Initial Pilot Program Research Articles

Evaluation of the safety and efficacy of peripheral vasopressors to decrease central line placement and associated bloodstream infections

Background In 2020, as a result of evidence of demonstrated safety of an initial pilot program, our institution set out to implement a peripheral vasopressor infusion protocol. Objective To evaluate the use of peripheral lines for vasopressor administration to reduce placement of unnecessary central lines and central line days. Methods This is an Institutional Review Board approved, single center retrospective chart review conducted as pre/post-analysis. Our hospital is a quaternary care, level 1 trauma center in Hartford, Connecticut that serves 100,000-120,000 patients annually. Patients >18 years admitted to an intensive care unit (ICU) were included if meeting protocol specific inclusion criteria pertaining to moderate expected duration and dose of vasopressor. Patients were excluded if vasculature not supportive of placement of two peripheral intravenous (PIV) sites, PIV sites without brisk blood return, had a limb restriction, or metacarpal line. All analyses were conducted with SPSS v. 26 (IBM; Armonk, NY 2019), using an a priori alpha level of 0.05 such that all results yielding p < .05 were deemed statistically significant. Primary efficacy outcomes of this study are number of central lines placed and number of central line days. The primary safety outcome is the number of extravasation events attributed to peripheral administration of vasopressors. Results Overall, 146 patients avoided central line placement constituting a 58.4% ( p < .001) decrease in central line placement with peripheral vasopressor use. Out of 382 administrations there were a total of 14 extravasation events that occurred with peripheral vasopressor use in the post-intervention group. Implementation was associated with a statistically significant reduction in CLABSI occurrence. Conclusions The results of this analysis demonstrate that vasopressors can peripherally administered safely, when proximal to the antecubital fossa, at lower doses, and for short durations of infusion with minimal adverse events.

Intensive preoperative ostomy education for the radical cystectomy patient.

Patients undergoing radical cystectomy with ileal conduit formation usually receive training on the use of their stoma during their initial hospitalization - while actively recovering from surgery - often with little follow-up or reinforcement. Many of these patients are not equipped to deal with these significant body changes, which can lead to additional clinic visits, stoma-related complications, and decreased patient satisfaction/health-related quality of life (HRQOL). In an effort to improve patient education, we sought to evaluate the feasibility of implementing a preoperative comprehensive stoma education session termed the "stoma bootcamp" for patients scheduled for a radical cystectomy and ileal conduit (RCIC). We tracked patient related outcomes to determine its impact. We performed a longitudinal, quality-improvement feasibility study at the University of Kansas Health System. All patients who were scheduled to undergo a RCIC for bladder cancer were offered enrollment into the study at their preoperative clinic visit. The "stoma boot camp" consisted of a 3-hour group session within 2 weeks of the surgery date. Patients were given a short presentation by residents and advanced practice providers regarding the operation, recovery, and expectations for their post-operative care. Ostomy nurses then demonstrated basic urostomy care - pouching, sizing, emptying - along with trouble-shooting tips for common ostomy problems. Measurements of HRQOL questionnaires were completed at the initial visit, after "boot camp," and at defined time points after surgery for 12 weeks. This included using an ostomy adjustment score. Length of stay, unplanned stoma-related interventions, and re-admissions within 30 days were also tracked. In this initial pilot program, 51 patients participated in the stoma bootcamp. The patients had an average ostomy adjustment score (OAS) of 150.4 (95% CI 142.0, 158.8) at discharge from the hospital, and these high OAS levels persisted throughout the 12 weeks of follow-up data without any significant decline. Short-form 36 (SF-36) scores demonstrated numerical improvements in each individual category at the 6-week mark above baseline. These improvements persisted at the 12-week mark. In this study we were able to establish the feasibility of implementing a preoperative comprehensive stoma education session for patients scheduled for a RCIC. Additionally, we were able to document favorable HRQOL data and improved ostomy adjustment scores surrounding the education session.

S1280 Evaluating the Use of a Customized Digital Navigation Program to Optimize Bowel Preparation Quality in Pediatric Colonoscopy: Outcomes From Initial Pilot Program

S1280 Evaluating the Use of a Customized Digital Navigation Program to Optimize Bowel Preparation Quality in Pediatric Colonoscopy: Outcomes From Initial Pilot Program

Design and implementation of a mobile health electronic data capture platform that functions in fully-disconnected settings: a pilot study in rural Liberia

BackgroundMobile phones and personal digital assistants have been used for data collection in developing world settings for over three decades, and have become increasingly common. However, the use of electronic data capture (EDC) through mobile phones is limited in many areas by inconsistent network connectivity and poor access to electricity, which thwart data transmission and device usage. This is the case in rural Liberia, where many health workers live and work in areas without any access to cellular connectivity or reliable power. Many existing EDC mobile software tools are built for occasionally-disconnected settings, allowing a user to collect data while out of range of a cell tower and transmit data to a central server when he/she regains a network connection. However, few tools exist that can be used indefinitely in fully-disconnected settings, where a user will never have access to the internet or a cell network. This led us to create and implement an EDC software tool that allows for completely offline data transfer and application updating.ResultsWe designed, pilot-tested, and scaled an open-source fork of Open Data Kit Collect (an Android application that can be used to create EDC systems) that allows for offline Bluetooth-based bidirectional data transfer, enabling a system in which permanently-offline users can collect data and receive application updates. We implemented this platform among a cohort of 317 community health workers and 28 supervisors in a remote area of rural Liberia with incomplete cellular connectivity and low access to power sources.ConclusionsRunning a fully-offline EDC program that completely bypasses the cellular network was found to be feasible; the system is still running, over 4 years after the initial pilot program. The users of this program can theoretically collect data offline for months or years, assuming they receive hardware support when needed. Fully-offline EDC has applications in settings where cellular network coverage is poor, as well as in disaster relief settings in which portions of the communications infrastructure may be temporarily nonfunctional.

Deep in the Weeds: Faculty Participation in a Large Scale Deselection Project

In 2014, the Pollak Library at California State University, Fullerton embarked on a project to simultaneously address an outdated collection and to provide more student oriented collaborative space by creating a large-scale deselection plan. The interim University Librarian believed it prudent to offer campus faculty the ability to provide input on the deselection plan and an online application was created to allow faculty to request retention of titles selected for weeding. Feedback from an initial weeding pilot program was instructive and the tool was updated for the following deselection rounds to compel faculty to justify reasons for retaining titles and deter arbitrary requests for retention. While ultimately successful in deselecting 95,074 titles, future weeding projects will focus on the most invested partners, rather than the entire campus community. This article describes Pollak Library’s weeding project and analyzes the results of three years of faculty feedback.

Integrating Correctional and Community Health Care: An Innovative Approach for Clinical Learning in a Baccalaureate Nursing Program.

With an evolving focus on primary, community-based, and patient-centered care rather than acute, hospital-centric, disease-focused care, and recognition of the importance of coordinating care and managing transitions across providers and settings of care, registered nurses need to be prepared from a different and broader knowledge base and skills set. A culture change among nurse educators and administrators and in nursing education is needed to prepare competent registered nurses capable of practicing from a health promotion, disease prevention, community- and population-focused construct in caring for a population of patients who are presenting health problems and conditions that persist across decades and/or lifetimes. While healthcare delivery is moving from the hospital to ambulatory and community settings, community-based educational opportunities for nursing students are shrinking due to a variety of reasons, including but not limited to increased regulatory requirements, the presence of competing numbers of nursing schools and their increased enrollment of students, and decreasing availability of community resources capable and willing to precept students in an all-day interactive learning environment. A detailed discussion of one college of nursings' journey to find an innovative solution and approach to the dilemma of limited and decreasing available community clinical sites to prepare senior level prelicensure baccalaureate nursing students for healthcare practice in the twenty-first century. This article demonstrated how medium/maximum prisons can provide an ideal learning experience for not only technical nursing skills but more importantly for reinforcing key learning goals for community-based care, raising population-based awareness, and promoting cultural awareness and sensitivity. In addition, this college of nursing overcame the challenges of initiating and maintaining clinical placement in a prison facility, collaboratively developed strategies to insure student and faculty safety satisfying legal and administrative concerns for both the college of nursing and the prison, and developed educational postclinical assignments that solidified clinical course and nursing program objectives. Lastly, this college of nursing quickly learned that not only did nursing students agree to clinical placement in an all-male medium- to maximum-security prison despite its accompanying restrictive regulations especially as it relates to their access to personal technology devices, but there was an unknown desire for a unique clinical experience. The initial pilot program of placing eight senior level prelicensure baccalaureate nursing students in a 4,000-person all male medium- to maximum-security prison for their community clinical rotation has expanded to include three state-run maximum all male prisons in two states, a 3,000-person male/female federal prison, and several juvenile detention centers. Clinical placement of students in these sites is by request only, resulting in lengthy student waiting lists. This innovative approach to clinical learning has piqued the interest of graduate nurse practitioner (NP) students as well. One MSN, NP student has been placed in the federal prison every semester for over a year. Due to increasing interest from graduate students to learn correctional health nursing, the college of nursing is now expanding NP placement to the other contracted maximum-security prisons. This entire experience has changed clinical policies within a well-established academic culture and promoted creative thinking regarding how and where to clinically educate and prepare registered baccalaureate nurses for the new culture of health and wellness.

Evaluation of a diabetes specialist–guided primary care diabetes treatment program

An initial pilot program demonstrated promising results in improvements in glycosylated hemoglobin (HbA(1c)), low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP) and prompted us to test these findings in a controlled trial. The purpose of the Diabetes-focused, Algorithm-directed care, Midlevel practitioner-administered, Electronically coached, Treatment (DAMET-2) program clinical trial was to investigate the benefits of a novel program for disseminating guidance in the treatment of diabetes from a central specialist clinic to primary care centers with access to midlevel provider services. DAMET-2 included standardized treatment algorithms and education disseminated through computer-assisted and traditional methods associated with distance medicine. Two primary care practices were selected and subjects with diagnosed type 2 diabetes > or =6 months, > or =18 years of age with one or more cardiovascular risk factors (identified by chart review) were eligible for inclusion. Midlevel practitioners for subjects in the experimental group (N = 34) received training in American Diabetes Association treatment algorithms, had telephone consultations at 2- to 4-week intervals and bimonthly visits with diabetes specialists, and received treatment guidance within 24 h from remote diabetes specialists. Weekly diabetes clinics were made available to subjects in the experimental group. After 12 months, the last available subject data were extracted from the subjects' charts and compared to 12-month chart data from a control group (N = 101) that did not receive additional study services. Mean HbA(1c) values decreased from baseline by 0.46% in the active treatment group versus 0.06% in the control group; however, reductions in HbA(1c) did not achieve statistical significance potentially because of the small sample size of the experimental group. Mean SBP values were significantly reduced in both groups; however, LDL-C was only significantly reduced in the control group, where more aggressive use of statins may have had an effect. Despite the inconsistencies in risk factor reduction from the pilot program, the DAMET-2 program provided insights regarding the importance of electronic records and provider notifications, patient adherence, prioritization of provider resources by risk factor level among patients, and access to self-management education.

Initial metrics and pilot program results for measuring the performance of the Canadian construction industry

A study has been initiated by the Canadian Construction Innovation Council to support the measurement of the performance of the Canadian construction industry. Metrics have been established to cover aspects of cost, time, scope, quality, safety, innovation, and sustainability. The metrics were piloted with industry partners and applied to institutional building and infrastructure projects. The metrics were selected in recognition of other national and international efforts in benchmarking and with a view of supporting analysis at the project, organization, and industry level. The experience gained through the pilot project indicates that the metrics are reasonably well understood in their definition. While the cost, time, scope, and safety information is readily available, as expected, the information for quality innovation and sustainability is not or requires more detailed in-person interviews of project participants to obtain a complete picture of project performance. The data analysis and presentation conducted to date indicates that a combination of radar charts and box plots works best as a means to communicate results. The result of the study to date is a standard set of metrics, and collection and reporting methods for the performance of the Canadian construction industry that are useful as the basis of a broad benchmarking program.

DERM (Dermatologic education for residents and medical students): a pilot program of web-based dermatologic teaching to maximize efficient use of time for residents and medical students

Due to the current emphasis on cost-containment measures in health care, primary care physicians are increasingly responsible for the initial evaluation of skin disorders. Multiple studies comparing the skills of generalists with dermatologists have concluded that further dermatological training is essential for improving the knowledge of generalist physicians. Studies have also demonstrated that appropriate educational intervention can help primary care residents in managing skin conditions at a level approximating that of dermatologists. At the same time, significant constraints on the average resident’s time for learning with a dermatologist make this educational aim difficult. With this in mind, we created and implemented a web-based educational program for primary care residents and medical students providing them with essential information on the diagnosis, pathophysiology, and management of common skin disorders, as well as evaluating their learning through on-line quizzes. Through this pilot program we attempt to determine whether online education is an effective method of improving the dermatological knowledge of primary care residents. Method: We describe the creation of a pilot program targeting pediatric and internal medicine residents as well as medical students at the community based NEOUCOM consortium hospitals in Akron. We utilized WebCT software to provide users with recommended reference materials including links to the AAD’s medical student core curriculum website for the monthly skin topic. Topics emphasized range from acne vulgaris to skin cancer. The effectiveness of the pilot program is evaluated by comparing the results of pre-reading and post-reading quizzes administered online to the students and residents, as well as online surveys. We also describe potential spin-off projects from this initial pilot program including virtual grand rounds, continuing medical education for physicians, and internet-based communication between generalist residents and dermatologists to clarify dermatological questions. Discussion and Conclusion: Currently primary care residents in the consortium hospitals acquire only minimal clinical dermatologic education. Our web-based program has the advantage of being convenient, easily accessible, inexpensive, and more efficient than a few days of dermatology rotation in that all the essential topics are sure to be emphasized. We believe that a web-based educational program has definite potential in improving the dermatologic knowledge of primary care residents and students.

MIAMI-DADE LATERAL PILOT PROGRAM

Since 1994 the Miami-Dade Water and Sewer Department (WASD) has been engaged in an extensive sanitary sewer system evaluation and rehabilitation program in an effort to reduce system infiltration, exfiltration and inflow (I/E/I). Under the I/E/I Program, the entire sanitary sewer collection system, which represents approximately 3,930 km (12.9 million feet) of gravity sewer lines and 58,000 manholes was evaluated by July, 1997. The Program sewer evaluation consisted of cleaning and televising 100 percent of the gravity lines, the visual inspection of each manhole and the smoke testing of the entire system to identify defects. A total of 32,194 defects were identified and repaired. The I/E/I Program has been highly successful with system flows to the regional treatment facilities reduced by approximately 100 mgd. Although the system-wide infiltration was greatly reduced, Rainfall Dependent Infiltration/Inflow (RDII) and the various pump station force main improvements have continued to increase the peak flows to the treatment facilities during heavy rainfall events. Since the mainline sewer components were fully investigated and laterals from the main sewer to the house (house lateral) have only been evaluated in close proximity to the mainline sewer, the sewer house laterals have been identified as the only system component not fully investigated. The house laterals above the normal water table were, therefore, considered the source of the RDII. In 1999, WASD initiated an Initial Lateral Pilot Program to determine if house laterals could be the cause of the RDII and to quantify the effectiveness and cost of a lateral evaluation and repair program. Three collection basins were selected for the initial pilot program. Although all main sewers were repaired under the I/E/I Program, all basin main sewers were re-televised and smoke tested and all manholes were again visually inspected for defects. The identified repairs were completed and the manholes were sealed to reduce system inflow. After a significant rain event, rainfall dependent infiltration/inflow hydrograph signatures were obtained for the “before” baseline flow. Each basin lateral, both public and private sides, were then pressure tested for leaks and the defects were identified and repaired. Figures 1, 2 and 3 illustrate the effectiveness of the program where the RDII signature is reduced after repairs are made.

Introducing end-of-life care into the University of Cincinnati Internal Medicine Residency Program.

In 1997, the American Board of Internal Medicine (ABIM) incorporated a new requirement to include knowledge and skills in end-of-life care into U.S. internal medicine residency training.1 Working in tandem with ABIM, David Weissman, M.D., Charles von Gunten, M.D., Bruce Ambuel, Ph.D., and Patricia Mullan, Ph.D., began the National Residency End-of-Life Physician Education Project (NRELEP) to help residency programs develop the necessary infrastructure to meet these new requirements, first with a pilot project in 1998. The project has been funded by The Robert Wood Johnson Foundation. The success of the pilot project in working with 30 residency programs from the Upper Midwest led to the continuation of this educational effort. Currently more than 200 residencies have participated, including programs in internal medicine, neurology, family medicine, and surgery. This effort includes several components: program recruitment and commitment, a needs assessment completed by program directors prior to participation, baseline surveys of knowledge and attitudes among participants, and a 2-day workshop to which each participating residency program sends a team. Teams must include two to four representatives, made up of program leaders or their designees, and residents. The workshop focuses on the process of educational change and specific techniques rather than end-of-life knowledge content per se. Topics covered include the following five domains: pain assessment and management with discussion of addiction; communication skills and self-reflection; hospice care and prognostication; incorporating clinical end-of-life care experiences into training; and faculty development in end-of-life care. The program and studies of its impact and outcomes among participating internal medicine programs have been described in detail elsewhere.2–5 Dr. Eric Warm, Associate Program Director of the University of Cincinnati Internal Medicine Residency Program, participated in the initial pilot program in fall of 1998. Now, 5 years later, he describes how he and his colleagues got started, the results of their residency curricular change efforts, and how these efforts have evolved over time. Dr. Warm continues to shepherd these changes and now also serves as faculty for NRELEP. What follows are edited comments from an interview conducted by Associate Editor Anna L. Romer, Ed.D. This interview is excerpted from the thematic issue “Designing Postgraduate Training in End-of-Life Care,” Volume 4, Number 5, 2002 of the online journal Innovations in End-of-Life Care at kwww.edc.org/lastacts/l

Implementing Change Through Training: A Case Study

In July of 1976, the CUNY Urban Academy and the New York City Office of Management and Budget applied for and received a training grant from the United States Civil Service Commission under the provisions of the Intergovernmental Personnel Act. The purpose of the training was to support the implementation of the City's new Management Plan and Reporting System (MP/R) in six local agencies. The Urban Academy had been created in 1974 as a cooperative effort between the City University of New York and the City of New York to provide management related training and technical assistance to local government employees. The Office of Management and Budget, part of the Mayor's Executive Office, had been given ultimate responsibility for implementing the City's new management system throughout thirty mayoral agencies. The grant proposal called for an initial pilot program in the City Department of Sanitation and the subsequent performance of similar training in five other agencies. Because of the size and complexity of that department, the Sanitation project turned out to be the most comprehensive program in the entire effort. It also proved to be the most successful. The purpose of this article is to describe the pilot program in the Department of Sanitation. It is presented as a case study which documents the notion that management training can be used as an effective instrument for overcoming bureaucratic passivism and/or resistance to change in the implementation of a new administrative policy, program, or system. While the New York City Sanitation Department is considerably larger than most local government agencies throughout the nation, the problems of implementing change in a bureaucratic environment are comparable among most public organizations, whether they be found at the local, state, or federal level. Thus, the following case study is intended to serve as a lesson to all public administrators on the value of training as a vehicle for implementation in the government service.