Improvement Project Research Articles

2246 Mind the HAP – an initiative to improve the diagnosis, management and prevention of hospital acquired pneumonia on elderly care

Abstract Introduction The commonest nosocomial infection in the UK is Hospital Acquired Pneumonia (HAP), associated with prolonged length of stay and mortality. The HAP incidence on Elderly care wards was >5% of admissions, exceeding the national average. An initiative ‘Mind the HAP’ was launched which included doctors, nurses, pharmacists, SLTs, physiotherapists and coders to improve HAP diagnosis, management and prevention. Methods To monitor the effectiveness of the interventions 3 audit cycles were performed between 2019 and 2023. Several interventions were implemented between 2019–2023.A multidisciplinary steering committee was formed with 3 work streams (diagnosis, management and prevention). To improve the accuracy of diagnosis and management of HAP, focused educational sessions were conducted for junior doctors with monthly meetings with coders. Nurses championed implementing the HAP prevention strategies i.e. hand hygiene, mouth care and positioning at 30–45 degrees. Regular comprehensive training sessions were held. HAP awareness and education campaign was launched. Daily nursing huddles helped to identify high risk patients. Physiotherapists provide chest physiotherapy to yield sputum sample collection among pneumonia patients. An electronic dashboard of incidence of HAP against the preventative measures and sputum culture reports has been launched with help from informatics. Information leaflets on HAP were created for patient awareness. An electronic HAP power plan to facilitate diagnosis and management of HAP will be launched from February 2024. Results HAP incidence has dropped to <2%, diagnostic accuracy improved from 35% to 81%, and sputum collection has increased from 9% to 24%. The HAP Quality Improvement Project received first prize for the most impactful Quality Improvement initiative at the Trust-wide conference in 2023. The results have been shared with the regional Microbiologists. Conclusion The collaborative efforts coupled with effective leadership and guidance, have been pivotal to the success of ‘Mind the HAP’ project.

2303 Improving the assessment and management of osteoporosis in a district general hospital

Abstract Introduction Over 500,000 fragility fractures occur in the UK each year (1). NICE guidelines state that all women aged ≥65 and all men aged ≥75 should be considered for a fracture risk assessment. It was recognised that locally these guidelines were not being met. The aim of this quality improvement project was to improve the number of patients being assessed for osteoporosis across two medical wards. Method This quality improvement project followed two ‘Plan Do Study Act’ (PDSA) cycles. The first cycle involved teaching sessions for junior doctors on using the FRAX tool—a tool recommended by NICE guidelines to estimate 10-year predicted absolute fracture risk. Posters and visual reminders were placed around the wards. The second cycle involved creating a sticker which was placed in patients’ medical records prompting doctors to calculate FRAX scores and document the results. Patients deemed inappropriate for bone protection and patients already receiving bone protection prior to admission were excluded. Results A baseline set of data showed that 0% of patients had undergone fracture risk assessment, therefore resulting in no patients being prescribed bone protection or being referred to osteoporosis clinic. Repeat assessment after the first intervention showed 29.7% of patients had undergone fracture risk assessment, 13.5% were prescribed bone protection and 16.2% referred to osteoporosis clinic. After the second intervention, 80% of patients had undergone fracture risk assessment, 10% were prescribed bone protection and 55% referred to osteoporosis clinic. Conclusion Use of the FRAX tool was moderately increased by the targeted training of junior doctors and markedly increased by using a visual memorandum in the patient records. This led to an increase in treatment for osteoporosis, reducing patients’ future risk of fragility fractures.

2354 Clinical assessment and documentation of delirium in older patients undergoing vascular surgery: a quality improvement project

Abstract Introduction The Centre for Perioperative Care recommends the assessment and documentation of delirium using a validated tool such as the 4-AT in older people undergoing surgery. Aim This quality improvement project (QIP) aimed to improve the assessment and documentation of delirium in patients aged 65 and above following vascular surgery in a tertiary centre. Methods Patients aged ≥65 years who had undergone vascular surgery were identified and data was collected with access to the electronic patient record system. Analysis was carried out using Microsoft Excel and SPSS. Following baseline measurements taken in August 2023, 1 plan-do-study-act (PDSA) cycle was completed between September 2023–January 2024. Baseline measures Baseline data collected between August 1-31st 2023 identified 51 patients, of which delirium was screened using the 4-AT tool in 39.2% (n = 20), on average 90 hours post-operatively. The 4-AT was never documented in a consultant-led surgical post-operative review (100%, n = 51). There were clinical concerns of post-operative delirium documented in 7 patients, with the 4-AT documented in 5 of those cases. Intervention Interventions included stakeholder discussions to identify key barriers in the assessment and documentation of delirium, multidisciplinary team education and poster reminders across the ward. These were introduced between November–December 2023. Results Post-intervention results reviewed between 10th-31st January 2024 showed that the 4-AT was used to screen for delirium in 61.9% of patients (n = 13), on average 45 hours post-operatively. The 4-AT was never documented in a consultant-led surgical post-operative review. In addition, 2 patients developed delirium post-operatively with the 4-AT reported in both cases. Conclusions This QIP has demonstrated a marked improvement in compliance with national guidelines on the assessment of delirium, highlighting the impact of multidisciplinary education in improving the perioperative clinical pathway for older people undergoing surgery. Future PDSA cycles will focus on improving the documentation of 4AT in the post-operative surgical review.

Supporting the Primary Care Workforce Through Training in Advanced Generalist Practice: An Evaluation of the Catalyst Program.

As a workforce crisis is causing recruitment and retention issues for new to practice GPs, we designed Catalyst, a one-year pilot career development program aiming to help new to practice GPs develop the skills of advanced generalist practice and build capacity for the complex work of primary care. In this paper, we report the findings of our evaluation of Catalyst. We used normalization process theory to investigate how Catalyst was contributing to the participants' understanding and implementation of generalist practice. We conducted 36 interviews and six focus groups investigating the participants' clinical practice and experience with the program and analyzed data using framework analysis. Establishing a shared language and reframing professional identity helped GPs develop an understanding of their role through generalist lenses. Generalist practice was legitimized by access to scientific evidence and facilitated interactive learning. Integration of scientific, applied knowledge and quality improvement work fostered the enactment of such practice. Structured reflection and research-informed quality improvement projects contributed to the participants' awareness of the primary care context. Knowledge creation activities observed through interactive learning and the integration of different types of knowledge facilitated the implementation of advanced generalist practice. The participants valued the community of practice gained through the program and would come to rely on programs designed to encourage networking and enable peer support. Finally, research-informed quality improvement projects built to analyze problems and monitor solutions are crucial for an early career physician to develop a sense of agency that shapes their primary care practice.

2341 Qualitative assessment of introducing bone health assessment for Parkinson’s disease patients in a university hospital setting

Abstract Introduction Parkinson’s disease (PD) patients with or without psychosis are at higher risk of recurrent falls and fracture and, as a consequence, higher mortality and morbidity NICE (13) Henderson et al. (2019). We conducted a qualitative study to understand barriers and facilitators of introducing ‘bone health assessment’ for PD patients. Method We conducted a pilot study to identify and implement a bone health assessment tool to communicate falls and fracture risks to GPs. • SWOT and Stakeholder analysis was conducted to identify an appropriate bone health assessment tool. • PDSA cycles were completed to assess barriers and facilitators of bone health assessment in all PD clinical areas. • 4 Participants were identified from all possible PD clinical settings and trained on how to use the FRAX assessment tool. • Semi structured interviews were conducted to explore themes from 6-week pilot study. Results Bone health assessments were not conducted routinely in PD clinical settings in our Trust Literature review/SWOT and Stake holder analysis identified ‘FRAX’ score as an appropriate bone health assessment tool for PD patients. Interviews with participants identified time constraints during the clinical consultation as a major barrier to conducting bone health assessment using the FRAX assessment tool. All participants agreed that this improved communication with patients and GPs in understanding bone health and risk of falls and fractures. Face to face PD Nurse Clinics were deemed the most appropriate clinical settings for these assessments. Conclusion As a result of this service improvement project bone health is now assessed in all PD Nurse clinics. This has enabled GPs to start the most appropriate bone protection treatment for PD patients.

Risk of transfusion-related iron overload varies based on oncologic diagnosis and associated treatment: Retrospective analysis from a single pediatric cancer center.

Transfusion-related iron overload (TRIO) is a widely acknowledged late effect of antineoplastic therapy in pediatric cancer survivors, but firm guidelines as to screening protocols or at-risk populations are lacking in the literature. We performed retrospective analysis of all oncology patients diagnosed at our center from 2014 to 2019, who underwent TRIO screening as part of an internal quality improvement project. Correlations of MRI-confirmed TRIO with patient-, disease-, and treatment-specific features were evaluated. We show that a tiered screening algorithm for TRIO, when followed as intended, led to the identification of the highest proportion of patients with TRIO. We confirm that cardiac TRIO is quite rare in the oncology patient population. However, accepted surrogate markers including red blood cell transfused volume and ferritin only modestly correlated with TRIO in our patient cohort. Instead, we found that older age, leukemia diagnosis, anthracycline exposure, and receipt of stem cell transplant were most strongly associated with risk for TRIO. We describe associations between TRIO and patient, disease, and treatment characteristics in a multivariate risk model that could lead to an improved risk stratification of off-therapy patients, and which should be validated in a prospective manner.

2211 Improving the proportion of patients > 65 years presenting with delirium who have appropriate bloods checked within 12 hours

Abstract Introduction Early identification and management of all contributory factors is vital in the management of delirium. Delay in investigation can lead to morbidity, mortality, longer length of stay or inappropriate discharge from hospital. We carried out a Quality Improvement project looking to ensure all patients with delirium had appropriate blood tests taken in the Emergency Department (ED). Methods For the first cycle, 25 patients >65 years admitted through ED in December 2022 and January 2023 with delirium were identified based on medical clerking and post take ward round diagnosis. Patients who had a cause for confusion which was clearly known, for example sepsis, were excluded. Data analysis revealed the percentage of patients who had their calcium and CRP bloods checked within 12 hours of admission was only 20% and 76%, respectively. We introduced a simple change: adding bone profile and CRP to the ‘confusion button’ on the ICE electronic requesting and reporting system. A second cycle of data collection was completed for a further 25 patients admitted with delirium between June and July 2023 to measure the effectiveness of the implemented change. Results From our initial analysis, only 20% of patients aged >65 years presenting with delirium had their calcium and 76% of patients had their CRP checked within 12 hours of admission. Following our intervention, we found that 88% of patients had their calcium and 96% of patients had their CRP checked within 12 hours of admission. Conclusion The amendment of the ‘confusion screen’ button, on the ICE requesting system in the hospital, resulted in a significant increase in the number of patents having appropriate blood tests within 12 hours of admission.

2192 Implementation of 4AT and delirium bundle in patient management—a quality improvement project

Abstract Introduction Delirium affects up to 50% of older individuals within hospital environments, with a notable occurrence in 30% of those aged 65 and above in emergency departments. This QIP aimed to enhance the early recognition of delirium by implementing the 4AT assessment and optimise assessments and investigations by implementing the Delirium Bundle. Method A survey involving 39 doctors was conducted to evaluate their comprehension of delirium and awareness of the Delirium Bundle. PDSA 1 involved retrospective data analysis of medical records for patients admitted with delirium and used as a preliminary baseline to evaluate how the delirium bundle is being utilised. PDSA 2 integrated multiple teaching sessions and the implementation of the Delirium Bundle, assessing the effectiveness of these interventions. Results In PDSA 1, twenty-nine patients were identified. None of the patients had a 4AT assessment done. Twenty patients (69%) had a haematological screen done, eight patients (27%) had an ECG done, twenty patients (69%) had a CXR done, eighteen patients (62%) had an MSU test done, eight patients (28%) had cultures done, and twenty-three (79%) had a CT head scan done. In PDSA 2, thirty patients were identified. Seven patients had a 4AT assessment done, sixteen patients (53%) had a haematological screen done, nineteen patients (63%) had an ECG done, twenty-two patients (73%) had a CXR done, fifteen patients (50%) had an MSU test done, fourteen patients (47%) had cultures done, and 20 patients (67%) had a CT head scan done. Conclusion The implemented changes showed effectiveness with increased 4AT assessments and enhanced confusion screening. Improvements in assessments and investigations for diagnosed delirium patients were evident. To further enhance efforts, future initiatives include incorporating the 4AT assessment in clerking booklets, conducting continuous teaching sessions, and displaying posters in relevant wards.

2259 Assessing antibiotic usage on a geriatric ward

Abstract Introduction The World Health Organisation lists antibiotic resistance as one of the biggest threats to global health [1]. We contribute to this as clinicians, through errors such as delayed review of prescriptions or prescribing against local trust guidelines. Method We have carried out a quality improvement project to improve antibiotic prescriptions on a geriatric ward at Croydon University Hospital. We carried out a fortnightly cross-sectional analysis of the antibiotic prescriptions on a geriatric ward. This included looking at the antibiotic prescribed, indication, duration, route of administration and presence of a review date. These were then compared to trust guidelines. After the first 8-weeks, we delivered a departmental teaching session on antibiotic prescriptions. We then re-audited the prescriptions. Following this, we sent out weekly email reminders on locating trust guidelines and information on prescriptions. We then re-audited following this. Finally, we created an e-learning resource to deliver to the ward on antibiotic prescriptions. We are planning to deliver this to the ward and re-audit afterwards. Results Initially, up to 90.0% of prescriptions differed from trust guidelines. Common reasons for differences when compared included incorrect drug prescribed, incorrect frequency of dosing, or non-specific indications leading to difficulty comparing. Following all interventions, approximately 32% of prescriptions differed from trust guidelines. This showed sustained improvement across 2 complete PDSA cycles (plan, do, study, act). A 3rd PDSA cycle is ongoing at present and preliminary data has shown approximately 28% of prescriptions differed from trust guidelines. Conclusion This quality improvement project has successfully contributed to a reduction in prescription errors and safe prescribing. We will continue to provide information to our colleagues on antibiotic stewardship, to further encourage safe prescribing. [1]. Antibiotic resistance (2020) World Health Organisation. Available at: https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance (Accessed: May 2023).

2329 A quality improvement project to improve bone health plan in trauma and orthopaedic discharge summaries

Abstract Introduction In 2022, 293 hip fractures had been admitted to the Bristol Royal Infirmary. As recommended by National Osteoporosis Guideline Group (NOGG) intravenous zoledronate is the first line treatment option following a hip fracture. Aims We wanted to improve bone health summaries on discharge summaries for the benefit of the General practitioner (GP), Fracture liaison service and patient. Results We used our local National Hip Fracture database to identify the patients who had had a fractured hip in September 2023. We then introduced our changes as part of the PDSA cycle. The change was copying and pasting a blank bone health paragraph into every discharge summary on day 1 of the patient’s admission to make it easier for the Trauma and Orthopaedic (T&O) junior doctor completing the discharge summary pre discharge. We then used an excel spreadsheet to collect results in September and October 2023 and analyse them and display them using pie charts. In September, 28.3% of discharge summaries did not have a bone health plan, compared to 25% in October. Not mentioning of Vitamin D levels in discharge summaries has increased from 57.1% to 59.4%. Mentioning of administration of inpatient zoledronic acid post fracture decreased from 32.1% to 25%. Conclusion Despite the intervention, the bone health plans are poorly communicated to the GP and the Fracture Liaison service, which leads to delay in administering bone health medication in a timely manner to prevent a second fracture. Next step Teaching Session with the T&O juniors to find out if they think it’s a good idea and discuss why they have not found the current standardised paragraph helpful. Then we can work together to make a further change (s) and start another PDSA cycle. References National Osteoporosis Guideline Group.UK (NOGG),2021.

2294 Improving communication and documentation in patients receiving end of life care

Abstract Introduction Improvement project in response to several bereavement meetings with families reporting concerns with communication and care received during their loved ones’ end of life care (EOLC). Methods Retrospective review of 79 inpatients documentation who died between August 2021–March 2022 in comparison against the Royal College of Physicians National Care of the dying audit to identify targets for intervention. Survey of 22 members of ward staff between (January–March 23) including medical, nursing, and allied health professionals to understand confidence, clinical knowledge and available resources to care for EOL patients and families. Results Retrospective audit showed 13.9% of families expressed concerns about EOLC received. Discussions held of the potential for progression into EOLC were 82.4% of cases and that of approaching the terminal phase of life 83.5%, which is similar to the national findings of 83% and 79% respectively. There was an absence in offering holistic support to families and patients like food vouchers, parking permits, and referral to chaplaincy team at only 27.8% cases. This theme was seen in the staff survey, with 16.5% of staff suggesting offering parking permits and 15.2% suggesting food vouchers. The survey also highlighted the relative lack of confidence of allied health professionals 5.9/10 vs the remaining team average of 8.1/10 when providing EOLC. Conclusions The audit and survey identified gaps in patient care and communication for our ward staff. To improve quality of care, teaching sessions in collaboration with palliative care team are set to start for ward staff. To improve communication, two proformas were developed; one tackles patient and family communication preferences in cases of acute health deterioration. Another proforma aims to standardise death verification documentation across the trust. These are first cycle interventions to help improve patients and families holistic.

2275 Enhancing delirium awareness among patients’ relatives: a quality improvement project in elderly care

Abstract Aim This Quality Improvement Project (QIP) addressed the pressing need for increased awareness of delirium among patients’ relatives. With a 26% rise in the elderly population in Cambridgeshire, surpassing the 18.6% national average, the project provides crucial information to enhance patients’ relatives access to information about delirium, a condition affecting up to 50% of older hospitalised patients. Method This prospective QIP was conducted across seven Cambridge University Hospital (CUH) geriatric wards. Qualitative surveys determined delirium awareness, understanding, interest and perception of information availability among patients’ relatives with delirium. Measurements included data on the views of online Trust delirium information. Interventions included designing a new eye-catching delirium information poster with a QR code linked to the Trust delirium information leaflet, strategically placing QR code-enabled posters in wards, awareness campaigns targeting healthcare professionals, liaison with the inpatient Dementia team, and targeted communication at Dementia and Delirium Champion training sessions for nursing and healthcare staff. Results Pre- and post-intervention questionnaires, involving 13 relatives visiting these wards, showed a 16%, 10% and 20% respective increase in respondents’ awareness, understanding, and interest in delirium. There was a 29% increase in awareness of location of delirium information post intervention. After the interventions, views of the Trust delirium website increased by 132%. Cycles of the QIP highlighted the importance of laminated posters to comply with infection control measures and the need liaison with ward teams about strategic poster placement. Conclusion this QIP successfully demonstrated the effectiveness of QR code enabled access to patient/relative information and that a multi-faceted approach is required to facilitate effective information provision. We also demonstrated these measures increased delirium awareness in relatives. Future recommendations include continuous monitoring of the availability of posters within clinical areas, content evaluation, and work with the Dementia team to roll this out to all wards with older people within Trust.

Development and implementation of evidence-based, nurse-leading early warning model and healthcare quality improvement project for transplant-associated thrombotic microangiopathy: a mixed-methods, before-and-after study

ObjectiveThe early identification and diagnosis of transplant-associated thrombotic microangiopathy (TA-TMA) are essential yet difficult in patients underwent hematopoietic stem cell transplantation (HSCT). To develop an evidence-based, nurse-leading early warning model for TA-TMA, and implement the healthcare quality review and improvement project.MethodsThis study was a mixed-methods, before-and-after study. The early warning model was developed based on quality evidence from literature search. The healthcare quality review and improvement project mainly included baseline investigation of nurse, improvement action and effectiveness evaluation. The awareness and knowledge of early parameter of TA-TMA among nurses and the prognosis of patients underwent HSCT were compared before and after the improvement.ResultsA total of 1 guideline, 1 evidence synthesis, 4 expert consensuses, 10 literature reviews, 2 diagnostic studies, and 9 case series were included in the best evidence. The early warning model including warning period, high-risk characteristics and early manifestation of TA-TMA was developed. The improvement action, including staff training and assessment, suspected TA-TMA identification and patient education, was implemented. The awareness and knowledge rate of early parameter of TA-TMA among nurses significantly improved after improvement action (100% vs. 26.7%, P < 0.001). The incidence of TA-TMA was similar among patients underwent HSCT before and after improvement action (2.8% vs. 1.2%, P = 0.643), while no fall event occurred after improvement action (0 vs. 1.2%, P < 0.001).ConclusionThe evidence-based early warning model and healthcare quality improvement project could enhance the awareness and knowledge of TA-TMA among healthcare providers and might improve the prognosis of patients diagnosed with TA-TMA.

Preparing Children for Invasive MedicalCancer Treatment with "My Logbook": Preliminary Results of a Pilot Study.

Pediatric cancer is one of the most burdensome chronic diseases, necessitating a variety of severe medical interventions. As a result, the disease and its treatment cause numerous acute and long-term medical, psychological, and socioeconomic strains for young patients and their families. Therefore, psychosocial care using evidence-based interventions (EBIs) before, during, and after medical treatments is essential to ensure that patients receive adequate information and to minimize the adverse emotional and psychosocial impacts such as insecurity, fear, and shame. The present study reports the first promising results of applying cancer-specific psychosocial methods developed in the quality improvement project "My Logbook." The four assessed tools are specifically designed to adequately prepare pediatric cancer patients for surgery, chemotherapy, radiotherapy, and stem cell transplantation. Self and proxy ratings were used to assess the patients' subjective knowledge and emotional well-being before and after each intervention session. The results showed that patient-centered interventions using various creative and developmentally adapted methodologies (e.g., psychoeducation, crafting, games) have the potential to effectively enhance patient health literacy (V = 120.5, p < .001, r = 0.33) and well-being as manifested in more positive (slope = 0.121, p = .016) and less negative (slope = - 0.350, p < .001) or neutral emotions (slope = - 0.202, p = .002). These findings highlight the importance of developing and implementing psychosocial tools in pediatric oncology to prevent psychological overload and negative emotions and to increase subjective control beliefs, autonomy, and empowerment. Moreover, the effective application and systematic evaluation of evidence-based psychosocial tools can facilitate the establishment of standardized guidelines for psychosocial care in pediatric oncology. Thereby, the final goal is to ensure the quality of care and to use education to increase the quality of life for all pediatric cancer patients.Trial registration: ClinicalTrials.gov Identifier: NCT04474678 (July 17, 2020).

Changing the Culture to Improve CCF: An Improvement Project

Objectives After identifying chest compression fraction (CCF) as a key area for improvement, our Emergency Medical Services (EMS) agency aimed to improve our baseline monthly median CCF from 81.5% to 90% or more in paramedic-attended medical cardiac arrests by December 2023. The CCF is a process measure that, if improved, has been shown to increase likelihood of survival from cardiac arrest. Working as a hospital EMS agency within a large urban 9-1-1 system, our interventions focused on paramedics once they arrived on scene. Methods This project used repeated Plan-Do-Study-Act (PDSA) cycles with brainstorming sessions, focus groups, and data review to achieve improvement. Interventions included standardized clinician feedback forms, increased follow-up for patients with ongoing resuscitation, a designated CPR team leader during resuscitations, and a pre-charged defibrillator prior to rhythm checks. These interventions were evaluated by tabulating weekly and monthly median CCF performance, seeking participant feedback, and reviewing control charts. These results were reported according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). Results Our control chart analysis revealed special cause variation and an increase in average CCF to 89.0%. This improvement was achieved through successful implementation of process changes using PDSA cycles. Our most effective and popular intervention was our clinician feedback forms. Additionally, re-unifying patients and their successful resuscitation teams, participating in resuscitation academy events, and pre-charging the defibrillator to minimize CPR pauses collectively resulted in systemic improvement in resuscitation performance. Conclusions The findings illustrate that targeted education, increased clinician feedback, patient-team reunification, and high-performance resuscitation strategies produce measurable improvement in CCF.

Starting continuous improvement; creating a common understanding of stroke care delivery in a general hospital

BackgroundContinuous improvement is based on fostering practitioners’ suggestions to modify their own work processes This improvement strategy is widely applied in healthcare but difficult to maintain. The cross-disciplinary nature of many care processes constitutes an extra impediment.MethodsThe study had an explorative design with a qualitative single-case approach. The case presents a project to improve the treatment of patients with thrombotic stroke. Data was obtained via hands on involvement, documents, observations, and interviews with participants in a cross-functional improvement group. A thematic analysis method was employed.ResultsThrough learning how tasks were carried out in other disciplines, the participants developed a common understanding of why it took so long to provide treatment to stroke patients. These insights were used to implement practical changes, leading to immediate improvements in stroke care delivery. The results were fed back so that successes became visible. Participants’ understandings of the local context enabled them to convince peers of the rationale of changes, setting in motion a permanent improvement structure. The participants considered that mapping and then assessing the entire workflow across disciplines were relevant methods for improving the quality of patient care.ConclusionStarting an improvement project in a cross disciplinary environment requires deep engagement on the part of professionals. A quintessential prerequisite is therefore the realization that the quality of care depends on cross-disciplinary cooperation. A facilitated learning arena needs to (1) create insights into each other’s colleagues’ tasks and process interdependencies, (2) increase understanding of how the distribution of tasks among specialist units affects the quality of care, and (3) frequently report and provide feedback on results to keep the process going.

Adaptive Pressure Control-Continuous Mandatory Ventilation Versus Volume Control-Continuous Mandatory Ventilation: Factors Associated With Initiation, Maintenance, and Adjustment.

Adaptive pressure control-continuous mandatory ventilation (APC-CMV) is a frequently utilized ventilator mode in ICU settings. This analysis compared APC-CMV and traditional volume control-continuous mandatory ventilation (VC-CMV) mode, describing factors associated with initiation, maintenance, and changes in settings of each mode. We analyzed ventilator data from a retrospective electronic health record data set collected as part of a quality improvement project in a single academic ICU. The majority ventilator mode was defined as the mode comprising the highest proportion of mechanical ventilation time. Multivariable logistic regression was used to identify variables associated with initial and majority APC-CMV or VC-CMV modes. Wilcoxon rank-sum tests were used to compare ventilator setting changes/d and sedation as a function of APC-CMV and VC-CMV majority modes. Among 1,213 subjects initiated on mechanical ventilation from January 2013-March 2017, 68% and 24% were initiated on APC-CMV and VC-CMV, respectively, which composed 62% and 21% of the majority ventilator modes. Age, sex, race, and ethnicity were not associated with the initial or majority APC-CMV or VC-CMV modes. Subjects initiated on APC-CMV spent 88% of the mechanical ventilation time on APC-CMV mode. Compared to VC-CMV, subjects with APC-CMV majority mode experienced more ventilator setting changes/d (1.1 vs 0.8, P < .001). There were no significant differences in sedative medications when comparing subjects receiving APC-CMV versus VC-CMV majority modes. APC-CMV was highly utilized in the medical ICU. Subjects on APC-CMV had more ventilator setting changes/d than those on VC-CMV. APC-CMV offered no advantage of reduced setting adjustments or less sedation compared to VC-CMV.

Assessing, Advising, and Advancing the Filling Practices of the Radiology Request Form in Africa: A Systematic Review.

Despite the increased use of diagnostic imaging in Africa, the completion of the Radiology Request Form (RRF) remains suboptimal, often relying on paper-based communication. To examine the practices surrounding RRF completion in the African continent, on 25 March 2024, we conducted a systematic review of peer-reviewed articles describing the practice in African settings. Non-African studies, studies involving non-human subjects, and articles examining the practice of the RRF for interventional usage were excluded. Our search involves PubMed/MEDLINE, ScienceDirect, Scopus, Web of Science, Google Scholar, and African Journals Online. The included studies were 3004, of which 30 met the inclusion criteria. These studies span eight countries and highlighted several shortcomings, including the usage of informal forms, unconventional abbreviations, illegibility, inaccuracy, and the lack of important fields from institutional forms, commonly the last menstrual period and the referrer's contact details. We also found widespread non-compliance in all RRF fields; half of the studies did not have an adequately filled form. Incomplete RRFs lead to delayed imaging, increased workloads for radiographers and radiologists, and potential misdiagnoses due to insufficient information. It will also impede the application of radiation protection principles. To address these challenges, empowering radiographers and radiologists and encouraging best practices is essential. Regular audits and educational initiatives aimed at clinicians are recommended. While transitioning to a paperless communication system might help, implementing nationwide quality improvement projects to standardise radiology request forms is currently more feasible.

The delivery of multiple benefits on the Llyn Tegid reservoir safety improvements project

When Wales’ largest natural lake, Llyn Tegid, required significant reservoir safety works, the execution of sympathetic yet well-engineering solutions ensured that the scheme could stand the test of time and achieve multiple benefits for future generations. Placing sustainability at its heart, the scheme, delivered in Spring 2023, totalling £7 million, has involved strengthening works to 3 km of embankments to protect the popular tourist town of Bala from extreme weather. Boosting the wellbeing of residents and visitors within the picturesque Snowdonia landscape, works on the high-risk reservoir did not come without unique challenges. From designing for overflowing events and significant mature tree removal, to protecting internationally important habitats and working within the live reservoir basin, to name just a few. The scheme's success has been a testament to building the right team, implementing the right contractual and management controls, and establishing the right culture for compliant and high-quality solutions. Opportunities for carbon reduction and maximising value for money have been taken alongside new works to facilitate possible future expansion of Bala Lake Railway. Involving the community at every stage of this award-winning scheme, the delivery of benefits has been many, and the experiences are ones to live on for all.

Post Anesthesia Care Unit Comprehension Safety Program Quality Improvement Project on De-escalation of Patients

Post Anesthesia Care Unit Comprehension Safety Program Quality Improvement Project on De-escalation of Patients