient outcomes, especially in mitigating acute kidney injury. While it has gained popularity in select institutions, there remains a gap in establishing it globally across multiple centers. The purpose of this investigation was to describe the development of a quality improvement process of targeted oxygen delivery during CPB across hospitals throughout the United States. A systematic approach to utilize oxygen delivery index (DO2i) as a key performance indicator within hospitals serviced by a national provider of perfusion services. The process included a review of the current literature on DO2i, which yielded a target nadir value (272mL/min/m2) and an area under the curve (DO2i272AUC) cut off of 632. All data is displayed on a dashboard with results categorized across multiple levels from system-wide to individual clinician performance. From January 2020 through December 2022, DO2i data from 91 hospitals and 11,165 coronary artery bypass graft procedures were collected. During this period the monthly proportion of DO2i measurements above the target nadir DO2i272 ranged from 60.5% to 78.4% with a mean+/-SD of 70.8 +/- 4.2%. Binary logistic regression for the first 7months following monthly DO2i performance reporting has shown a statistically significant positive linear trend in the probability of achieving the target DO2i272 (p < .001), with a crude increase of approximately 7.8% for DO2i272AUC, and a 73.8% success rate (p < .001). A survey was sent to all individuals measuring oxygen delivery during CPB to assess why a target DO2i272 could not be reached. The two most common responses were an 'inability to improve CPB flow rates' and 'restrictive allogeneic red blood cell transfusion policies'. This study demonstrates that targeting a minimum level of oxygen delivery can serve as a key performance indicator during CPB using a structured quality improvement process.

Abstract 53: Implementing Equitable Cancer Support Program: Lessons From Cervical Cancer Chemotherapy Access Program (C3AP)

Abstract Purpose: There is an inverse relationship between diagnosis to initiation of treatment interval and outcome of cancer treatment. A significant number of diagnosed cervical cancer patients don’t receive timely treatment in low resource settings. The Cervical Cancer Chemotherapy Access Program (C3AP) is one of End Cervical Cancer Nigeria Initiative’s interventions to IMProve Access to Cervical Cancer Treatment (IMPACT) in low resource settings. This report provides documentary evidence of the evolution of the implementation of the C3AP and highlights best practices that can be scaled up. Methods: The C3AP was conceptualized to increase the proportion of diagnosed cervical cancer patients that receive timely treatment by exploring adjuvant and neoadjuvant role of chemotherapy in the management of cervical cancer patients in settings where access to radiotherapy services can not be guaranteed. We instituted Plan Do Study and Act (PDSA) quality improvement cycle for the C3AP and used RE-AIM framework to study the implementation processes to be acted upon as part of the PDSA quality improvement process towards improving reach of the program. Results: The C3AP supported treatment of only 4 patients over the reporting period of 5months. Poor referral to the program is a major hurdle the program is battling. Only 2(17%) of the 12 confirmed cases of cervical cancer diagnosed in the facility within the 5month study period were able to access chemoradiation, suggesting a missed opportunity for 6/10(60%) that couldn’t afford chemoradiation. The program evolved over a PDSA cycle to eliminate social eligibility in the criteria to access the support thereby able to shorten application -support interval to same day with potential positive impact on prognosis. Conclusion: Providing equitable support for indigent cancer patients should be beyond the emotion to help humanity. We recommend the use of structured quality improvement for all programs providing support to indigent cancer patients to ensure implementation fidelity. Citation Format: Qudus Lawal, Kasimu Umar Adoke, Jummai Jimeta Tuko, Aminu Magashi Garba, Ishak K. Lawal. Implementing Equitable Cancer Support Program: Lessons From Cervical Cancer Chemotherapy Access Program (C3AP) [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 53.

Factors Impacting Treatment of Out-of-Hospital Cardiac Arrest: A Qualitative Study of Emergency Responders.

Background Of the more than 250 000 emergency medical services-treated out-of-hospital cardiac arrests that occur each year in the United States, only about 8% survive to hospital discharge with good neurologic function. Treatment for out-of-hospital cardiac arrest involves a system of care that includes complex interactions among multiple stakeholders. Understanding the factors inhibiting optimal care is fundamental to improving outcomes. Methods and Results We conducted group interviews with emergency responders including 911 telecommunicators, law enforcement officers, firefighters, and transporting emergency medical services personnel (ie, emergency medical technicians and paramedics) who responded to the same out-of-hospital cardiac arrest incident. We used the American Heart Association System of Care as the framework for our analysis to identify themes and their contributory factors from these interviews. We identified 5 themes under the structure domain, which included workload, equipment, prehospital communication structure, education and competency, and patient attitudes. In the process domain, 5 themes were identified focusing on preparedness, field response and access to patient, on-scene logistics, background information acquisition, and clinical interventions. We identified 3 system themes including emergency responder culture; community support, education, and engagement; and stakeholder relationships. Three continuous quality improvement themes were identified, which included feedback provision, change management, and documentation. Conclusions We identified structure, process, system, and continuous quality improvement themes that may be leveraged to improve outcomes for out-of-hospital cardiac arrest. Interventions or programs amenable to rapid implementation include improving prearrival communication between agencies, appointing patient care and logistical leadership on-scene, interstakeholder team training, and providing more standardized feedback to all responder groups.

Improving Compliance With Institutional Performance on Train of Four Monitoring.

We performed a multistep quality improvement project related to neuromuscular blockade and monitoring to evaluate the effectiveness of a comprehensive quality improvement program based upon the Multi-institutional Perioperative Outcomes Group (MPOG) Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) metrics targeted specifically at improving train of four (TOF) monitoring rates. We adapted the plan-do-study-act (PDSA) framework and implemented 2 PDSA cycles between January 2021 and December 2021. PDSA Cycle 1 (Phase I) and PDSA Cycle 2 (Phase II) included a multipart program consisting of (1) a departmental survey assessing attitudes toward intended results, outcomes, and barriers for TOF monitoring, (2) personalized MPOG ASPIRE quality performance reports displaying provider performance, (3) a dashboard access to help providers complete a case-by-case review, and (4) a web-based app spaced education module concerning TOF monitoring and residual neuromuscular blockade. Our primary outcome was to identify the facilitators and barriers to implementation of our intervention aimed at increasing TOF monitoring. In Phase I, 25 anesthesia providers participated in the preintervention and postintervention needs assessment survey and received personalized quality metric reports. In Phase II, 222 providers participated in the preintervention needs assessment survey and 201 participated in the postintervention survey. Thematic analysis of Phase I survey data aimed at identifying the facilitators and barriers to implementation of a program aimed at increasing TOF monitoring revealed the following: intended results were centered on quality of patient care, barriers to implementation largely encompassed issues with technology/equipment and the increased burden placed on providers, and important outcomes were focused on patient outcomes and improving provider knowledge. Results of Phase II survey data was similar to that of Phase I. Notably in Phase II a few additional barriers to implementation were mentioned including a fear of loss of individualization due to standardization of patient care plan, differences between the attending overseeing the case and the in-room provider who is making decisions/completing documentation, and the frequency of intraoperative handovers. Compared to preintervention, postintervention compliance with TOF monitoring increased from 42% to 70% (28% absolute difference across N = 10 169 cases; P < .001). Implementation of a structured quality improvement program using a novel educational intervention showed improvements in process metrics regarding neuromuscular monitoring, while giving us a better understanding of how best to implement improvements in this metric at this magnitude.

Comprehensive quality initiative leads to immediate postoperative extubation following liver transplant

BackgroundImmediate postoperative extubation (IPE) can reduce perioperative complications and length of stay (LOS), however it is performed variably after liver transplant across institutions and has historically excluded high-risk recipients from consideration. In late 2012, we planned and implemented a single academic institution structured quality improvement (QI) initiative to standardize perioperative care of liver transplant recipients without exceptions. We hypothesized that such an approach would lead to a sustained increase in IPE after primary (PAC) and delayed abdominal closure (DAC). MethodsWe retrospectively studied 591 patients from 2013 to 2018 who underwent liver transplant after initiative implementation. We evaluated trends in incidence of IPE versus delayed extubation (DE), and reintubation, LOS, and mortality. ResultsOverall, 476/591 (80.5%) recipients underwent PAC (278 IPE, 198 DE) and 115/591 (19.5%) experienced DAC (39 IPE, 76 DE). When comparing data from 2013 to data from 2018, the incidence of IPE increased from 9/67 (13.4%) to 78/90 (86.7%) after PAC and from 1/12 (8.3%) to 16/23 (69.6%) after DAC. For the same years, the incidence of IPE after PAC for recipients with MELD scores ≥30 increased from 0/19 (0%) to 12/17 (70.6%), for recipients who underwent simultaneous liver-kidney transplant increased from 1/8 (12.5%) to 4/5 (80.0%), and for recipients who received massive transfusion (>10 units of packed red blood cells) increased from 0/17 (0%) to 10/13 (76.9%). Reintubation for respiratory considerations <48 h after IPE occurred in 3/278 (1.1%) after PAC and 1/39 (2.6%) after DAC. IPE was associated with decreased intensive care unit (HR of discharge: 1.92; 95% CI: 1.58, 2.33; P < 0.001) and hospital LOS (HR of discharge: 1.45; 95% CI: 1.20, 1.76; P < 0.001) but demonstrated no association with mortality. ConclusionA structured QI initiative led to sustained high rates of IPE and reduced LOS in all liver transplant recipients, including those classified as high risk.

Impact of a quality improvement intervention on neonatal mortality in a regional hospital in Burkina Faso

Background The neonatal period is the most vulnerable time in terms of a child’s survival, with mortality during this period accounting for approximately half of the deaths before the age of 5 years. The Neonatal Essential Survival Technology (NEST) project is a program aiming to reduce mortality by improving the quality of neonatal care in sub-Saharan Africa. This study presents the evaluation of the first phase of the NEST intervention program at Saint Camille Hospital Ouagadougou (HOSCO), Burkina Faso, in terms of the reduction in neonatal mortality. Methods This is a retrospective analysis, based on “pre-intervention” data collected in 2015, and “post-intervention” data collected in 2018, including all infants admitted to the neonatal unit of HOSCO. The intervention period (2016 and 2017) comprised a structured quality improvement process conducted by a multidisciplinary working group that focused on improving infrastructure, equipment, training and use of clinical protocols, team working within the neonatal unit and with other hospital departments, and communication with referring healthcare facilities. Mortality data were compared pre- vs. post-intervention using a logistic regression model. Results The analysis included 1427 infants in the pre-intervention period, and 819 post-intervention. In both time periods, more than 75% of admissions were infants with low birth weight, and nearly 50% were very low birth weight. Post-intervention, while there was a decrease in overall admission, the proportion of multiple births increased from 20% to 24% (p = .01). The overall mortality rate was 44.9% (641/1427) pre-intervention, and 42.2% (346/819) post-intervention (OR 0.90, 95% confidence interval (CI) 0.76–1.07; p = .23). Adjusting for clinically relevant factors, the intervention was not associated with a change in overall mortality (OR 1.39, 95% CI 0.91–2.12; p = .13), but was associated with a reduced likelihood of mortality in outborn infants compared to inborn infants (OR 0.57, 95% CI 0.36–0.92; p = .02). Conclusions The first phase of the NEST quality improvement program was associated with a decrease in mortality in outborn infants admitted to the neonatal unit at HOSCO. Long-term assessment is expected to provide a more comprehensive evaluation of the program in a low-income setting.

Preventing Teen Pregnancies on Teratogenic Drugs by Quality Improvement and Behavioral Economics.

Adolescents with chronic disease engage in sexual activity similar to their healthy peers, with generally low utilization of contraception. Adolescents with rheumatic diseases prescribed teratogenic medications may be at risk for unplanned pregnancy. Using structured quality improvement (QI) methods with behavior economic (BE) principles, a multidisciplinary team aimed to implement pregnancy prevention processes for females on high-risk medications. We leveraged BE-inspired interventions including improved accessibility of consents, utilizing distinctly colored consent forms, real-time reminders, peer comparison, and audit and feedback. Our primary aim was to increase the number of days between pregnancies for postmenarcheal females followed in rheumatology clinics who were taking teratogenic medications. Phase 1 focused on annual consenting of female adolescents prescribed teratogenic drugs. Phase 2 emphasized sexual history screening and pregnancy prevention planning at every clinic visit for females ≥12 years on teratogenic medications. We increased the days between pregnancies for female adolescents prescribed teratogenic medications from 52 days to >900 days by using QI methodology with BE strategies. In phase 1, annual consents for postmenarcheal patients on teratogenic medications improved from 0% in 2017 to 95% in 2021. In phase 2, sexual history screening and pregnancy prevention planning at every clinic visit improved from 2% in 2019 to over 78% in 2021. A multiphase, multidisciplinary QI project with integration of behavior economic strategies can improve patient and caregiver counseling to prevent unplanned pregnancies for adolescents on teratogenic medications.

2022 Association for Vascular Access Scientific Meeting: Poster Abstracts

2022 Association for Vascular Access Scientific Meeting: Poster Abstracts

2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

Compositions and properties of high-conductivity nitrogen-doped p-type β-Ga2O3 films prepared by the thermal oxidation of GaN in N2O ambient

A remarkable improvement in the conductivity of grown nitrogen-doped p-type β-Ga2O3 films was successfully achieved via the thermal oxidation of GaN in N2O ambient at 1100 °C. In the vacuum test environment, its room temperature Hall hole concentration is 1.64 × 1017 cm−3, the Hall resistivity is 7.66 Ω cm, the Hall hole mobility is 4.98 cm2 V−1 s−1, and the acceptor ionization energy is 0.087 eV. In addition, the compositions and properties were also extensively investigated. When the oxidation temperature was raised from 900 to 1100 °C, the FWHM of the {2¯ 01}-oriented β-Ga2O3 diffraction peak from the X-ray diffraction (XRD) pattern decreased to 0.237°, confirming an improvement in the crystalline quality of the β-Ga2O3 nanocrystal structure. From both the cross-sectional view of the field emission scanning electron microscopy (FESEM) image and the cross-sectional lamellae prepared by focused ion beam (FIB) milling, it was observed that the generated β-Ga2O3 film transformed into a two-layer morphology when oxidized at 1100 °C. The top layer is a rather loose film composed of nanorods, and the selected area electron diffraction (SAED) pattern of a nanorod confirmed it as high-quality (6¯03)-dominated monocrystal β-Ga2O3. The second layer is a comparatively compact β-Ga2O3 film. This approach to the efficient growth of p-type β-Ga2O3 can broaden the applicability of these two-layered structures. The randomly distributed monocrystal nanorods on the top layer are an appropriate candidate for the photocatalyst, while the relatively more compact second layer with high p-type conductivity can be employed in high-performance solar-blind UV photodetectors or high-power electronic devices.

Improving Vitamin D Screening in a Pediatric Rheumatology Clinic Using Structured Quality Improvement Process.

Monitoring levels of 25-hydroxyvitamin D (25-OHD) is an integral part of bone health assessment in the general pediatric population, especially in at-risk populations such as children with juvenile idiopathic arthritis (JIA), childhood-onset systemic lupus erythematosus (c-SLE), and juvenile dermatomyositis (JDM). However, only 38% of the patients with JIA, c-SLE, and JDM receiving care at Nationwide Children's Hospital Rheumatology clinic in 2016 had a 25-OHD level ordered in the preceding year. The objective of this project was to increase the percentage of 25-OHD levels ordered in patients with JIA, c-SLE, and JDM from 38% to 80% in 11 months and sustain it for 6 months. A multidisciplinary team initiated a continuous improvement project utilizing the Lean Six Sigma methodology. The team diagrammed the clinical process and identified steps that needed improvement. In addition, the team completed a root cause analysis of the process and brainstormed subsequent countermeasures. The team did not meet the 80% target but did order a 25-OHD level on 61% of patients by the end of the study period compared to 38% at the start of the study (P value 0.001). The level was sustained after the study period, with 68% of these children having a 25-OHD level ordered. The team successfully improved the screening processes for vitamin D deficiency in a busy subspecialty clinic setting using Lean Six Sigma methodology.

Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm.

Significant adverse drug events (ADEs) due to anesthesia infusion pump programming errors were reported at our institution. We incorporated independent two-provider infusion pump programming verification, an evidence-supported intervention, into our anesthesia medication infusion process with a goal of reducing associated ADEs to zero in 2 years. Using the model for improvement, we developed key drivers and interventions and utilized plan-do-study-act (PDSA) cycles. Drivers included education and training, verification process, visual aids, information technology, and safety culture. Interventions included anesthesia provider training, information dissemination, independent two-provider verification process of smart pump programming, verification documentation capability, verification compliance tracking, and visual aids. Our outcome measures were relevant ADEs and near-miss events. Process and balancing measures were the percentage of smart pump programs with independent second verification and delayed case starts due to second provider verification, respectively. During the project period, only one related grade E ADE occurred, and the root cause was not conducting an independent pump programming verification. Thirteen grade B near-miss events were prevented due to independent second verification. Second verification adherence reached 85% and was sustained, and no delayed case starts occurred. With structured quality improvement methods, the process of independent two-provider verification of infusion pump programming during anesthesia can be successfully implemented, and errors in a high-volume setting reduced without negatively affecting case start times. The cultural and organizational factors we report may aid other institutions in gaining project buy-in and sustainment.

A novel bi-level programming model for structure sustainability optimization of passenger transport corridor

The transportation industry has entered a new stage from quantity expanding to structure optimization, quality and efficiency improvement, and from respective governance to integrative development. This indicates that the traditional corridor mode allocation dominated by quantity equilibrium can no longer meet the requirements of the new stage. In this paper, we propose a multi-entity programming model based on the economic equilibrium between supply and demand. It not only ensures the economic equilibrium in the market, but also maximizes the social benefits of the whole system, thereby realizing the sustainable development of the transportation system. Also, the Globalsearch algorithm and intlinprog algorithm are designed to solve the problem. The actual case of Beijing-Shanghai corridor shows that the model and algorithms are effective, providing decision support for the optimal allocation of regional transport network resources.

Novel solutions to old problems: improving the reliability of emergency equipment provision in critical care using accessible digital solutions

Reliable provision of emergency equipment in Critical Care is key to ensure patient safety during medical emergencies and transfers. A problem was identified in incident reports and external inspections of...